We found a match
Your institution may have rights to this item. Sign in to continue.
- Title
Performance of 4 clinical decision rules in the diagnostic management of acute pulmonary embolism: a prospective cohort study.
- Authors
Douma RA; Mos IC; Erkens PM; Nizet TA; Durian MF; Hovens MM; van Houten AA; Hofstee HM; Klok FA; ten Cate H; Ullmann EF; Büller HR; Kamphuisen PW; Huisman MV; Prometheus Study Group; Douma, Renée A; Mos, Inge C M; Erkens, Petra M G; Nizet, Tessa A C; Durian, Marc F
- Abstract
<bold>Background: </bold>Several clinical decision rules (CDRs) are available to exclude acute pulmonary embolism (PE), but they have not been directly compared. <bold>Objective: </bold>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. <bold>Design: </bold>Prospective cohort study. <bold>Setting: </bold>7 hospitals in the Netherlands. <bold>Patients: </bold>807 consecutive patients with suspected acute PE. <bold>Intervention: </bold>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. <bold>Measurements: </bold>Results of the CDRs were compared with the prevalence of PE identified by computed tomography or venous thromboembolism at 3-month follow-up. <bold>Results: </bold>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. <bold>Limitation: </bold>Management was based on a combination of decision rules and d-dimer testing rather than only 1 CDR combined with d-dimer testing. <bold>Conclusion: </bold>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. <bold>Primary Funding Source: </bold>Academic Medical Center, VU University Medical Center, Rijnstate Hospital, Leiden University Medical Center, Maastricht University Medical Center, Erasmus Medical Center, and Maasstad Hospital.
- Publication
Annals of Internal Medicine, 2011, Vol 154, Issue 11, p709
- ISSN
0003-4819
- Publication type
journal article
- DOI
10.7326/0003-4819-154-11-201106070-00002