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Pulmonary Embolism Clinical Scoring Systems

  • Author: Kamran Boka, MD, MS; Chief Editor: Ryland P Byrd, Jr, MD  more...
 
Updated: Oct 09, 2015
 

Overview

Evidence-based literature supports the practice of determining the clinical pretest probability of pulmonary embolism before proceeding with diagnostic testing.[1] A clinical practice guideline, Current Diagnosis of Venous Thromboembolism in Primary Care, from the American Academy of Family Physicians (AAFP) and the American College of Physicians (ACP), recommends that validated clinical prediction rules be used to estimate pretest probability of pulmonary embolism and to interpret test results.[2, 3] Clinical scoring algorithms are less objective and less powerful than some authors would claim.

Below are 2 validated systems: the Modified Wells Scoring System and the Revised Geneva Scoring System. Simplified versions of the Wells score and the revised Geneva score have been developed. Initial studies support the validity of these scores. Points are assigned to each of the criteria.[4, 5]

In 2015, pulmonary embolism guidelines were released by the American College of Physicians and are summarized as follows:[6, 7]

  • Plasma D-dimer tests are more appropriate for those at intermediate risk for a pulmonary embolism, and no testing may be necessary for some patients at low risk.
  • Use either the Wells or Geneva rules to choose tests based on a patient's risk for pulmonary embolism.
  • If the patient is at low risk, clinicians should use the 8  Pulmonary Embolism Rule-Out Criteria (PERC); if a patient meets all 8 criteria, the risks of testing are greater than the risk for embolism, and no testing is needed.
  • For patients at intermediate risk, or for those at low risk who do not meet all of the rule-out criteria, use a high-sensitivity plasma D-dimer test as the initial test.
  • In patients older than 50 years, use an age-adjusted threshold (age × 10 ng/mL, rather than a blanket 500 ng/mL), because normal D-dimer levels increase with age.
  • Patients with a D-dimer level below the age-adjusted cutoff should not receive any imaging studies.
  • Patients with elevated D-dimer levels should then receive imaging.
  • Patients at high risk should skip the D-dimer test and proceed to CT pulmonary angiography, because a negative D-dimer test will not eliminate the need for imaging in these patients.
  • Clinicians should only obtain ventilation-perfusion scans in patients with a contraindication to CT pulmonary angiography or if CT pulmonary angiography is unavailable.
  • Clinicians should use validated clinical prediction rules to estimate pretest probability in patients in whom acute PE is being considered.

To see complete information on pulmonary embolism, please see Medscape Reference article Pulmonary Embolism.

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Modified Wells Scoring System

The AAFP/ACP guideline advocates use of the Modified Wells prediction rule for the above-specified estimation and interpretation requirements (see Table 1, below). However, the guideline notes that the Wells rule performs better in younger patients without comorbidities or a history of venous thromboembolism. Current evidence also suggests this tool is effective in pregnant patients.[8]

Moreover, the objective components of the Wells (Canadian Pulmonary Embolism Score) criteria have been shown to have little effect on the stratification power of the criteria; virtually all of the classification power is associated with a physician's subjective prejudgment of the likelihood of pulmonary embolism.

Table 1. Modified Wells Prediction Rule for Diagnosing Pulmonary Embolism: Clinical Evaluation Table for Predicting Pretest Probability of Pulmonary Embolism* (Open Table in a new window)

Clinical CharacteristicScore
Previous pulmonary embolism or deep vein thrombosis+ 1.5
Heart rate >100 beats per minute+ 1.5
Recent surgery or immobilization (within the last 30 d)+ 1.5
Clinical signs of deep vein thrombosis+ 3
Alternative diagnosis less likely than pulmonary embolism+ 3
Hemoptysis+ 1
Cancer (treated within the last 6 mo)+ 1
Clinical Probability of Pulmonary EmbolismScore
Low0-1
Intermediate2-6
High≥6
*Reprinted from Am J Med, Vol. 113, Chagnon I, Bounameaux H, Aujesky D, et al, Comparison of two clinical prediction rules and implicit assessment among patients with suspected pulmonary embolism, pp 269-75, Copyright 2002.
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Revised Geneva Scoring System

Another validated clinical prediction rule for use in the diagnosis of pulmonary embolism is the revised Geneva score (see Table 2, below).[9] The performance of this scoring system appears equivalent to that of the Wells score[8] ; however, it should be mentioned that emerging evidence suggests the Wells score to be more accurate.[10, 11]

The Geneva criteria, which depend only on objective measures, lead to a stratification with a pulmonary embolism prevalence of 8% in the lowest-risk group (Geneva score of 0)—a prevalence too high to be neglected. Table 2. Revised Geneva Score*

Table. (Open Table in a new window)

Risk FactorsPoints
Age older than 65 y1
Previous DVT or pulmonary embolism3
Surgery (under general anesthesia) or fracture (of the lower limbs) within 1 mo2
Active malignant condition (solid or hematologic, currently active or considered cured < 1 y)2
Symptoms 
Unilateral lower limb pain3
Hemoptysis2
Clinical Signs 
Heart rate 75-94 beats/min3
Heart rate ≥95 beats/min5
Pain on lower limb deep venous palpation and unilateral edema4
Clinical ProbabilityScore
Low0-3 total
Intermediate4-10 total
High≥11 total
*Adapted from Prediction of pulmonary embolism in the emergency department: the revised Geneva score. Le Gal G, Righini M, Roy PM, Sanchez O, Aujesky D, Bounameaux H, Perrier A. Ann Intern Med. 2006 Feb 7;144(3):165-71.

To see complete information on pulmonary embolism, please see Medscape Reference article Pulmonary Embolism.

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Simplified Revised Geneva Score

In 2008, the Revised Geneva Score was hypothesized to lead to potential miscalculations in the acute setting. Since the variables have different weights, researchers sought to simplify the Revised Geneva Score with equally weighted parameters. Although they were successful in its validation as a clinical decision tool, the study held limitations as a retrospective study, with lack of D-dimer results in all their patients.[5] This simplified score should be confirmed in a prospective study prior to its widespread clinical adoption and use.[12]

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Gestalt

Until now, little evidence-based literature exists analyzing a physician’s approach to a patient with suspected pulmonary embolism. Clinical scoring systems, such as the Wells and the revised Geneva score, have outlined the “what to look for” in medical decision-making, but not the “how to look for.” Emerging evidence worthy of mention illustrates that a physician Gestalt may perform better than sole reliance on clinical scoring systems.[13]

This new body of research illustrates the German concept of Gestalt theory, a philosophical and psychiatric principle in which the process is taken into consideration versus the content—in other words, the whole is not the sum of its parts, but greater than the sum of its parts. A physician’s clinical judgment should not be replaced by clinical scoring systems, but should instead be used in conjunction with evidence-based validated systems when deciding the most likely diagnosis for a patient.

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Contributor Information and Disclosures
Author

Kamran Boka, MD, MS Faculty, Division of Critical Care, Department of Internal Medicine, The University of Texas Health Science Center at Houston (UTHealth)

Kamran Boka, MD, MS is a member of the following medical societies: American College of Physicians, American Thoracic Society

Disclosure: Creator of Boka's Notes Internal Medicine Series Apps for: Vagal Thoughts, LLC.

Coauthor(s)

Daniel R Ouellette, MD, FCCP Associate Professor of Medicine, Wayne State University School of Medicine; Chair of the Clinical Competency Committee, Pulmonary and Critical Care Fellowship Program, Senior Staff and Attending Physician, Division of Pulmonary and Critical Care Medicine, Henry Ford Health System; Chair, Guideline Oversight Committee, American College of Chest Physicians

Daniel R Ouellette, MD, FCCP is a member of the following medical societies: American College of Chest Physicians, Society of Critical Care Medicine, American Thoracic Society

Disclosure: Nothing to disclose.

Nader Kamangar, MD, FACP, FCCP, FCCM Professor of Clinical Medicine, University of California, Los Angeles, David Geffen School of Medicine; Chief, Division of Pulmonary and Critical Care Medicine, Vice-Chair, Department of Medicine, Olive View-UCLA Medical Center

Nader Kamangar, MD, FACP, FCCP, FCCM is a member of the following medical societies: Academy of Persian Physicians, American Academy of Sleep Medicine, American Association for Bronchology and Interventional Pulmonology, American College of Chest Physicians, American College of Critical Care Medicine, American College of Physicians, American Lung Association, American Medical Association, American Thoracic Society, Association of Pulmonary and Critical Care Medicine Program Directors, Association of Specialty Professors, California Sleep Society, California Thoracic Society, Clerkship Directors in Internal Medicine, Society of Critical Care Medicine, Trudeau Society of Los Angeles, World Association for Bronchology and Interventional Pulmonology

Disclosure: Nothing to disclose.

Annie Harrington, MD Fellow in Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center

Annie Harrington, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Chest Physicians

Disclosure: Nothing to disclose.

Chief Editor

Ryland P Byrd, Jr, MD Professor of Medicine, Division of Pulmonary Disease and Critical Care Medicine, James H Quillen College of Medicine, East Tennessee State University

Ryland P Byrd, Jr, MD is a member of the following medical societies: American College of Chest Physicians, American Thoracic Society

Disclosure: Nothing to disclose.

Acknowledgements

Mark S McDonnell, MD, MBA Fellow, Department of Cardiology, Keck School of Medicine of the University of Southern California

Disclosure: Nothing to disclose.

Sat Sharma, MD, FRCPC Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St Boniface General Hospital

Sat Sharma, MD, FRCPC is a member of the following medical societies: American Academy of Sleep Medicine, American College of Chest Physicians, American College of Physicians-American Society of Internal Medicine, American Thoracic Society, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, Royal Society of Medicine, Society of Critical Care Medicine, and World Medical Association

Disclosure: Nothing to disclose.

Gregory Tino, MD Director of Pulmonary Outpatient Practices, Associate Professor, Department of Medicine, Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania Medical Center and Hospital

Gregory Tino, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and American Thoracic Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References
  1. Tapson VF. Acute pulmonary embolism. N Engl J Med. 2008 Mar 6. 358(10):1037-52. [Medline].

  2. [Guideline] Qaseem A, Snow V, Barry P, Hornbake ER, Rodnick JE, Tobolic T, et al. Current diagnosis of venous thromboembolism in primary care: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians. Ann Fam Med. 2007 Jan-Feb. 5(1):57-62. [Medline]. [Full Text].

  3. [Guideline] Qaseem A, Snow V, Barry P, Hornbake ER, Rodnick JE, Tobolic T, et al. Current diagnosis of venous thromboembolism in primary care: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians. Ann Intern Med. 2007 Mar 20. 146(6):454-8. [Medline].

  4. Douma RA, Gibson NS, Gerdes VE, Büller HR, Wells PS, Perrier A, et al. Validity and clinical utility of the simplified Wells rule for assessing clinical probability for the exclusion of pulmonary embolism. Thromb Haemost. 2009 Jan. 101(1):197-200. [Medline].

  5. Klok FA, Mos IC, Nijkeuter M, Righini M, Perrier A, Le Gal G, et al. Simplification of the revised Geneva score for assessing clinical probability of pulmonary embolism. Arch Intern Med. 2008 Oct 27. 168(19):2131-6. [Medline].

  6. Skwarecki B. Pulmonary embolism guidelines released by ACP. Medscape Medical News. WebMD Inc. Sept 28, 2015. Available at http://www.medscape.com/viewarticle/851745.

  7. Raja AS, Greenberg JO, Qaseem A, Denberg TD, Fitterman N, Schuur JD. Evaluation of Patients With Suspected Acute Pulmonary Embolism: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. 2015 Sep 29. [Medline].

  8. O'Connor C, Moriarty J, Walsh J, Murray J, Coulter-Smith S, Boyd W. The application of a clinical risk stratification score may reduce unnecessary investigations for pulmonary embolism in pregnancy. J Matern Fetal Neonatal Med. 2011 Dec. 24(12):1461-4. [Medline].

  9. Klok FA, Kruisman E, Spaan J, Nijkeuter M, Righini M, Aujesky D, et al. Comparison of the revised Geneva score with the Wells rule for assessing clinical probability of pulmonary embolism. J Thromb Haemost. 2008 Jan. 6(1):40-4. [Medline].

  10. Penaloza A, Melot C, Motte S. Comparison of the Wells score with the simplified revised Geneva score for assessing pretest probability of pulmonary embolism. Thromb Res. 2011 Feb. 127(2):81-4. [Medline].

  11. Wong DD, Ramaseshan G, Mendelson RM. Comparison of the Wells and Revised Geneva Scores for the diagnosis of pulmonary embolism: an Australian experience. Intern Med J. 2011 Mar. 41(3):258-63. [Medline].

  12. Le Gal G, Righini M, Roy PM, et al. Prediction of pulmonary embolism in the emergency department: the revised Geneva score. Ann Intern Med. 2006 Feb 7. 144(3):165-71. [Medline].

  13. Penaloza A, Verschuren F, Meyer G, Quentin-Georget S, Soulie C, Thys F, et al. Comparison of the Unstructured Clinician Gestalt, the Wells Score, and the Revised Geneva Score to Estimate Pretest Probability for Suspected Pulmonary Embolism. Ann Emerg Med. 2013 Feb 20. [Medline].

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Table 1. Modified Wells Prediction Rule for Diagnosing Pulmonary Embolism: Clinical Evaluation Table for Predicting Pretest Probability of Pulmonary Embolism*
Clinical CharacteristicScore
Previous pulmonary embolism or deep vein thrombosis+ 1.5
Heart rate >100 beats per minute+ 1.5
Recent surgery or immobilization (within the last 30 d)+ 1.5
Clinical signs of deep vein thrombosis+ 3
Alternative diagnosis less likely than pulmonary embolism+ 3
Hemoptysis+ 1
Cancer (treated within the last 6 mo)+ 1
Clinical Probability of Pulmonary EmbolismScore
Low0-1
Intermediate2-6
High≥6
*Reprinted from Am J Med, Vol. 113, Chagnon I, Bounameaux H, Aujesky D, et al, Comparison of two clinical prediction rules and implicit assessment among patients with suspected pulmonary embolism, pp 269-75, Copyright 2002.
Table.
Risk FactorsPoints
Age older than 65 y1
Previous DVT or pulmonary embolism3
Surgery (under general anesthesia) or fracture (of the lower limbs) within 1 mo2
Active malignant condition (solid or hematologic, currently active or considered cured < 1 y)2
Symptoms 
Unilateral lower limb pain3
Hemoptysis2
Clinical Signs 
Heart rate 75-94 beats/min3
Heart rate ≥95 beats/min5
Pain on lower limb deep venous palpation and unilateral edema4
Clinical ProbabilityScore
Low0-3 total
Intermediate4-10 total
High≥11 total
*Adapted from Prediction of pulmonary embolism in the emergency department: the revised Geneva score. Le Gal G, Righini M, Roy PM, Sanchez O, Aujesky D, Bounameaux H, Perrier A. Ann Intern Med. 2006 Feb 7;144(3):165-71.
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