Article

Prediction of pulmonary embolism in the emergency department: The revised Geneva score

Brest University Hospital, Brest, France.
Annals of internal medicine (Impact Factor: 16.1). 02/2006; 144(3):165-71.
Source: PubMed

ABSTRACT Diagnosis of pulmonary embolism requires clinical probability assessment. Implicit assessment is accurate but is not standardized, and current prediction rules have shortcomings.
To construct a simple score based entirely on clinical variables and independent from physicians' implicit judgment.
Derivation and external validation of the score in 2 independent management studies on pulmonary embolism diagnosis.
Emergency departments of 3 university hospitals in Europe.
Consecutive patients admitted for clinically suspected pulmonary embolism.
Collected data included demographic characteristics, risk factors, and clinical signs and symptoms suggestive of venous thromboembolism. The variables statistically significantly associated with pulmonary embolism in univariate analysis were included in a multivariate logistic regression model. Points were assigned according to the regression coefficients. The score was then externally validated in an independent cohort.
The score comprised 8 variables (points): age older than 65 years (1 point), previous deep venous thrombosis or pulmonary embolism (3 points), surgery or fracture within 1 month (2 points), active malignant condition (2 points), unilateral lower limb pain (3 points), hemoptysis (2 points), heart rate of 75 to 94 beats/min (3 points) or 95 beats/min or more (5 points), and pain on lower-limb deep venous palpation and unilateral edema (4 points). In the validation set, the prevalence of pulmonary embolism was 8% in the low-probability category (0 to 3 points), 28% in the intermediate-probability category (4 to 10 points), and 74% in the high-probability category (> or =11 points).
Interobserver agreement for the score items was not studied.
The proposed score is entirely standardized and is based on clinical variables. It has sustained internal and external validation and should now be tested for clinical usefulness in an outcome study.

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    • "All extracted charts were reviewed by trained abstractors, and the following patients were excluded from analysis: -Patients with incomplete charts and missing data to calculate PERC score -Patients with D-dimer testing for any other reason than excluding PE (suspicion of dural sinus thrombosis, deep vein thrombosis, septic patients with coagulation screen, etc.) -Patients with a positive PERC score, i.e., any positive answer to the following: age above 49 years, pulse rate above 99 beats per minute, pulse oxymetry less than 95% on room air, history of hemoptysis, exogenous estrogen intake, prior diagnosis of PE or deep vein thrombosis, recent surgery or trauma in the last 4 weeks, and unilateral leg swelling. -Patients with an intermediate or high pre-test probability using RGS [16] [17] "
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    ABSTRACT: The Pulmonary Embolism Rule-out Criteria (PERC) score has shown excellent negative predictive value; however, its use in the European population with high prevalence of PE is controversial. In Europe, PERC is not part of routine practice. For low-risk patients, guidelines recommend D-dimer testing, followed if positive by imaging study. We aimed to study the rate of diagnosis of PE after D-dimer testing in PERC-negative patients that could have been discharged if PERC was applied. This was a multicenter retrospective study in Paris, France. We included all patients with a suspicion of PE who had D-dimer testing in the emergency department, low pre-test probability, and a negative PERC score (that was retrospectively calculated). Patients with insufficient record to calculate PERC score were excluded. The primary end point was the rate of PE diagnosis before discharge in this population. Secondary end points included rate of invasive imaging studies and subsequent adverse events. We screened 4301 patients who had D-dimer testing, 1070 of whom were PERC negative and could be analyzed. The mean age was 35 years and 46% were men. D-dimer was positive (>500 ng/L) in 167 (16%) of them; CTPA or V/Q scan was performed in 153 (14%) cases. PE was confirmed in 5 cases (total rate 0.5%, 95% confidence interval 0.1%-1.1%). Fifteen patients (1%) experienced non-severe adverse events. D-dimer testing in PERC-negative patients led to a diagnosis of PE in 0.5% of them, with 15% of patients undergoing unnecessary irradiative imaging studies.
    The American journal of emergency medicine 03/2014; 32(6). DOI:10.1016/j.ajem.2014.03.008 · 1.15 Impact Factor
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    • "allergy to iodine contrast agents, creatinine clearance of less than 30 ml/minute, or pregnancy ), previous documented diagnosis of PE on presentation, terminal illness with expected survival of less than three months and ongoing anticoagulant therapy on presentation. The patients' clinical probability of PE was initially assessed using the RGS [12] (Table 1), followed by the PE diagnostic work-up, detailed elsewhere [13] (see appendix for diagnostic algorithm). The patients analyzed were those with confirmed PE and where 3-month status was known (death or readmission). "
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    ABSTRACT: BACKGROUND: Assessment of pre-test probability of pulmonary embolism (PE) and prognostic stratification are two widely recommended steps in the management of patients with suspected PE. Some items of the Geneva prediction rule may have a prognostic value. We analyzed whether the initial probability assessed by the Geneva rule was associated with the outcome of patients with PE. METHODS: In a post-hoc analysis of a multicenter trial including 1,693 patients with suspected PE, the all-cause death or readmission rates during the 3-month follow-up of patients with confirmed PE were analyzed. PE probability group was prospectively assessed by the revised Geneva score (RGS). Similar analyses were made with the a posteriori-calculated simplified Geneva score (SGS). RESULTS: PE was confirmed in 357 patients and 21 (5.9%) died during the 3-month follow-up. The mortality rate differed significantly with the initial RGS group, as with the SGS group. For the RGS, the mortality increased from 0% (95% Confidence Interval: [0-5.4%]) in the low-probability group to 14.3% (95% CI: [6.3-28.2%]) in the high-probability group, and for the SGS, from 0% (95% CI: [0-5.4%] to 17.9% (95% CI: [7.4-36%]). Readmission occurred in 58 out of the 352 patients with complete information on readmission (16.5%). No significant change of readmission rate was found among the RGS or SGS groups. CONCLUSIONS: Returning to the initial PE probability evaluation may help clinicians predict 3-month mortality in patients with confirmed PE. (ClinicalTrials.gov: NCT00117169).
    Thrombosis Research 05/2013; 132(1). DOI:10.1016/j.thromres.2013.05.001 · 2.43 Impact Factor
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    • "Les scores de probabilité clinique de MTE sont inapplicables chez les parturientes, celles-ci ayant e ´ té exclues des e ´ tudes [32] [33]. E ´ voquer le diagnostic conduit donc trè s souvent a ` engager une dé marche d'exploration paraclinique. "
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    ABSTRACT: Objective Pulmonary embolism remains a leading cause of maternal death in France and in other developed countries. Prevention is well codified, but management remains complex both for diagnosis and therapeutics. The objective of this review was to update the knowledge on diagnosis and treatment of pulmonary embolism during pregnancy.Article typeReview.Data sourceMedline® database looking for articles published in English or French between 1965 and 2012, using pulmonary embolism, pregnancy, heparin, thrombolysis and vena cava filter as keywords. Editorials, original articles, reviews and cases reports were selected.Data synthesisPulmonary embolism is one of the leading causes of maternal death in France. Clinical signs and biologic tests are not specific during pregnancy. Doppler ultrasound is helpful for diagnosis and avoids maternal and fetal radiation. Treatment is based on full anticoagulation. Low molecular weight heparin is the treatment of choice. A temporary vena cava filter may be proposed, especially at the end of pregnancy, or when heparin is contraindicated. In case of pulmonary embolism with cardiogenic shock, thrombolysis is an alternative treatment.Conclusion Diagnostic approach is first based on the use of ultrasound- Doppler, and frequently on-to computed tomographic pulmonary angiography or ventilation–perfusion lung scanning. The treatment is based on low molecular weight heparin. Others therapeutics, such as thrombolysis or temporary vena cava filter, may be useful in certain circumstances.
    Annales francaises d'anesthesie et de reanimation 04/2013; 32(4):257–266. DOI:10.1016/j.annfar.2013.01.024 · 0.84 Impact Factor
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