Predictive Tools for PE
Research also shows that decision rules incorporating lengthy prediction rules (such as the Wells rule) are seldom used by emergency physicians because of rule complexity, rule credibility, and local culture - Kerstin de Wit MD
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Risk Stratification
Clinical decision rules developed for risk stratification of suspected PE include Wells Criteria for PE as well as the Pulmonary Embolism Rule Out Criteria ( PERC). These rules can help guide diagnostic testing. Well’s uses clinical features to determine low, moderate, or high-risk patients.
In patients who are low risk according to Wells, the PERC criteria may be applied. If a patient is low risk according to Wells and meets all of the PERC criteria, they are considered very low risk for PE and would not benefit from—and may actually be harmed by—further testing. Patients who are moderate risk for PE according to Wells should undergo d-dimer testing. In most patients the threshold…
Resources
Geneva Score (Revised)
Objectifies risk of PE, like Wells’ score. How do you use the Geneva Score (Revised) in your own clinical practice? Pretty much in all patients with a clinical suspicion of PE. I only do the score (and the D-dimer test if the score is non-high) in patients in whom I am ready to order a CTPA should the score be high probability or the D-dimer positive.
Two-level Wells score
DVT likely 2 points or more...
PERC Rule
... aimed at assessing which patients with chest pain or shortness of breath could safely not undergo any testing (not even a D-dimer test).
YEARS Algorithm
Helps rule out pulmonary embolism; also validated in pregnant patients with clinically suspected PE.
Hestia Criteria for Outpatient Pulmonary Embolism Treatment
Identifies low-risk PE patients safe for outpatient treatment. Use in hemodynamically stable patients with acute pulmonary embolism (PE).
PESI (Pulmonary Embolism Severity Index)
Predicts 30-day outcome of patients with pulmonary embolism using 11 clinical criteria.
Wells' Criteria
Objectifies risk of pulmonary embolism. The model should be applied only after a history and physical suggests that venous thromboembolism is a diagnostic possibility. it should not be applied to all patients with chest pain or dyspnea or to all patients with leg pain or swelling.
Comparison of YEARS and Adjust-Unlikely D-dimer Testing for Pulmonary Embolism in the Emergency Department
The “Adjust-Unlikely” rule would modestly reduce imaging and identify all cases of PE. YEARS would substantially reduce imaging but miss 1 in 14 cases of PE.
PERC Rule for Pulmonary Embolism
The PERC (Pulmonary Embolism Rule-out Criteria) Rule is utilized by physicians to avoid further testing for pulmonary embolism in patients deemed to be at low risk.
Pulmonary Embolism Clinical Scoring Systems
Evidence-based literature supports the practice of determining the clinical pretest probability of pulmonary embolism before proceeding with diagnostic testing.
Values of the Wells and Revised Geneva Scores Combined with D-dimer in Diagnosing Elderly Pulmonary Embolism Patients
In conclusion, for elderly cases, the Wells score appeared to be a more accurate rule, with which could reduce the rate of misdiagnosis and avoid unnecessary tests; D-dimer is of greater value in excluding PE when combined with Wells score or revised Geneva score.
Risk Stratification
These risk stratification tools have not been verified in pregnancy and caution should be given to applying them to these patients. Compared with nonpregnant women, the risk of venous thromboembolism increases fivefold during pregnancy and is increased by 60-fold in the first 3 months after delivery.
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