Pulmonary Embolism Clinical Scoring Systems

Updated: Dec 30, 2020

Author: Kamran Boka, MD, MS; Chief Editor: Guy W Soo Hoo, MD, MPH

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 three validated systems: the Modified Wells Scoring System, the Revised Geneva Scoring System, and the Pulmonary Embolism Rule Out Criteria (PERC).[4, 5, 6] 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.

In 2015, pulmonary embolism guidelines were released by the American College of Physicians and are summarized as follows[7, 8] :

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 eight PERC; if a patient does not meet all eight 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.

See the image below.

Pulmonary embolus.

To see complete information on pulmonary embolism, please see the Medscape Drugs & Diseases article Pulmonary Embolism.

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.[9]

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 Characteristic	Score
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 Embolism	Score
Low	0-1
Intermediate	2-6
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.

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).[10] The performance of this scoring system appears equivalent to that of the Wells score[9] ; however, it should be mentioned that emerging evidence suggests the Wells score to be more accurate.[11, 12]

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 2. (Open Table in a new window)

Risk Factors	Points
Age older than 65 y	1
Previous DVT or pulmonary embolism	3
Surgery (under general anesthesia) or fracture (of the lower limbs) within 1 mo	2
Active malignant condition (solid or hematologic, currently active or considered cured < 1 y)	2
Symptoms
Unilateral lower limb pain	3
Hemoptysis	2
Clinical Signs
Heart rate 75-94 beats/min	3
Heart rate ≥95 beats/min	5
Pain on lower limb deep venous palpation and unilateral edema	4
Clinical Probability	Score
Low	0-3 total
Intermediate	4-10 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 the Medscape Drugs & Diseases article Pulmonary Embolism.

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.[13]

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.[14]

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.

It should be noted that clinical Gestalt requires clinical experience and therefore is highly variable between providers. For example, the results of a decision comparing clinical Gestalt between a new intern and a seasoned clinician with a decade of experience is not expected to be the same when compared with a validated scoring system.

PERC Rule

In 2004, Kline conducted a prospective study looking at eight variables (see below) to rule out pulmonary embolism when clinical Gestalt was low in the patient with low pretest probability for having pulmonary embolism.[6] The rule-out test (with poor specificity of 27% in low-risk patients and 15% in very-low-risk patients) was validated in two studies.[15]

Pulmonary Embolism Rule out Criteria (PERC) are as follows:

Age greater than or equal to 50 years
Heart rate greater than or equal to 100 beats per minute
Arterial oxygen saturation (SaO2) on room air less than 95%
Venous thromboembolism
Recent (< 28 days) trauma or surgery
Unilateral leg swelling
Hemoptysis
Oral hormone use

Pulmonary embolism workup can be ruled out if (1) none of the above eight variables is positive and (2) there is a less than 15% (very low) pretest probability that the patient has a pulmonary embolism. A PERC evaluation is considered positive if any one of the eight criteria are met.

Questions & Answers

Overview

What are the pulmonary embolism clinical scoring systems?

What are the ACP guidelines for pulmonary embolism clinical scoring?

What is the Modified Wells clinical scoring system for pulmonary embolism?

What is the revised Geneva clinical scoring system for pulmonary embolism?

What is the simplified revised Geneva clinical scoring system for pulmonary embolism?

What is the Gestalt clinical scoring system for pulmonary embolism?

What are the Pulmonary Embolism Rule out Criteria (PERC)?

Author

Kamran Boka, MD, MS Attending Physician in Pulmonary and Critical Care Medicine, StatCare

Kamran Boka, MD, MS is a member of the following medical societies: American College of Critical Care Medicine, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Daniel R Ouellette, MD, FCCP Associate Professor of Medicine, Wayne State University School of Medicine; Medical Director, Pulmonary Medicine General Practice Unit (F2), Senior Staff and Attending Physician, Division of Pulmonary and Critical Care Medicine, Henry Ford Hospital

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

Disclosure: Received research grant from: Sanofi Pharmaceutical.

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.

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.

Chief Editor

Guy W Soo Hoo, MD, MPH Professor of Clinical Medicine, University of California, Los Angeles, David Geffen School of Medicine; Director, Medical Intensive Care Unit, Chief, Pulmonary, Critical Care and Sleep Section, West Los Angeles VA Healthcare Center, Veteran Affairs Greater Los Angeles Healthcare System

Guy W Soo Hoo, MD, MPH is a member of the following medical societies: American Association for Respiratory Care, American College of Chest Physicians, American College of Physicians, American Thoracic Society, California Thoracic Society, Society of Critical Care Medicine

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

Tapson VF. Acute pulmonary embolism. N Engl J Med. 2008 Mar 6. 358(10):1037-52. [QxMD MEDLINE Link].
[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. [QxMD MEDLINE Link]. [Full Text].
[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. [QxMD MEDLINE Link].
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Pulmonary Embolism Clinical Scoring Systems

Overview

Modified Wells Scoring System

Revised Geneva Scoring System

Simplified Revised Geneva Score

Gestalt

PERC Rule

Questions & Answers

Contributor Information and Disclosures

References