Pulmonary embolism assessment of clinical probability and risk scores

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Editor(s)-In-Chief: C. Michael Gibson, M.S., M.D. [1], The APEX Trial Investigators; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Rim Halaby, M.D. [3]

Overview

The diagnosis of pulmonary embolism (PE) is based primarily on the clinical assessment of the pretest probability of PE combined with diagnostic modalities such as spiral CT, V/Q scan, use of the D-dimer, and lower extremity ultrasound. Clinical prediction rules for PE include: the Wells score, the Geneva score and the PE rule-out criteria (PERC).

Assessment of Clinical Probability

A clinical prediction rule is a type of medical research study in which the researchers try to identify the best combination of signs, symptoms, and other findings to predict the probability of a specific disease or outcome.[1] Clinical prediction rules for PE include: the Wells score, the Geneva score and the PE rule-out criteria. Its noteworthy that the use of any clinical prediction rule is associated with reduction in recurrent thromboembolism.[2]

These clinical prediction rules, coupled with diagnostic tests, are used to identify patients who should be treated.

Supportive Trial Data

  • Prospective Investigation On Pulmonary Embolism Diagnosis (PIOPED) investigators demonstrated that all patients with or without PE had abnormal V/Q scans of high, intermediate, or low probability (sensitivity, 98%; specificity, 10%). Furthermore, of the 116 patients with high-probability scans and definitive angiograms, only 88% had a PE. On the contrary, only a minority of patients with pulmonary embolism demonstrated high-probability scans (sensitivity, 41%; specificity, 97%). Similarly, of the 322 patients with intermediate-probability scans and definitive angiograms, only 33% had a PE. The majority of these patients demonstrated low to moderate clinical probability which required no further intervention.[3]
  • Prospective multicenter outcome study by Musset et al, demonstrated that with-holding anticoagulation treatment in patients with low or intermediate clinical probability was safe as long as there was a negative spiral CT and negative ultrasonagraphy. Of the 1041 patients enrolled in the study, 525 were assessed as having low or intermediate clinical probability and 507 were not treated with anticoagulation. During a 3-month follow-up, only 9 patients experienced venous thromboembolism (1.8% [0.8-3.3]) and the diagnostic strategy proved inconclusive in 95 (9.1%) patients.[4][5]

Wells Score

The Wells score is a simple, commonly used clinical risk prediction tool to evaluate the need for further testing in patients suspected to have pulmonary embolism.[6][7][8][9]

Calculation of Wells Score

Pulmonary embolism Wells Score Calculator

Variable Wells Score[8]
Clinically suspected DVT (leg swelling, pain with palpation) 3.0
Alternative diagnosis is less likely than PE 3.0
Immobilization/surgery in previous four weeks 1.5
Previous history of DVT or PE 1.5
Tachycardia (heart rate more than 100 bpm) 1.5
Malignancy (treatment for within 6 months, palliative) 1.0
Hemoptysis 1.0

Interpretation of Wells Score

Wells Criteria

Shown below is the pretest probability of PE according to Wells criteria.[8][9][10]

  • Score >6.0: High probability (Rate of PE: ~66.7%)
  • Score 2.0 to 6.0: Moderate probability (Rate of PE: ~20.5%)
  • Score <2.0: Low probability (Rate of PE: ~3.6%)

Modified Wells Criteria

Shown below is the pretest probability of PE according to the modified Wells Criteria.[8][9][10][11]

  • Score > 4: PE likely (Rate of PE: ~40.7%)
  • Score 4 or less: PE unlikely (Rate of PE: ~7.8%)

Geneva Score

  • The Geneva score has been revised and simplified from its original version, but it has been shown to have the same diagnostic utility as the original score.[14]

Original Geneva Score

Calculation of the Geneva Score

The original Geneva score is calculated using 7 risk factors and clinical variables:[12]

Geneva score calculator

Variable Score
Age
60–79 years 1.0
≥80 years 2.0
Previous venous thromboembolism
History of prior DVT or PE 2.0
Previous surgery
Recent surgery within 4 weeks 3.0
Heart rate
Heart rate >100 beats per minute 1.0
PaCO2 (partial pressure of CO2 in arterial blood)
<35 mmHg (<4.8 kPa) 2.0
35-39 mmHg (4.8-5.19 kPa) 1.0
PaO2 (partial pressure of O2 in arterial blood)
<49 mmHg (<6.5 kPa) 4.0
49-59 mmHg (6.5-7.99 kPa) 3.0
60-71 mmHg (8-9.49 kPa) 2.0
72-82 mmHg (9.5-10.99 kPa) 1.0
Chest X-ray findings
Band atelectasis 1.0
Elevation of hemidiaphragm 1.0
Interpretation of the Geneva Score

Shown below is the interpretation of the Geneva score:[12]

  • Score ≤ 4 points: low probability of PE (~10%)
  • Score 5 to 8 points: moderate probability of PE (~38%)
  • Score ≥ 9 points: high probability of PE (~81%)

Revised Geneva Score

Recently in 2006, the revised Geneva score was introduced with a more standarized and simplified algorithm to help predict the probability that a patient has a pulmonary embolism.[15]

Calculation of the Revised Geneva Score

Revised Geneva score calculator

Variable Score
Age more than 65 years 1.0
Prior history of DVT or PE 3.0
Surgery under general anesthesia or fracture of the lower limbs within the last month 2.0
Active malignant condition (currently active or cured less than 1 year ago) 2.0
Unilateral lower limb pain 3.0
Hemoptysis 2.0
Heart rate 75 to 94 beats per minute 3.0
Heart rate 95 or more beats per minute 5.0
Pain on deep palpation of lower limb and unilateral edema 4.0
Interpretation of the Revised Geneva Score
  • Score 0-3 points: lower probability of PE (8%)
  • Score 4-10 points: intermediate probability of PE (28%)
  • Score ≥ 11 points: higher probability of PE (74%)

Simplified Geneva Score

A one-point simplified scoring system replaced the previously weighted scores for each parameter. This was done to reduce the likelihood of error when the score is used in clinical settings. The simplified Geneva score does not lead to a decrease in diagnostic utility when compared to the previous Geneva scores.[14]

Calculation of the Simplified Geneva Score

Simplified Geneva Score calculator

Variable Score
Age >65 1.0
Previous history of DVT or PE 1.0
Surgery under general anesthesia or fracture of the lower limbs within the last month 1.0
Active malignant condition (currently active or cured less than 1 year ago) 1.0
Unilateral lower limb pain 1.0
Hemoptysis 1.0
Heart rate 75 to 94 bpm 1.0
Heart rate greater than 94 bpm* +1
Pain on deep vein palpation of lower limb and unilateral edema 1.0
* Heart rates of 75 to 94 bpm receive 1 point, while heart rates higher than 94bpm receive a further point (i.e. 2 points in total)
Interpretation of the Simplified Geneva Score
Trichotomous Use of the Simplified Revised Geneva Score
  • Score 0-1 points: low probability of PE (7.7%)
  • Score 2-4 points: intermediate probability of PE (29.4%)
  • Score ≥5 points: high probability of PE (64.3%)
Dichotomous Use of the Simplified Revised Geneva Score
  • Score 0-2 points: PE is unlikely (11.5%)
  • Score ≥3 points: PE is likely (41.6%)

PE Rule-Out Criteria (PERC)

  • Unlike the Wells Score and Geneva score, which are clinical prediction rules intended to risk stratify patients with suspected PE, the PERC rule is designed to rule out the risk of PE in low-risk patients stratified clinically by the physicians; hence, to prevent unnecessary diagnostic testing in this patient population.[17]
Variables in PERC[16]
Age less than 50 years?
No hemoptysis?
No estrogen use?
No prior history of DVT or PE?
No unilateral leg swelling?
No surgery or trauma requiring hospitalization within the past four weeks?
Heart rate less than 100 bpm?
Oxyhemoglobin saturation ≥95 percent?

Interpretation of PERC

If the answer to every question above is yes, then a pulmonary embolism can be ruled out according to the PERC rule.[16]

Pulmonary Embolism Severity Index (PESI) Score

The Pulmonary Embolism Severity Index (PESI) score aims to stratify patients with PE into classes of increasing rate of mortality and adverse outcomes.[20]

Calculation of PESI Score

Age, per yr Age, in yr
Male sex 10
Cancer 30
Heart failure 10
Chronic lung disease 10
Pulse ≥110 beat/min 20
Systolic blood pressure <100 mmHg 30
Respiratory rate ≥30/min 20
Temperature <36 20
Altered mental status 60
Arterial oxygen saturation <90% 20

Interpretation of PESI Score

Class Score Class–specific 30-day mortality
Class I, very low risk ≤65 1.1%
Class II, low risk 65-85 3.1%
Class III, intermediate risk 86-105 6.5%
Class IV, high risk 106-125 10.4%
Class V, very high risk >125 24.5%

Summary of PE Clinical Probability based on Clinical Prediction Rules

Clinical Prediction Rules Clinical Probability of PE
Low (%) Moderate (%) High (%)
Empirical[12] ~10 ~33 ~66
Extended Wells Score[21][9][7] 4 20 68
Simplified Wells Score[21][8][22] 15 29 59
Original Geneva Score[12] 10 38 81
Revised Geneva Score[15] 8 28 74

Based on pooled study data. Adapted from Recommendations of The PIOPED II Investigators.[23]

2008 Guidelines on the Diagnosis and Management of Acute Pulmonary Embolism- The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)(DO NOT EDIT)[24]

The clinical predictive scores of PE are important in the interpretation of the different diagnostic modalities used to diagnose the disease. The combination of the pre-test probability and the tests results helps in the inclusion/exclusion of PE.

Exclusion Criteria for PE

Diagnostic Criteria Clinical Probability of PE
Low Intermediate High
Normal pulmonary angiogram + + +
D-dimer: Negative result, highly sensitive assay + + -
D-dimer: Negative result, moderately sensitive assay + - -
V/Q Scan: Normal lung scan + + +
V/Q Scan: Non-diagnostic lung scana + - -
V/Q Scan: Non-diagnostic lung scana and negative proximal compression venous ultrasonography + + ±
Chest CT: Normal single-detector CT and negative proximal compression venous ultrasonography + + ±
Chest CT: Normal multi-detector CT alone + + ±

Confirmation of PE

Diagnostic Criteria Clinical Probability of PE
Low Intermediate High
Pulmonary angiogram showing PE + + +
High-probability V/Q Scan ± + +
Compression venous ultrasonography showing proximal DVT + + +
Chest CT: Single or multi-detector helical CT showing PE (at least segmental) ± + +
Chest CT: Single or multi-detector helical CT showing sub-segmental PE ± ± ±

alow or intermediate probability lung scan according to the PIOPED classification

+ Valid Criteria: No further testing required.
- Invalid Criteria: Further testing necessary.
+ Controversial Criteria: Further testing to be considered.

Adapted from 2008 ESC guidelines on the diagnosis and management of acute pulmonary embolism.

References

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