Grégoire Le Gal, MD; Marc Righini, MD; Pierre-Marie Roy, MD; Olivier Sanchez, MD; Drahomir Aujesky, MD, MSc; Henri Bounameaux, MD; Arnaud Perrier, MD
Grant Support: By the Hirsch Fund of the University of Geneva, the Swiss National Research Foundation (grant 32-61773.00), the Royal College of Physicians and Surgeons of Canada (grants 97/4-T10 and 00/4-T9), La Fondation Québécoise pour le Progrès de la Médecine Interne and Les Internistes et Rhumatologues Associés de l'Hôpital du Sacré-Cœur, and the Direction of Clinical Research of the Angers University Hospital (grant 2001/021).
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Grégoire Le Gal, MD, EA 3878, Département de Médecine Interne et Pneumologie, CHU de la Cavale Blanche, 29609 Brest Cedex, France; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Le Gal: EA 3878, Département de Médecine Interne et Pneumologie, CHU de la Cavale Blanche, 29609 Brest Cedex, France.
Drs. Righini, Bounameaux, and Perrier: Geneva University Hospital, Rue Micheli du Crest 24, 1211 Geneva, Switzerland.
Dr. Roy: Emergency Service, CHU, 4 Rue Larrey, 49033 Angers, France.
Dr. Sanchez: Service of Pneumology, Hôpital Européen Georges-Pompidou, 20 Rue Leblanc, 75015 Paris, France.
Dr. Aujesky: Centre Hospitalier Universitaire Vaudois, Rue du Bugnon 46, 1011 Lausanne, Switzerland.
Author Contributions: Conception and design: G. Le Gal, M. Righini, H. Bounameaux, A. Perrier.
Analysis and interpretation of the data: G. Le Gal, M. Righini, A. Perrier.
Drafting of the article: G. Le Gal, A. Perrier.
Critical revision of the article for important intellectual content: M. Righini, D. Aujesky, H. Bounameaux.
Final approval of the article: G. Le Gal, M. Righini, P.-M. Roy, O. Sanchez, D. Aujesky, H. Bounameaux, A. Perrier.
Provision of study materials or patients: M. Righini, P.-M. Roy, O. Sanchez, D. Aujesky.
Statistical expertise: G. Le Gal.
Obtaining of funding: H. Bounameaux.
Administrative, technical, or logistic support: O. Sanchez, H. Bounameaux.
Collection and assembly of data: P.-M. Roy, O. Sanchez.
Le Gal G., Righini M., Roy P., Sanchez O., Aujesky D., Bounameaux H., Perrier A.; Prediction of Pulmonary Embolism in the Emergency Department: The Revised Geneva Score. Ann Intern Med. 2006;144:165-171. doi: 10.7326/0003-4819-144-3-200602070-00004
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Published: Ann Intern Med. 2006;144(3):165-171.
In recent years, clinical probability assessment into 3 categories has become an important component of strategies for optimal diagnosis of pulmonary embolism (1-7) using noninvasive tests (3, 6). For instance, highly sensitive d-dimer assays safely rule out pulmonary embolism in patients with a low or intermediate clinical probability (7, 8), while less sensitive assays have been validated only in low-probability patients in outcome studies (1, 9). Clinical assessment has been shown to be useful for reducing the requirement for invasive tests in outcome studies (1, 2, 7, 8) and to be cost-effective (10).
Nord Deux SÃ¨vres Hospital, France
October 17, 2006
Pulmonary Embolism : which problem ?
The work of Le Gal et al is very interesting. There is now a half dozen tools of assistance to the diagnosis of pulmonary embolism (PE). However, mortality by PE is the same in spite of these tools, the powerful complementary examinations and the development of thromboembolic disease prevention. In France, the incidence of PE is between 60 and 111 per 100,000 and PE cause more than 3,500 deaths annually . The autopsic studies show that the prevalence of the PE among in-patients is the same since three decades, and that the diagnosis of EP is evoked only among approximately 7 patients out of 10 . The principal causes of error of diagnostic are its protean clinical presentations and failure to suspect PE . In spite of therapeutic and diagnostic progress, the autopsic studies show an increase of none diagnosed fatal PE . In this study, only 16 percent of the PE had been diagnosed ante mortem. In addition, the weak rate of scientific autopsies involves underestimate of the false negative whatever the pathology, and thus overestimates the diagnostic performances . Clinical research on PE should concentrate on methods of detection of the disease. The autopsic studies show that the majority of the fatal PE did not have evocative clinical signs, but have favorable factors of comorbidity : older, active cancers, acute medical episode in the previous weeks, congestive heart disease... If we want to have an impact on the mortality of the disease, we must find means to suspect PE even in the absence of evocative clinical signs. A clinical score could be useful for this tracking while being based on epidemiologic data like the age and the medico-surgical history of the patients.
1. BÃ©nard E, Lafuma A, Ravaud P. Epidemiology of venous thromboembolic disease. Presse Med 2005;34: 415-19
2. Stein PD, Henry JW. Prevalence of acute pulmonary embolism among patients in a general hospital at autopsy. Chest 1995:108;978-81
3. Morpurgo M, Schmid C. The spectrum of pulmonary embolism. Clinicopathologic correlations. Chest 1995;107;18-20
4. Karwinski B, Svendsen E. Comparison of clinical and postmortem diagnosis of pulmonary embolism. J Clin Pathol 1989;42:135-139
5. Shojania KG, Burton EC, McDonald KM, Goldman L. Overestimation of clinical diagnostic performance caused by low necropsy rates. Qual Saf Health Care. 2005 Dec;14(6):408-13
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Emergency Medicine, Pulmonary/Critical Care, Venous Thromboembolism, Pulmonary Embolism.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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