Renée A. Douma, MD; Inge C.M. Mos, MD; Petra M.G. Erkens, MSc; Tessa A.C. Nizet, MD; Marc F. Durian, MD; Marcel M. Hovens, MD; Anja A. van Houten, MD; Herman M.A. Hofstee, MD; Frederikus A. Klok, MD; Hugo ten Cate, MD; Erik F. Ullmann, MD; Harry R. Büller, MD; Pieter W. Kamphuisen, MD; Menno V. Huisman, MD; for the Prometheus Study Group
Douma RA, Mos IC, Erkens PM, Nizet TA, Durian MF, Hovens MM, et al. Performance of 4 Clinical Decision Rules in the Diagnostic Management of Acute Pulmonary Embolism: A Prospective Cohort Study. Ann Intern Med. 2011;154:709-718. doi: 10.7326/0003-4819-154-11-201106070-00002
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Published: Ann Intern Med. 2011;154(11):709-718.
Several clinical decision rules (CDRs) are available to exclude acute pulmonary embolism (PE), but they have not been directly compared.
To directly compare the performance of 4 CDRs (Wells rule, revised Geneva score, simplified Wells rule, and simplified revised Geneva score) in combination with d-dimer testing to exclude PE.
Prospective cohort study.
7 hospitals in the Netherlands.
807 consecutive patients with suspected acute PE.
The clinical probability of PE was assessed by using a computer program that calculated all CDRs and indicated the next diagnostic step. Results of the CDRs and d-dimer tests guided clinical care.
Results of the CDRs were compared with the prevalence of PE identified by computed tomography or venous thromboembolism at 3-month follow-up.
Prevalence of PE was 23%. The proportion of patients categorized as PE-unlikely ranged from 62% (simplified Wells rule) to 72% (Wells rule). Combined with a normal d-dimer result, the CDRs excluded PE in 22% to 24% of patients. The total failure rates of the CDR and d-dimer combinations were similar (1 failure, 0.5% to 0.6% [upper-limit 95% CI, 2.9% to 3.1%]). Even though 30% of patients had discordant CDR outcomes, PE was not detected in any patient with discordant CDRs and a normal d-dimer result.
Management was based on a combination of decision rules and d-dimer testing rather than only 1 CDR combined with d-dimer testing.
All 4 CDRs show similar performance for exclusion of acute PE in combination with a normal d-dimer result. This prospective validation indicates that the simplified scores may be used in clinical practice.
Academic Medical Center, VU University Medical Center, Rijnstate Hospital, Leiden University Medical Center, Maastricht University Medical Center, Erasmus Medical Center, and Maasstad Hospital.
Several clinical decision rules (CDRs) are available to evaluate patients with possible pulmonary embolism (PE). It is not known which CDR, if any, is best to use.
In this multicenter, prospective study, 4 CDRs were used to determine whether PE was likely or unlikely, combined with the results of d-dimer testing, and did equally well at excluding PE or indicating the need for further testing. The CDRs were the Wells rule, the revised Geneva score, the simplified Wells rule, and the simplified revised Geneva score.
Provided that these 4 CDRs are used correctly, clinicians can confidently choose them according to personal or institutional preferences to assist in the evaluation of possible PE.
CDR = clinical decision rule; CT = computed tomography; PE = pulmonary embolism; VTE = venous thromboembolism.
CT = computed tomography; DVT = deep venous thrombosis; LMWH = low-molecular-weight heparin; PE = pulmonary embolism; V̇/Q̇= ventilation–perfusion; VTE = venous thromboembolism.
* Some of the 195 patients met more than 1 exclusion criterion.
† In 7 patients, CT was done although it was not indicated; CT confirmed the diagnosis of PE in 1 patient. “Received treatment” or “did not receive treatment” refers to treatment with anticoagulant drugs.
‡ Ten patients in whom PE was excluded by CT received anticoagulant treatment for reasons other than VTE.
Appendix Table 1.
Appendix Table 2.
Area under the receiver-operating characteristic curves were 0.73 (95% CI, 0.69 to 0.77) for the Wells rule, 0.72 (CI, 0.68 to 0.76) for the simplified Wells rule, 0.70 (CI 0.65 to 0.74) for the revised Geneva score, and 0.69 (CI, 0.65 to 0.74) for the simplified revised Geneva score.
Appendix Table 3.
Appendix Table 4.
The area under the receiving-operating characteristic curve was similar when 4 different RGS cutoff levels were applied: 0.67 (95% CI, 0.59 to 0.75) for a cutoff ≤4, 0.66 (CI, 0.58 to 0.75) for a cutoff ≤5, 0.65 (CI, 0.56 to 0.74) for a cutoff ≤6, and 0.65 (CI, 0.56 to 0.75) for a cutoff ≤7. RGS = revised Geneva score.
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Emergency Medicine, Hospital Medicine, Pulmonary/Critical Care, Venous Thromboembolism, Pulmonary Embolism.
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