Pulmonary embolism assessment of clinical probability and risk scores: Difference between revisions

	Pulmonary Embolism Microchapters
Home
Patient Information
Overview
Historical Perspective
Classification
Pathophysiology
Causes
Differentiating Pulmonary Embolism from other Diseases
Epidemiology and Demographics
Risk Factors
Triggers
Natural History, Complications and Prognosis
Diagnosis
Diagnostic criteria
Assessment of Clinical Probability and Risk Scores
Pulmonary Embolism Assessment of Probability of Subsequent VTE and Risk Scores
History and Symptoms
Physical Examination
Laboratory Findings
Arterial Blood Gas Analysis
D-dimer
Biomarkers
Electrocardiogram
Chest X Ray
Ventilation/Perfusion Scan
Echocardiography
Compression Ultrasonography
CT
MRI
Treatment
Treatment approach
Medical Therapy
IVC Filter
Pulmonary Embolectomy
Pulmonary Thromboendarterectomy
Discharge Care and Long Term Treatment
Prevention
Cost-Effectiveness of Therapy
Future or Investigational Therapies
Follow-Up
Support group
Special Scenario
Pregnancy
Cancer
Trials
Landmark Trials
Case Studies
Case #1
Pulmonary embolism assessment of clinical probability and risk scores On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Pulmonary embolism assessment of clinical probability and risk scores
CDC on Pulmonary embolism assessment of clinical probability and risk scores
Pulmonary embolism assessment of clinical probability and risk scores in the news
Blogs on Pulmonary embolism assessment of clinical probability and risk scores
Directions to Hospitals Treating Pulmonary embolism assessment of clinical probability and risk scores
Risk calculators and risk factors for Pulmonary embolism assessment of clinical probability and risk scores

VisualWikitext

Latest revision as of 17:52, 12 December 2021

Editor(s)-In-Chief: C. Michael Gibson, M.S., M.D. [1], The APEX Trial Investigators; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Rim Halaby, M.D. [3]

Overview

The diagnosis of pulmonary embolism (PE) is based primarily on the clinical assessment of the pretest probability of PE combined with diagnostic modalities such as spiral CT, V/Q scan, use of the D-dimer, and lower extremity ultrasound. Clinical prediction rules for PE include: the Wells score, the Geneva score and the PE rule-out criteria (PERC).

Assessment of Clinical Probability

A clinical prediction rule is a type of medical research study in which the researchers try to identify the best combination of signs, symptoms, and other findings to predict the probability of a specific disease or outcome.^[1] Clinical prediction rules for PE include: the Wells score, the Geneva score and the PE rule-out criteria. Its noteworthy that the use of any clinical prediction rule is associated with reduction in recurrent thromboembolism.^[2]

These clinical prediction rules, coupled with diagnostic tests, are used to identify patients who should be treated.

Supportive Trial Data

Prospective Investigation On Pulmonary Embolism Diagnosis (PIOPED) investigators demonstrated that all patients with or without PE had abnormal V/Q scans of high, intermediate, or low probability (sensitivity, 98%; specificity, 10%). Furthermore, of the 116 patients with high-probability scans and definitive angiograms, only 88% had a PE. On the contrary, only a minority of patients with pulmonary embolism demonstrated high-probability scans (sensitivity, 41%; specificity, 97%). Similarly, of the 322 patients with intermediate-probability scans and definitive angiograms, only 33% had a PE. The majority of these patients demonstrated low to moderate clinical probability which required no further intervention.^[3]

Prospective multicenter outcome study by Musset et al, demonstrated that with-holding anticoagulation treatment in patients with low or intermediate clinical probability was safe as long as there was a negative spiral CT and negative ultrasonagraphy. Of the 1041 patients enrolled in the study, 525 were assessed as having low or intermediate clinical probability and 507 were not treated with anticoagulation. During a 3-month follow-up, only 9 patients experienced venous thromboembolism (1.8% [0.8-3.3]) and the diagnostic strategy proved inconclusive in 95 (9.1%) patients.^[4]^[5]

Wells Score

The Wells score is a simple, commonly used clinical risk prediction tool to evaluate the need for further testing in patients suspected to have pulmonary embolism.^[6]^[7]^[8]^[9]

Calculation of Wells Score

Pulmonary embolism Wells Score Calculator

Variable	Wells Score^[8]
Clinically suspected DVT (leg swelling, pain with palpation)	3.0
Alternative diagnosis is less likely than PE	3.0
Immobilization/surgery in previous four weeks	1.5
Previous history of DVT or PE	1.5
Tachycardia (heart rate more than 100 bpm)	1.5
Malignancy (treatment for within 6 months, palliative)	1.0
Hemoptysis	1.0

Interpretation of Wells Score

Wells Criteria

Shown below is the pretest probability of PE according to Wells criteria.^[8]^[9]^[10]

Score >6.0: High probability (Rate of PE: ~66.7%)
Score 2.0 to 6.0: Moderate probability (Rate of PE: ~20.5%)
Score <2.0: Low probability (Rate of PE: ~3.6%)

Modified Wells Criteria

Shown below is the pretest probability of PE according to the modified Wells Criteria.^[8]^[9]^[10]^[11]

Score > 4: PE likely (Rate of PE: ~40.7%)
Score 4 or less: PE unlikely (Rate of PE: ~7.8%)

Geneva Score

The Geneva score is a clinical prediction rule used to determine the pre-test probability of pulmonary embolism based on the patient's risk factors and clinical findings.^[12]

The Geneva score has shown to be as accurate as the Wells score, but it is less reliant on the physicians clinical judgement.^[13]

The Geneva score has been revised and simplified from its original version, but it has been shown to have the same diagnostic utility as the original score.^[14]

Original Geneva Score

Calculation of the Geneva Score

The original Geneva score is calculated using 7 risk factors and clinical variables:^[12]

Geneva score calculator

Variable	Score
Age
60–79 years	1.0
≥80 years	2.0
Previous venous thromboembolism
History of prior DVT or PE	2.0
Previous surgery
Recent surgery within 4 weeks	3.0
Heart rate
Heart rate >100 beats per minute	1.0
PaCO₂ (partial pressure of CO₂ in arterial blood)
<35 mmHg (<4.8 kPa)	2.0
35-39 mmHg (4.8-5.19 kPa)	1.0
PaO₂ (partial pressure of O₂ in arterial blood)
<49 mmHg (<6.5 kPa)	4.0
49-59 mmHg (6.5-7.99 kPa)	3.0
60-71 mmHg (8-9.49 kPa)	2.0
72-82 mmHg (9.5-10.99 kPa)	1.0
Chest X-ray findings
Band atelectasis	1.0
Elevation of hemidiaphragm	1.0

Interpretation of the Geneva Score

Shown below is the interpretation of the Geneva score:^[12]

Score ≤ 4 points: low probability of PE (~10%)
Score 5 to 8 points: moderate probability of PE (~38%)
Score ≥ 9 points: high probability of PE (~81%)

Revised Geneva Score

Recently in 2006, the revised Geneva score was introduced with a more standarized and simplified algorithm to help predict the probability that a patient has a pulmonary embolism.^[15]

Calculation of the Revised Geneva Score

Revised Geneva score calculator

Variable	Score
Age more than 65 years	1.0
Prior history of DVT or PE	3.0
Surgery under general anesthesia or fracture of the lower limbs within the last month	2.0
Active malignant condition (currently active or cured less than 1 year ago)	2.0
Unilateral lower limb pain	3.0
Hemoptysis	2.0
Heart rate 75 to 94 beats per minute	3.0
Heart rate 95 or more beats per minute	5.0
Pain on deep palpation of lower limb and unilateral edema	4.0

Interpretation of the Revised Geneva Score

Score 0-3 points: lower probability of PE (8%)
Score 4-10 points: intermediate probability of PE (28%)
Score ≥ 11 points: higher probability of PE (74%)

Simplified Geneva Score

A one-point simplified scoring system replaced the previously weighted scores for each parameter. This was done to reduce the likelihood of error when the score is used in clinical settings. The simplified Geneva score does not lead to a decrease in diagnostic utility when compared to the previous Geneva scores.^[14]

Calculation of the Simplified Geneva Score

Simplified Geneva Score calculator

Variable	Score
Age >65	1.0
Previous history of DVT or PE	1.0
Surgery under general anesthesia or fracture of the lower limbs within the last month	1.0
Active malignant condition (currently active or cured less than 1 year ago)	1.0
Unilateral lower limb pain	1.0
Hemoptysis	1.0
Heart rate 75 to 94 bpm	1.0
Heart rate greater than 94 bpm*	+1
Pain on deep vein palpation of lower limb and unilateral edema	1.0
* Heart rates of 75 to 94 bpm receive 1 point, while heart rates higher than 94bpm receive a further point (i.e. 2 points in total)

Interpretation of the Simplified Geneva Score

Trichotomous Use of the Simplified Revised Geneva Score

Score 0-1 points: low probability of PE (7.7%)
Score 2-4 points: intermediate probability of PE (29.4%)
Score ≥5 points: high probability of PE (64.3%)

Dichotomous Use of the Simplified Revised Geneva Score

Score 0-2 points: PE is unlikely (11.5%)
Score ≥3 points: PE is likely (41.6%)

PE Rule-Out Criteria (PERC)

The Pulmonary Embolism Rule-out Criteria, or PERC rule, helps to evaluate patients in whom pulmonary embolism is suspected, but is unlikely.^[16]

Unlike the Wells Score and Geneva score, which are clinical prediction rules intended to risk stratify patients with suspected PE, the PERC rule is designed to rule out the risk of PE in low-risk patients stratified clinically by the physicians; hence, to prevent unnecessary diagnostic testing in this patient population.^[17]

In 2008, Kline et al, demonstrated that the PERC rule had a sensitivity of 97.4%, specificity of 21.9% and a false negative rate of 1.0% when used as a diagnostic test. The study further concluded that among patients with low suspicion for PE, a negative PERC rule reduced the probability of VTE to below 2% and in about 20% of outpatients with suspected PE.^[18] On the similar lines, among the low pretest probability population, Wolf et al, demonstrated that the use of PERC-approach had a high negative predictive value and sensitivity, but a low positive predictive value and specificity.^[17] On the contrary, among patients with a higher prevalence of PE (>20%), the PERC based approach has shown to have significantly poor predictive value.^[19]

Variables in PERC^[16]

Age less than 50 years?

No hemoptysis?

No estrogen use?

No prior history of DVT or PE?

No unilateral leg swelling?

No surgery or trauma requiring hospitalization within the past four weeks?

Heart rate less than 100 bpm?

Oxyhemoglobin saturation ≥95 percent?

Interpretation of PERC

If the answer to every question above is yes, then a pulmonary embolism can be ruled out according to the PERC rule.^[16]

Pulmonary Embolism Severity Index (PESI) Score

The Pulmonary Embolism Severity Index (PESI) score aims to stratify patients with PE into classes of increasing rate of mortality and adverse outcomes.^[20]

Calculation of PESI Score

Age, per yr	Age, in yr
Male sex	10
Cancer	30
Heart failure	10
Chronic lung disease	10
Pulse ≥110 beat/min	20
Systolic blood pressure <100 mmHg	30
Respiratory rate ≥30/min	20
Temperature <36	20
Altered mental status	60
Arterial oxygen saturation <90%	20

Interpretation of PESI Score

Class	Score	Class–specific 30-day mortality
Class I, very low risk	≤65	1.1%
Class II, low risk	65-85	3.1%
Class III, intermediate risk	86-105	6.5%
Class IV, high risk	106-125	10.4%
Class V, very high risk	>125	24.5%

YEARS Algorithm

A comparison of the YEARS to the original Wells found that the YEARS is more sensitive, less specific, and a very similar Youden's J index or Gain in Certainty^[21].

The YEARS algorithm uses the following three clinical variables:

clinical signs of deep vein thrombosis (as swelling and edema)
hemoptysis
whether the physician considers PE to be "the most probable diagnosis."

The YEARS algorithm excludes PE in patients who either had:

A d-dimer level less than 1,000 ng/mL and no clinical variables of YEARS
OR
d-dimer level less than 500 ng/mL and one or more YEARS items

A cluster-randomized, crossover comparison of the YEARS to a strategy of "all patients underwent D-dimer testing with the threshold set at the age-adjusted level" found similar clinical outcomes but less chest imaging with the YEARS algorithm^[22].

Summary of PE Clinical Probability based on Clinical Prediction Rules

Clinical Prediction Rules	Clinical Probability of PE
	Low (%)	Moderate (%)	High (%)
Empirical^[12]	~10	~33	~66
Extended Wells Score^[23]^[9]^[7]	4	20	68
Simplified Wells Score^[23]^[8]^[24]	15	29	59
Original Geneva Score^[12]	10	38	81
Revised Geneva Score^[15]	8	28	74

Based on pooled study data. Adapted from Recommendations of The PIOPED II Investigators.^[25]

2008 Guidelines on the Diagnosis and Management of Acute Pulmonary Embolism- The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)(DO NOT EDIT)^[26]

The clinical predictive scores of PE are important in the interpretation of the different diagnostic modalities used to diagnose the disease. The combination of the pre-test probability and the tests results helps in the inclusion/exclusion of PE.

Exclusion Criteria for PE

Diagnostic Criteria	Clinical Probability of PE
	Low	Intermediate	High
Normal pulmonary angiogram	+	+	+
D-dimer: Negative result, highly sensitive assay	+	+	-
D-dimer: Negative result, moderately sensitive assay	+	-	-
V/Q Scan: Normal lung scan	+	+	+
V/Q Scan: Non-diagnostic lung scan^a	+	-	-
V/Q Scan: Non-diagnostic lung scan^a and negative proximal compression venous ultrasonography	+	+	±
Chest CT: Normal single-detector CT and negative proximal compression venous ultrasonography	+	+	±
Chest CT: Normal multi-detector CT alone	+	+	±

Confirmation of PE

Diagnostic Criteria	Clinical Probability of PE
	Low	Intermediate	High
Pulmonary angiogram showing PE	+	+	+
High-probability V/Q Scan	±	+	+
Compression venous ultrasonography showing proximal DVT	+	+	+
Chest CT: Single or multi-detector helical CT showing PE (at least segmental)	±	+	+
Chest CT: Single or multi-detector helical CT showing sub-segmental PE	±	±	±

^alow or intermediate probability lung scan according to the PIOPED classification

+	Valid Criteria: No further testing required.
-	Invalid Criteria: Further testing necessary.
+	Controversial Criteria: Further testing to be considered.

“

Adapted from 2008 ESC guidelines on the diagnosis and management of acute pulmonary embolism.

”

References

↑ McGinn TG, Guyatt GH, Wyer PC, Naylor CD, Stiell IG, Richardson WS (2000). "Users' guides to the medical literature: XXII: how to use articles about clinical decision rules. Evidence-Based Medicine Working Group". JAMA : the Journal of the American Medical Association. 284 (1): 79–84. PMID 10872017. Retrieved 2012-04-26. Unknown parameter |month= ignored (help)
↑ Roy PM, Meyer G, Vielle B, Le Gall C, Verschuren F, Carpentier F, Leveau P, Furber A (2006). "Appropriateness of diagnostic management and outcomes of suspected pulmonary embolism". Ann. Intern. Med. 144 (3): 157–64. PMID 16461959.
↑ "Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). The PIOPED Investigators". JAMA : the Journal of the American Medical Association. 263 (20): 2753–9. 1990. PMID 2332918. |access-date= requires |url= (help)
↑ Musset D, Parent F, Meyer G, Maître S, Girard P, Leroyer C, Revel MP, Carette MF, Laurent M, Charbonnier B, Laurent F, Mal H, Nonent M, Lancar R, Grenier P, Simonneau G (2002). "Diagnostic strategy for patients with suspected pulmonary embolism: a prospective multicentre outcome study". Lancet. 360 (9349): 1914–20. doi:10.1016/S0140-6736(02)11914-3. PMID 12493257. Retrieved 2012-04-26. Unknown parameter |month= ignored (help)
↑ Perrier A, Miron MJ, Desmarais S, de Moerloose P, Slosman D, Didier D, Unger PF, Junod A, Patenaude JV, Bounameaux H (2000). "Using clinical evaluation and [[lung]] scan to rule out suspected pulmonary embolism: Is it a valid option in patients with normal results of lower-limb venous compression ultrasonography?". Archives of Internal Medicine. 160 (4): 512–6. PMID 10695691. Retrieved 2012-04-26. Unknown parameter |month= ignored (help); URL–wikilink conflict (help)
↑ Wells PS, Hirsh J, Anderson DR, Lensing AW, Foster G, Kearon C, Weitz J, D'Ovidio R, Cogo A, Prandoni P (1995). "Accuracy of clinical assessment of deep-vein thrombosis". Lancet. 345 (8961): 1326–30. PMID 7752753. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
↑ ^7.0 ^7.1 Wells PS, Ginsberg JS, Anderson DR, Kearon C, Gent M, Turpie AG, Bormanis J, Weitz J, Chamberlain M, Bowie D, Barnes D, Hirsh J (1998). "Use of a clinical model for safe management of patients with suspected pulmonary embolism". Ann Intern Med. 129 (12): 997–1005. PMID 9867786.
↑ ^8.0 ^8.1 ^8.2 ^8.3 ^8.4 Wells P, Anderson D, Rodger M, Ginsberg J, Kearon C, Gent M, Turpie A, Bormanis J, Weitz J, Chamberlain M, Bowie D, Barnes D, Hirsh J (2000). "Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer". Thromb Haemost. 83 (3): 416–20. PMID 10744147.
↑ ^9.0 ^9.1 ^9.2 ^9.3 Wells PS, Anderson DR, Rodger M, Stiell I, Dreyer JF, Barnes D, Forgie M, Kovacs G, Ward J, Kovacs MJ (2001). "Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer". Ann Intern Med. 135 (2): 98–107. PMID 11453709.
↑ ^10.0 ^10.1 Stein PD, Woodard PK, Weg JG, Wakefield TW, Tapson VF, Sostman HD, Sos TA, Quinn DA, Leeper KV, Hull RD, Hales CA, Gottschalk A, Goodman LR, Fowler SE, Buckley JD (2007). "Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II Investigators". Radiology. 242 (1): 15–21. doi:10.1148/radiol.2421060971. PMID 17185658.
↑ van Belle A, Büller HR, Huisman MV, Huisman PM, Kaasjager K, Kamphuisen PW; et al. (2006). "Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography". JAMA. 295 (2): 172–9. doi:10.1001/jama.295.2.172. PMID 16403929.
↑ ^12.0 ^12.1 ^12.2 ^12.3 ^12.4 Wicki J, Perneger TV, Junod AF, Bounameaux H, Perrier A (2001). "Assessing clinical probability of pulmonary embolism in the emergency ward: a simple score". Arch. Intern. Med. 161 (1): 92–7. PMID 11146703. Retrieved 2012-04-26. Unknown parameter |month= ignored (help)
↑ Iles S, Hodges AM, Darley JR, Frampton C, Epton M, Beckert LE, Town GI (2003). "Clinical experience and pre-test probability scores in the diagnosis of pulmonary embolism". QJM. 96 (3): 211–5. PMID 12615985. Retrieved 2012-04-26. Unknown parameter |month= ignored (help)
↑ ^14.0 ^14.1 Klok FA, Mos IC, Nijkeuter M, Righini M, Perrier A, Le Gal G, Huisman MV (2008). "Simplification of the revised Geneva score for assessing clinical probability of pulmonary embolism". Arch. Intern. Med. 168 (19): 2131–6. doi:10.1001/archinte.168.19.2131. PMID 18955643. Retrieved 2012-04-26. Unknown parameter |month= ignored (help)
↑ ^15.0 ^15.1 Le Gal G, Righini M, Roy PM, Sanchez O, Aujesky D, Bounameaux H, Perrier A (2006). "Prediction of pulmonary embolism in the emergency department: the revised Geneva score". Ann. Intern. Med. 144 (3): 165–71. PMID 16461960. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
↑ ^16.0 ^16.1 ^16.2 Kline JA, Mitchell AM, Kabrhel C, Richman PB, Courtney DM (2004). "Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism". J Thromb Haemost. 2 (8): 1247–55. doi:10.1111/j.1538-7836.2004.00790.x. PMID 15304025.
↑ ^17.0 ^17.1 Wolf SJ, McCubbin TR, Nordenholz KE, Naviaux NW, Haukoos JS (2008). "Assessment of the pulmonary embolism rule-out criteria rule for evaluation of suspected pulmonary embolism in the emergency department". The American Journal of Emergency Medicine. 26 (2): 181–5. doi:10.1016/j.ajem.2007.04.026. PMID 18272098. Retrieved 2012-04-30. Unknown parameter |month= ignored (help)
↑ Kline JA, Courtney DM, Kabrhel C, Moore CL, Smithline HA, Plewa MC, Richman PB, O'Neil BJ, Nordenholz K (2008). "Prospective multicenter evaluation of the pulmonary embolism rule-out criteria". J. Thromb. Haemost. 6 (5): 772–80. doi:10.1111/j.1538-7836.2008.02944.x. PMID 18318689. Retrieved 2012-04-26. Unknown parameter |month= ignored (help)
↑ Hugli O, Righini M, Le Gal G, Roy PM, Sanchez O, Verschuren F, Meyer G, Bounameaux H, Aujesky D (2011). "The pulmonary embolism rule-out criteria (PERC) rule does not safely exclude pulmonary embolism". J. Thromb.Haemost. 9 (2): 300–4. doi:10.1111/j.1538-7836.2010.04147.x. PMID 21091866. Retrieved 2011-12-19. Unknown parameter |month= ignored (help)
↑ Aujesky D, Obrosky DS, Stone RA, Auble TE, Perrier A, Cornuz J; et al. (2005). "Derivation and validation of a prognostic model for pulmonary embolism". Am J Respir Crit Care Med. 172 (8): 1041–6. doi:10.1164/rccm.200506-862OC. PMC 2718410. PMID 16020800.
↑ Abdelaal Ahmed Mahmoud M Alkhatip A, Donnelly M, Snyman L, Conroy P, Hamza MK, Murphy I; et al. (2020). "YEARS Algorithm Versus Wells' Score: Predictive Accuracies in Pulmonary Embolism Based on the Gold Standard CT Pulmonary Angiography". Crit Care Med. 48 (5): 704–708. doi:10.1097/CCM.0000000000004271. PMID 32079894 Check |pmid= value (help).
↑ Freund Y, Chauvin A, Jimenez S, Philippon AL, Curac S, Fémy F; et al. (2021). "Effect of a Diagnostic Strategy Using an Elevated and Age-Adjusted D-Dimer Threshold on Thromboembolic Events in Emergency Department Patients With Suspected Pulmonary Embolism: A Randomized Clinical Trial". JAMA. 326 (21): 2141–2149. doi:10.1001/jama.2021.20750. PMID 34874418 Check |pmid= value (help).
↑ ^23.0 ^23.1 Sanson BJ, Lijmer JG, Mac Gillavry MR, Turkstra F, Prins MH, Büller HR (2000). "Comparison of a clinical probability estimate and two clinical models in patients with suspected pulmonary embolism. ANTELOPE-Study Group". Thrombosis and Haemostasis. 83 (2): 199–203. PMID 10739372. Retrieved 2012-04-30. Unknown parameter |month= ignored (help)
↑ Chagnon I, Bounameaux H, Aujesky D, Roy PM, Gourdier AL, Cornuz J, Perneger T, Perrier A (2002). "Comparison of two clinical prediction rules and implicit assessment among patients with suspected pulmonary embolism". The American Journal of Medicine. 113 (4): 269–75. PMID 12361811. Retrieved 2012-04-30. Unknown parameter |month= ignored (help)
↑ {{cite journal |author=Stein PD, Woodard PK, Weg JG, Wakefield TW, Tapson VF, Sostman HD, Sos TA, Quinn DA, Leeper KV, Hull RD, Hales CA, Gottschalk A, Goodman LR, Fowler SE, Buckley JD |title=Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II investigators |journal=[[The American Journal of Medicine|The American Journal of Medicine]] |volume=119 |issue=12 |pages=1048–55 |year=2006 |month=December |pmid=17145249 |doi=10.1016/j.amjmed.2006.05.060 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002-9343(06)00779-0 |accessdate=2012-04-30}}
↑ Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P, Bengel F, Brady AJ, Ferreira D, Janssens U, Klepetko W, Mayer E, Remy-Jardin M, Bassand JP (2008). "Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)". Eur. Heart J. 29 (18): 2276–315. doi:10.1093/eurheartj/ehn310. PMID 18757870. Retrieved 2011-12-07. Unknown parameter |month= ignored (help)

Template:WH Template:WS

[pmid10872017-1] McGinn TG, Guyatt GH, Wyer PC, Naylor CD, Stiell IG, Richardson WS (2000). "Users' guides to the medical literature: XXII: how to use articles about clinical decision rules. Evidence-Based Medicine Working Group". JAMA : the Journal of the American Medical Association. 284 (1): 79–84. PMID 10872017. Retrieved 2012-04-26. Unknown parameter |month= ignored (help)

[pmid16461959-2] Roy PM, Meyer G, Vielle B, Le Gall C, Verschuren F, Carpentier F, Leveau P, Furber A (2006). "Appropriateness of diagnostic management and outcomes of suspected pulmonary embolism". Ann. Intern. Med. 144 (3): 157–64. PMID 16461959.

[pmid2332918-3] "Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). The PIOPED Investigators". JAMA : the Journal of the American Medical Association. 263 (20): 2753–9. 1990. PMID 2332918. |access-date= requires |url= (help)

[pmid12493257-4] Musset D, Parent F, Meyer G, Maître S, Girard P, Leroyer C, Revel MP, Carette MF, Laurent M, Charbonnier B, Laurent F, Mal H, Nonent M, Lancar R, Grenier P, Simonneau G (2002). "Diagnostic strategy for patients with suspected pulmonary embolism: a prospective multicentre outcome study". Lancet. 360 (9349): 1914–20. doi:10.1016/S0140-6736(02)11914-3. PMID 12493257. Retrieved 2012-04-26. Unknown parameter |month= ignored (help)

[pmid10695691-5] Perrier A, Miron MJ, Desmarais S, de Moerloose P, Slosman D, Didier D, Unger PF, Junod A, Patenaude JV, Bounameaux H (2000). "Using clinical evaluation and [[lung]] scan to rule out suspected pulmonary embolism: Is it a valid option in patients with normal results of lower-limb venous compression ultrasonography?". Archives of Internal Medicine. 160 (4): 512–6. PMID 10695691. Retrieved 2012-04-26. Unknown parameter |month= ignored (help); URL–wikilink conflict (help)

[pmid7752753-6] Wells PS, Hirsh J, Anderson DR, Lensing AW, Foster G, Kearon C, Weitz J, D'Ovidio R, Cogo A, Prandoni P (1995). "Accuracy of clinical assessment of deep-vein thrombosis". Lancet. 345 (8961): 1326–30. PMID 7752753. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)

[pmid9867786-7] 7.0 ^7.1 Wells PS, Ginsberg JS, Anderson DR, Kearon C, Gent M, Turpie AG, Bormanis J, Weitz J, Chamberlain M, Bowie D, Barnes D, Hirsh J (1998). "Use of a clinical model for safe management of patients with suspected pulmonary embolism". Ann Intern Med. 129 (12): 997–1005. PMID 9867786.

[pmid10744147-8] 8.0 ^8.1 ^8.2 ^8.3 ^8.4 Wells P, Anderson D, Rodger M, Ginsberg J, Kearon C, Gent M, Turpie A, Bormanis J, Weitz J, Chamberlain M, Bowie D, Barnes D, Hirsh J (2000). "Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer". Thromb Haemost. 83 (3): 416–20. PMID 10744147.

[pmid11453709-9] 9.0 ^9.1 ^9.2 ^9.3 Wells PS, Anderson DR, Rodger M, Stiell I, Dreyer JF, Barnes D, Forgie M, Kovacs G, Ward J, Kovacs MJ (2001). "Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer". Ann Intern Med. 135 (2): 98–107. PMID 11453709.

[pmid17185658-10] 10.0 ^10.1 Stein PD, Woodard PK, Weg JG, Wakefield TW, Tapson VF, Sostman HD, Sos TA, Quinn DA, Leeper KV, Hull RD, Hales CA, Gottschalk A, Goodman LR, Fowler SE, Buckley JD (2007). "Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II Investigators". Radiology. 242 (1): 15–21. doi:10.1148/radiol.2421060971. PMID 17185658.

[pmid16403929-11] van Belle A, Büller HR, Huisman MV, Huisman PM, Kaasjager K, Kamphuisen PW; et al. (2006). "Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography". JAMA. 295 (2): 172–9. doi:10.1001/jama.295.2.172. PMID 16403929.

[pmid11146703-12] 12.0 ^12.1 ^12.2 ^12.3 ^12.4 Wicki J, Perneger TV, Junod AF, Bounameaux H, Perrier A (2001). "Assessing clinical probability of pulmonary embolism in the emergency ward: a simple score". Arch. Intern. Med. 161 (1): 92–7. PMID 11146703. Retrieved 2012-04-26. Unknown parameter |month= ignored (help)

[pmid12615985-13] Iles S, Hodges AM, Darley JR, Frampton C, Epton M, Beckert LE, Town GI (2003). "Clinical experience and pre-test probability scores in the diagnosis of pulmonary embolism". QJM. 96 (3): 211–5. PMID 12615985. Retrieved 2012-04-26. Unknown parameter |month= ignored (help)

[pmid18955643-14] 14.0 ^14.1 Klok FA, Mos IC, Nijkeuter M, Righini M, Perrier A, Le Gal G, Huisman MV (2008). "Simplification of the revised Geneva score for assessing clinical probability of pulmonary embolism". Arch. Intern. Med. 168 (19): 2131–6. doi:10.1001/archinte.168.19.2131. PMID 18955643. Retrieved 2012-04-26. Unknown parameter |month= ignored (help)

[pmid16461960-15] 15.0 ^15.1 Le Gal G, Righini M, Roy PM, Sanchez O, Aujesky D, Bounameaux H, Perrier A (2006). "Prediction of pulmonary embolism in the emergency department: the revised Geneva score". Ann. Intern. Med. 144 (3): 165–71. PMID 16461960. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)

[pmid15304025-16] 16.0 ^16.1 ^16.2 Kline JA, Mitchell AM, Kabrhel C, Richman PB, Courtney DM (2004). "Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism". J Thromb Haemost. 2 (8): 1247–55. doi:10.1111/j.1538-7836.2004.00790.x. PMID 15304025.

[pmid18272098-17] 17.0 ^17.1 Wolf SJ, McCubbin TR, Nordenholz KE, Naviaux NW, Haukoos JS (2008). "Assessment of the pulmonary embolism rule-out criteria rule for evaluation of suspected pulmonary embolism in the emergency department". The American Journal of Emergency Medicine. 26 (2): 181–5. doi:10.1016/j.ajem.2007.04.026. PMID 18272098. Retrieved 2012-04-30. Unknown parameter |month= ignored (help)

[pmid18318689-18] Kline JA, Courtney DM, Kabrhel C, Moore CL, Smithline HA, Plewa MC, Richman PB, O'Neil BJ, Nordenholz K (2008). "Prospective multicenter evaluation of the pulmonary embolism rule-out criteria". J. Thromb. Haemost. 6 (5): 772–80. doi:10.1111/j.1538-7836.2008.02944.x. PMID 18318689. Retrieved 2012-04-26. Unknown parameter |month= ignored (help)

[pmid21091866-19] Hugli O, Righini M, Le Gal G, Roy PM, Sanchez O, Verschuren F, Meyer G, Bounameaux H, Aujesky D (2011). "The pulmonary embolism rule-out criteria (PERC) rule does not safely exclude pulmonary embolism". J. Thromb.Haemost. 9 (2): 300–4. doi:10.1111/j.1538-7836.2010.04147.x. PMID 21091866. Retrieved 2011-12-19. Unknown parameter |month= ignored (help)

[pmid16020800-20] Aujesky D, Obrosky DS, Stone RA, Auble TE, Perrier A, Cornuz J; et al. (2005). "Derivation and validation of a prognostic model for pulmonary embolism". Am J Respir Crit Care Med. 172 (8): 1041–6. doi:10.1164/rccm.200506-862OC. PMC 2718410. PMID 16020800.

[pmid32079894-21] Abdelaal Ahmed Mahmoud M Alkhatip A, Donnelly M, Snyman L, Conroy P, Hamza MK, Murphy I; et al. (2020). "YEARS Algorithm Versus Wells' Score: Predictive Accuracies in Pulmonary Embolism Based on the Gold Standard CT Pulmonary Angiography". Crit Care Med. 48 (5): 704–708. doi:10.1097/CCM.0000000000004271. PMID 32079894 Check |pmid= value (help).

[pmid34874418-22] Freund Y, Chauvin A, Jimenez S, Philippon AL, Curac S, Fémy F; et al. (2021). "Effect of a Diagnostic Strategy Using an Elevated and Age-Adjusted D-Dimer Threshold on Thromboembolic Events in Emergency Department Patients With Suspected Pulmonary Embolism: A Randomized Clinical Trial". JAMA. 326 (21): 2141–2149. doi:10.1001/jama.2021.20750. PMID 34874418 Check |pmid= value (help).

[pmid10739372-23] 23.0 ^23.1 Sanson BJ, Lijmer JG, Mac Gillavry MR, Turkstra F, Prins MH, Büller HR (2000). "Comparison of a clinical probability estimate and two clinical models in patients with suspected pulmonary embolism. ANTELOPE-Study Group". Thrombosis and Haemostasis. 83 (2): 199–203. PMID 10739372. Retrieved 2012-04-30. Unknown parameter |month= ignored (help)

[pmid12361811-24] Chagnon I, Bounameaux H, Aujesky D, Roy PM, Gourdier AL, Cornuz J, Perneger T, Perrier A (2002). "Comparison of two clinical prediction rules and implicit assessment among patients with suspected pulmonary embolism". The American Journal of Medicine. 113 (4): 269–75. PMID 12361811. Retrieved 2012-04-30. Unknown parameter |month= ignored (help)

[pmid17145249-25] {{cite journal |author=Stein PD, Woodard PK, Weg JG, Wakefield TW, Tapson VF, Sostman HD, Sos TA, Quinn DA, Leeper KV, Hull RD, Hales CA, Gottschalk A, Goodman LR, Fowler SE, Buckley JD |title=Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II investigators |journal=[[The American Journal of Medicine|The American Journal of Medicine]] |volume=119 |issue=12 |pages=1048–55 |year=2006 |month=December |pmid=17145249 |doi=10.1016/j.amjmed.2006.05.060 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002-9343(06)00779-0 |accessdate=2012-04-30}}

[pmid18757870-26] Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P, Bengel F, Brady AJ, Ferreira D, Janssens U, Klepetko W, Mayer E, Remy-Jardin M, Bassand JP (2008). "Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)". Eur. Heart J. 29 (18): 2276–315. doi:10.1093/eurheartj/ehn310. PMID 18757870. Retrieved 2011-12-07. Unknown parameter |month= ignored (help)

[1]

[2]

[3]

[4]

[5]

[6]

[7]

[8]

[9]

[10]

[11]

[12]

[13]

[14]

[15]

[16]

[17]

[18]

[19]

[20]

[21]

[22]

[23]

[24]

[25]

[26]

@@ Line 1: / Line 1: @@
+__NOTOC__
+{| class="infobox" style="float:right;"
+|-
+| [[File:Siren.gif|30px|link=Pulmonary embolism resident survival guide]]|| <br> || <br>
+| [[Pulmonary embolism resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
+|}
 {{Pulmonary embolism}}
-{{PE editors}}
+'''Editor(s)-In-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com], {{ATI}}; {{AE}} {{CZ}}; {{Rim}}
 ==Overview==
-The diagnosis of pulmonary embolism is based on clinical evaluation in conjunction with imaging modalities. Despite their individual sensitivities and specificities, studies have demonstrated that a combination of both these variables may help to discriminate suspected patients depending on their risk of developing pulmonary embolism and offer immediate management which is life-saving.
+The diagnosis of pulmonary embolism (PE) is based primarily on the clinical assessment of the pretest probability of PE combined with diagnostic modalities such as [[Pulmonary embolism CT|spiral CT]], [[Pulmonary embolism ventilation/perfusion scan|V/Q scan]], use of the [[Pulmonary embolism laboratory tests#D-dimers|D-dimer]], and [[Pulmonary embolism echocardiography or ultrasound|lower extremity ultrasound]].  Clinical prediction rules for PE include: the [[Wells score]], the [[Geneva score]] and the PE rule-out criteria ([[PERC]]).
-==Pretest Probability==
-The diagnosis of PE is based primarily on the clinical evaluation combined with diagnostic modalities such as spiral [[Pulmonary embolism CT|CT]], [[Pulmonary embolism ventilation/perfusion scan|V/Q scan]], use of the [[Pulmonary embolism laboratory tests#D-dimers|D-dimer]] and [[Pulmonary embolism echocardiography or ultrasound|lower extremity ultrasound]].
-Although, the clinical pretest probability has shown to be fairly accurate,<ref name="pmid2332918">{{cite journal |author= |title=Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). The PIOPED Investigators |journal=[[JAMA : the Journal of the American Medical Association]] |volume=263 |issue=20 |pages=2753–9 |year=1990 |pmid=2332918 |doi= |url= |accessdate=2012-04-26}}</ref> the lack of validation has led to the use of a combination of both: clinical and diagnostic variables to predict the pretest probability that aids in the immediate management of high-risk patients.
+== Assessment of Clinical Probability ==
+A clinical prediction rule is a type of medical research study in which the researchers try to identify the best combination of [[medical sign|signs]], [[symptoms]], and other findings to predict the probability of a specific disease or outcome.<ref name="pmid10872017">{{cite journal |author=McGinn TG, Guyatt GH, Wyer PC, Naylor CD, Stiell IG, Richardson WS |title=Users' guides to the medical literature: XXII: how to use articles about clinical decision rules. Evidence-Based Medicine Working Group |journal=[[JAMA : the Journal of the American Medical Association]] |volume=284 |issue=1 |pages=79–84 |year=2000 |month=July |pmid=10872017 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=10872017 |accessdate=2012-04-26}}</ref> Clinical prediction rules for PE include: the [[Wells score]], the [[Geneva score]] and the PE rule-out criteria. Its noteworthy that the use of any clinical prediction rule is associated with reduction in recurrent [[thromboembolism]].<ref name="pmid16461959">{{cite journal |author=Roy PM, Meyer G, Vielle B, Le Gall C, Verschuren F, Carpentier F, Leveau P, Furber A |title=Appropriateness of diagnostic management and outcomes of suspected pulmonary embolism |journal=Ann. Intern. Med. |volume=144 |issue=3 |pages=157-64 |year=2006 |pmid=16461959}}</ref>
-===Supportive trial data===
+These clinical prediction rules, coupled with diagnostic tests, are used to identify patients who should be treated.
-*The '''''Prospective Investigation On Pulmonary Embolism Diagnosis (PIOPED) investigators''''' demonstrated that all patients with or without pulmonary embolism had [[Pulmonary embolism ventilation/perfusion scan|abnormal V/Q scans]] of high, intermediate, or low probability ''(sensitivity, 98%; specificity, 10%)''. Furthermore, of the 116 patients with high-probability [[Pulmonary embolism ventilation/perfusion scan|scans]] and definitive angiograms, only 88% had pulmonary embolism. On the contrary, only a minority of patients with pulmonary embolism demonstrated high-probability scans ''(sensitivity, 41%; specificity, 97%)''. Similarly, of the 322 patients with intermediate-probability scans and definitive angiograms, only 33% had pulmonary embolism. Despite these contrast findings, classification of patients based on clinical probability was fairly accurate and that with increasing clinical probability, an increase in PE prevalence was also observed. However, majority of these patients demonstrated low to moderate clinical probability which required no further intervention.<ref name="pmid2332918">{{cite journal |author= |title=Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). The PIOPED Investigators |journal=[[JAMA : the Journal of the American Medical Association]] |volume=263 |issue=20 |pages=2753–9 |year=1990 |pmid=2332918 |doi= |url= |accessdate=2012-04-26}}</ref>
-*Another '''''prospective multicentre outcome study by Musset et al''''', demonstrated that with-holding anticoagulation in patients with low or intermediate clinical probability and negative spiral CT and ultrasonagraphy was safe. Of the 1041 patients enrolled in the study, 525 were assessed as having low or intermediate clinical probability and 507 were not treated with anticoagulation. During a 3-month follow-up, only 9 patients experienced [[venous thromboembolism]] ''(1.8% [0.8-3.3])'' and the diagnostic strategy proved inconclusive in 95 ''(9.1%)'' patients.<ref name="pmid12493257">{{cite journal |author=Musset D, Parent F, Meyer G, Maître S, Girard P, Leroyer C, Revel MP, Carette MF, Laurent M, Charbonnier B, Laurent F, Mal H, Nonent M, Lancar R, Grenier P, Simonneau G |title=Diagnostic strategy for patients with suspected pulmonary embolism: a prospective multicentre outcome study |journal=[[Lancet]] |volume=360 |issue=9349 |pages=1914–20 |year=2002 |month=December |pmid=12493257 |doi=10.1016/S0140-6736(02)11914-3 |url=http://linkinghub.elsevier.com/retrieve/pii/S0140-6736(02)11914-3 |accessdate=2012-04-26}}</ref><ref name="pmid10695691">{{cite journal |author=Perrier A, Miron MJ, Desmarais S, de Moerloose P, Slosman D, Didier D, Unger PF, Junod A, Patenaude JV, Bounameaux H |title=Using clinical evaluation and lung scan to rule out suspected pulmonary embolism: Is it a valid option in patients with normal results of lower-limb venous compression ultrasonography? |journal=[[Archives of Internal Medicine]] |volume=160 |issue=4 |pages=512–6 |year=2000 |month=February |pmid=10695691 |doi= |url=http://archinte.ama-assn.org/cgi/pmidlookup?view=long&pmid=10695691 |accessdate=2012-04-26}}</ref>
+=== Supportive Trial Data ===
+*[[Prospective Investigation On Pulmonary Embolism Diagnosis]] (PIOPED) investigators demonstrated that all patients with or without PE had [[Pulmonary embolism ventilation/perfusion scan|abnormal V/Q scans]] of high, intermediate, or low probability ''(sensitivity, 98%; specificity, 10%)''. Furthermore, of the 116 patients with high-probability [[Pulmonary embolism ventilation/perfusion scan|scans]] and definitive [[angiograms]], only 88% had a PE. On the contrary, only a minority of patients with pulmonary embolism demonstrated high-probability scans ''(sensitivity, 41%; specificity, 97%)''. Similarly, of the 322 patients with intermediate-probability scans and definitive [[angiogram]]s, only 33% had a PE. The majority of these patients demonstrated low to moderate clinical probability which required no further intervention.<ref name="pmid2332918">{{cite journal |author= |title=Value of the ventilation/perfusion scan in [[acute]] pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). The [[PIOPED]] Investigators |journal=[[JAMA : the Journal of the American Medical Association]] |volume=263 |issue=20 |pages=2753–9 |year=1990 |pmid=2332918 |doi= |url= |accessdate=2012-04-26}}</ref>
-==Clinical Prediction Rules==
+*Prospective multicenter outcome study by Musset et al, demonstrated that with-holding [[anticoagulation]] treatment in patients with low or intermediate clinical probability was safe as long as there was a negative spiral CT and negative ultrasonagraphy. Of the 1041 patients enrolled in the study, 525 were assessed as having low or intermediate clinical probability and 507 were not treated with [[anticoagulation]]. During a 3-month follow-up, only 9 patients experienced [[venous thromboembolism]] ''(1.8% [0.8-3.3])'' and the diagnostic strategy proved inconclusive in 95 ''(9.1%)'' patients.<ref name="pmid12493257">{{cite journal |author=Musset D, Parent F, Meyer G, Maître S, Girard P, Leroyer C, Revel MP, Carette MF, Laurent M, Charbonnier B, Laurent F, Mal H, Nonent M, Lancar R, Grenier P, Simonneau G |title=Diagnostic strategy for patients with suspected pulmonary embolism: a prospective multicentre outcome study |journal=[[Lancet]] |volume=360 |issue=9349 |pages=1914–20 |year=2002 |month=December |pmid=12493257 |doi=10.1016/S0140-6736(02)11914-3 |url=http://linkinghub.elsevier.com/retrieve/pii/S0140-6736(02)11914-3 |accessdate=2012-04-26}}</ref><ref name="pmid10695691">{{cite journal |author=Perrier A, Miron MJ, Desmarais S, de Moerloose P, Slosman D, Didier D, Unger PF, Junod A, Patenaude JV, Bounameaux H |title=Using clinical evaluation and [[lung]] scan to rule out suspected pulmonary embolism: Is it a valid option in patients with normal results of lower-limb venous compression ultrasonography? |journal=[[Archives of Internal Medicine]] |volume=160 |issue=4 |pages=512–6 |year=2000 |month=February |pmid=10695691 |doi= |url=http://archinte.ama-assn.org/cgi/pmidlookup?view=long&pmid=10695691 |accessdate=2012-04-26}}</ref>
-Clinical prediction rule is a type of medical research study in which the researchers try to identify the best combination of [[medical sign]], [[symptoms]], and other findings to predict the probability of a specific disease or outcome.<ref name="pmid10872017">{{cite journal |author=McGinn TG, Guyatt GH, Wyer PC, Naylor CD, Stiell IG, Richardson WS |title=Users' guides to the medical literature: XXII: how to use articles about clinical decision rules. Evidence-Based Medicine Working Group |journal=[[JAMA : the Journal of the American Medical Association]] |volume=284 |issue=1 |pages=79–84 |year=2000 |month=July |pmid=10872017 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=10872017 |accessdate=2012-04-26}}</ref> Clinical prediction rules for PE include: the Wells score, the Geneva score and the PE rule-out criteria. Its noteworthy that the use of '''any clinical prediction rule''' is associated with reduction in recurrent [[thromboembolism]].<ref name="pmid16461959">{{cite journal |author=Roy PM, Meyer G, Vielle B, Le Gall C, Verschuren F, Carpentier F, Leveau P, Furber A |title=Appropriateness of diagnostic management and outcomes of suspected pulmonary embolism |journal=Ann. Intern. Med. |volume=144 |issue=3 |pages=157-64 |year=2006 |pmid=16461959}}</ref>
-===Wells Score===
+== Wells Score ==
-'''''Wells score''''' is a simple and most commonly used clinical risk prediction tool to evaluate the need for further testing in patients suspected to have [[pulmonary embolism]].<ref name="pmid7752753">{{cite journal |author=Wells PS, Hirsh J, Anderson DR, Lensing AW, Foster G, Kearon C, Weitz J, D'Ovidio R, Cogo A, Prandoni P |title=Accuracy of clinical assessment of deep-vein thrombosis |journal=[[Lancet]] |volume=345 |issue=8961 |pages=1326–30 |year=1995|month=May |pmid=7752753 |doi= |url= |accessdate=2012-04-26}}</ref> and has undergo modifications since.<ref name="pmid9867786">{{cite journal |author=Wells PS, Ginsberg JS, Anderson DR, Kearon C, Gent M, Turpie AG, Bormanis J, Weitz J, Chamberlain M, Bowie D, Barnes D, Hirsh J |title=Use of a clinical model for safe management of patients with suspected pulmonary embolism |journal=Ann Intern Med |volume=129 |issue=12 |pages=997-1005 |year=1998|pmid=9867786}}</ref><ref name="pmid10744147">{{cite journal | author = Wells P, Anderson D, Rodger M, Ginsberg J, Kearon C, Gent M, Turpie A, Bormanis J, Weitz J, Chamberlain M, Bowie D, Barnes D, Hirsh J | title = Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer. | journal = Thromb Haemost | volume = 83 | issue = 3 | pages = 416-20 | year = 2000 | id = PMID 10744147}}</ref><ref name="pmid11453709">{{cite journal |author=Wells PS, Anderson DR, Rodger M, Stiell I, Dreyer JF, Barnes D, Forgie M, Kovacs G, Ward J, Kovacs MJ |title=Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer |journal=Ann Intern Med |volume=135 |issue=2 |pages=98-107 |year=2001|pmid=11453709 | url=http://www.annals.org/cgi/content/full/135/2/98}}</ref>
+The [[Wells score]] is a simple, commonly used clinical risk prediction tool to evaluate the need for further testing in patients suspected to have [[pulmonary embolism]].<ref name="pmid7752753">{{cite journal |author=Wells PS, Hirsh J, Anderson DR, Lensing AW, Foster G, Kearon C, Weitz J, D'Ovidio R, Cogo A, Prandoni P |title=Accuracy of clinical assessment of deep-vein thrombosis |journal=[[Lancet]] |volume=345 |issue=8961 |pages=1326–30 |year=1995|month=May |pmid=7752753 |doi= |url= |accessdate=2012-04-26}}</ref><ref name="pmid9867786">{{cite journal |author=Wells PS, Ginsberg JS, Anderson DR, Kearon C, Gent M, Turpie AG, Bormanis J, Weitz J, Chamberlain M, Bowie D, Barnes D, Hirsh J |title=Use of a clinical model for safe management of patients with suspected pulmonary embolism |journal=Ann Intern Med |volume=129 |issue=12 |pages=997-1005 |year=1998|pmid=9867786}}</ref><ref name="pmid10744147">{{cite journal | author = Wells P, Anderson D, Rodger M, Ginsberg J, Kearon C, Gent M, Turpie A, Bormanis J, Weitz J, Chamberlain M, Bowie D, Barnes D, Hirsh J | title = Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer. | journal = Thromb Haemost | volume = 83 | issue = 3 | pages = 416-20 | year = 2000 | id = PMID 10744147}}</ref><ref name="pmid11453709">{{cite journal |author=Wells PS, Anderson DR, Rodger M, Stiell I, Dreyer JF, Barnes D, Forgie M, Kovacs G, Ward J, Kovacs MJ |title=Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer |journal=Ann Intern Med |volume=135 |issue=2 |pages=98-107 |year=2001|pmid=11453709 | url=http://www.annals.org/cgi/content/full/135/2/98}}</ref>
-'''[[Wells score calculator|Wells Score Calculator for PE]]'''
+=== Calculation of [[Wells Score]]===
+'''[[Wells score calculator|Pulmonary embolism Wells Score Calculator]]'''
-{| class=wikitable border=1
+{| style="cellpadding=0; cellspacing= 0; width: 600px;"
-!Variable
-!Wells<ref name="pmid10744147">{{cite journal |author=Wells PS, Anderson DR, Rodger M, Ginsberg JS, Kearon C, Gent M, Turpie AG, Bormanis J, Weitz J, Chamberlain M, Bowie D, Barnes D, Hirsh J |title=Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer |journal=Thromb. Haemost. |volume=83 |issue=3 |pages=416–20 |year=2000 |month=March |pmid=10744147 |doi=|url=http://www.schattauer.de/index.php?id=1268&L=1&pii=th00030416&no_cache=1 |accessdate=2012-05-01}}</ref>
 |-
-|Clinically suspected [[DVT]] (leg swelling, pain with palpation)
+| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF; width: 70%" align=center | '''Variable'''||style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center | '''Wells Score'''<ref name="pmid10744147">{{cite journal |author=Wells PS, Anderson DR, Rodger M, Ginsberg JS, Kearon C, Gent M, Turpie AG, Bormanis J, Weitz J, Chamberlain M, Bowie D, Barnes D, Hirsh J |title=Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer |journal=Thromb. Haemost. |volume=83 |issue=3 |pages=416–20 |year=2000 |month=March |pmid=10744147 |doi=|url=http://www.schattauer.de/index.php?id=1268&L=1&pii=th00030416&no_cache=1 |accessdate=2012-05-01}}</ref>
-|style="text-align:center"|3.0
 |-
-|Alternative diagnosis is less likely than PE
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | Clinically suspected [[DVT]] (leg swelling, pain with palpation)|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | 3.0
-|style="text-align:center"|3.0
 |-
-|Immobilization/[[surgery]] in previous four weeks
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | Alternative diagnosis is less likely than PE|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | 3.0
-|style="text-align:center"|1.5
 |-
-|Previous history of [[DVT]] or [[PE]]
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | Immobilization/[[surgery]] in previous four weeks|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | 1.5
-|style="text-align:center"|1.5
 |-
-|[[Tachycardia]] (heart rate more than 100 bpm)
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | Previous history of [[DVT]] or [[PE]]|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | 1.5
-|style="text-align:center"|1.5
 |-
-|[[Malignancy]] (treatment for within 6 months, palliative)
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | [[Tachycardia]] (heart rate more than 100 bpm)|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | 1.5
-|style="text-align:center"|1.0
 |-
-|[[Hemoptysis]]
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | [[Malignancy]] (treatment for within 6 months, palliative)|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | 1.0
-|style="text-align:center"|1.0
+|-
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | [[Hemoptysis]]|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | 1.0
 |-
 |}
-====Wells criteria <ref name="pmid10744147"/><ref name="pmid11453709"/>====
+=== Interpretation of Wells Score===
-* The following scoring system is used for assessment of risk<ref name="pmid17185658">{{cite journal |author=Stein PD, Woodard PK, Weg JG, Wakefield TW, Tapson VF, Sostman HD, Sos TA, Quinn DA, Leeper KV, Hull RD, Hales CA, Gottschalk A, Goodman LR, Fowler SE, Buckley JD |title=Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II Investigators |journal=Radiology |volume=242 |issue=1 |pages=15-21 |year=2007 |doi=10.1148/radiol.2421060971 | pmid=17185658}}</ref> and need for further testing with [[Pulmonary embolism D-dimer|D-dimer]] or [[Pulmonary embolism CT|CT]] scan:
+==== Wells Criteria ====
+Shown below is the pretest probability of [[PE]] according to Wells criteria.<ref name="pmid10744147"/><ref name="pmid11453709"/><ref name="pmid17185658">{{cite journal |author=Stein PD, Woodard PK, Weg JG, Wakefield TW, Tapson VF, Sostman HD, Sos TA, Quinn DA, Leeper KV, Hull RD, Hales CA, Gottschalk A, Goodman LR, Fowler SE, Buckley JD |title=Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II Investigators |journal=Radiology |volume=242 |issue=1 |pages=15-21 |year=2007 |doi=10.1148/radiol.2421060971 | pmid=17185658}}</ref>
+* Score >6.0: High probability (Rate of [[PE]]: ~66.7%)
+* Score 2.0 to 6.0: Moderate probability (Rate of [[PE]]: ~20.5%)
+* Score <2.0: Low probability (Rate of [[PE]]: ~3.6%)
-:* Score >6.0 - High probability (~59%).
+====Modified Wells Criteria====
-:* Score 2.0 to 6.0 - Moderate probability (~29%).
+Shown below is the pretest probability of [[PE]] according to the modified Wells Criteria.<ref name="pmid10744147"/><ref name="pmid11453709"/><ref name="pmid17185658">{{cite journal |author=Stein PD, Woodard PK, Weg JG, Wakefield TW, Tapson VF, Sostman HD, Sos TA, Quinn DA, Leeper KV, Hull RD, Hales CA, Gottschalk A, Goodman LR, Fowler SE, Buckley JD |title=Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II Investigators |journal=Radiology |volume=242 |issue=1 |pages=15-21 |year=2007 |doi=10.1148/radiol.2421060971 | pmid=17185658}}</ref><ref name="pmid16403929">{{cite journal| author=van Belle A, Büller HR, Huisman MV, Huisman PM, Kaasjager K, Kamphuisen PW et al.| title=Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. | journal=JAMA | year= 2006 | volume= 295 | issue= 2 | pages= 172-9 | pmid=16403929 | doi=10.1001/jama.295.2.172 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16403929  }} </ref>
-:* Score <2.0 - Low probability (~15%).
+:* Score > 4: PE likely (Rate of [[PE]]: ~40.7%)
+:* Score 4 or less: PE unlikely (Rate of [[PE]]: ~7.8%)
-* The '''''modified extended version''''' of the Wells score has been proposed.<ref name="pmid10739372">{{cite journal |author=Sanson BJ, Lijmer JG, Mac Gillavry MR, Turkstra F, Prins MH, Büller HR |title=Comparison of a clinical probability estimate and two clinical models in patients with suspected pulmonary embolism. ANTELOPE-Study Group |journal=Thromb. Haemost. |volume=83 |issue=2 |pages=199-203 |year=2000 |pmid=10739372}}</ref>
+== [[Geneva Score]]==
-* An alternate dichotomous interpretation is:<ref>{{Cite journal | doi = 10.1136/bmj.e6564 | issn = 1756-1833 | volume = 345 | issue = oct04 2 | pages = e6564-e6564 | last = Geersing | first = G.-J. | coauthors = P. M. G. Erkens, W. A. M. Lucassen, H. R. Buller, H. t. Cate, A. W. Hoes, K. G. M. Moons, M. H. Prins, R. Oudega, H. C. P. M. van Weert, H. E. J. H. Stoffers | title = Safe exclusion of pulmonary embolism using the Wells rule and qualitative D-dimer testing in primary care: prospective cohort study | journal = BMJ
+*The [[Geneva score]] is a [[clinical prediction rule]] used to determine the pre-test probability of [[pulmonary embolism]] based on the patient's risk factors and clinical findings.<ref name="pmid11146703">{{cite journal|author=Wicki J, Perneger TV, Junod AF, Bounameaux H, Perrier A |title=Assessing clinical probability of pulmonary embolism in the emergency ward: a simple score |journal=Arch. Intern. Med. |volume=161 |issue=1 |pages=92–7|year=2001 |month=January |pmid=11146703 |doi= |url=http://archinte.ama-assn.org/cgi/pmidlookup?view=long&pmid=11146703 |accessdate=2012-04-26}}</ref>
-| accessdate = 2012-10-05 | date = 2012-10-04 | url = http://www.bmj.com/content/345/bmj.e6564?etoc=
-}}</ref><ref name="pmid10744147"/><ref name="pmid16403929"/><ref name="pmid18165667"/>
-:* Score > 4 - PE likely. Consider diagnostic imaging.
-:* Score 4 or less - PE unlikely. Consider [[Pulmonary embolism D-dimer|D-dimer]] to rule out PE.
-* A simplified Wells criteria has been proposed<ref name="pmid18217159"/>, according to which all the 7 risk variables (table) are assigned 1 point each. A score ≤ 1 is categorized as unlikely to be PE. This score needs further validation in prospective studies.
+*The [[Geneva score]] has shown to be as accurate as the [[Wells score]], but it is less reliant on the physicians clinical judgement.<ref name="pmid12615985">{{cite journal |author=Iles S, Hodges AM, Darley JR, Frampton C, Epton M, Beckert LE, Town GI |title=Clinical experience and pre-test probability scores in the diagnosis of pulmonary embolism |journal=QJM |volume=96 |issue=3 |pages=211–5 |year=2003 |month=March |pmid=12615985 |doi= |url=http://qjmed.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=12615985 |accessdate=2012-04-26}}</ref>
-===Geneva Score<ref name="pmid11146703">{{cite journal|author=Wicki J, Perneger TV, Junod AF, Bounameaux H, Perrier A |title=Assessing clinical probability of pulmonary embolism in the emergency ward: a simple score |journal=Arch. Intern. Med. |volume=161 |issue=1 |pages=92–7|year=2001 |month=January |pmid=11146703 |doi= |url=http://archinte.ama-assn.org/cgi/pmidlookup?view=long&pmid=11146703 |accessdate=2012-04-26}}</ref>===
+*The [[Geneva score]] has been revised and simplified from its original version, but it has been shown to have the same diagnostic utility as the original score.<ref name="pmid18955643">{{cite journal |author=Klok FA, Mos IC, Nijkeuter M, Righini M, Perrier A, Le Gal G, Huisman MV |title=Simplification of the revised Geneva score for assessing clinical probability of pulmonary embolism |journal=Arch. Intern. Med. |volume=168 |issue=19 |pages=2131–6 |year=2008 |month=October |pmid=18955643 |doi=10.1001/archinte.168.19.2131 |url=http://archinte.ama-assn.org/cgi/pmidlookup?view=long&pmid=18955643 |accessdate=2012-04-26}}</ref>
-*The Geneva score is a [[clinical prediction rule]] used to determine the pre-test probability of [[pulmonary embolism]] based on the patient's risk factors and clinical findings.
+==== Original [[Geneva Score]] ====
+=====Calculation of the [[Geneva Score]]=====
+The original [[Geneva score]] is calculated using 7 risk factors and clinical variables:<ref name="pmid11146703">{{cite journal| author=Wicki J, Perneger TV, Junod AF, Bounameaux H, Perrier A| title=Assessing clinical probability of pulmonary embolism in the emergency ward: a simple score. | journal=Arch Intern Med | year= 2001 | volume= 161 | issue= 1 | pages= 92-7 | pmid=11146703 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11146703  }} </ref>
-*The Geneva score has shown to be fairly accurate as the Wells score, and is less reliant on the physicians clinical judgement.<ref name="pmid12615985">{{cite journal |author=Iles S, Hodges AM, Darley JR, Frampton C, Epton M, Beckert LE, Town GI |title=Clinical experience and pre-test probability scores in the diagnosis of pulmonary embolism |journal=QJM |volume=96 |issue=3 |pages=211–5 |year=2003 |month=March |pmid=12615985 |doi= |url=http://qjmed.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=12615985 |accessdate=2012-04-26}}</ref>
+'''[[Geneva score calculator]]'''
-*The Geneva score has been revised and simplified from its original version and has shown to have the same diagnostic utility as the original score.<ref name="pmid18955643">{{cite journal |author=Klok FA, Mos IC, Nijkeuter M, Righini M, Perrier A, Le Gal G, Huisman MV |title=Simplification of the revised Geneva score for assessing clinical probability of pulmonary embolism |journal=Arch. Intern. Med. |volume=168 |issue=19 |pages=2131–6 |year=2008 |month=October |pmid=18955643 |doi=10.1001/archinte.168.19.2131 |url=http://archinte.ama-assn.org/cgi/pmidlookup?view=long&pmid=18955643 |accessdate=2012-04-26}}</ref>
+{|
+|style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF; width: 70%" align=center |'''Variable'''
-===Original Geneva Score===
+| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF; width: 70%" align=center |'''Score'''
-=====Variables:=====
-The original Geneva score is calculated using 7 risk factors and clinical variables:
-{| class=wikitable border=1
-!Variable
-!Score
 |-
-!colspan=2|Age
+|style="padding: 0 5px; font-size: 100%; background: #B8B8B8; width: 70%" align=left colspan=2 |'''''Age'''''
 |-
-|60–79 years
+|style="font-size: 100; padding: 0 5px; background: #F5F5F5" align=left |60–79 years
-|style="text-align:center"|1.0
+|style="font-size: 100; padding: 0 5px; background: #F5F5F5" align=left |1.0
 |-
-|80+ years
+|style="font-size: 100; padding: 0 5px; background: #F5F5F5" align=left |≥80 years
-|style="text-align:center"|2.0
+|style="font-size: 100; padding: 0 5px; background: #F5F5F5" align=left |2.0
 |-
-!colspan=2|Previous venous thromboembolism
+|style="padding: 0 5px; font-size: 100%; background: #B8B8B8; width: 70%" align=left colspan=2 |'''''Previous venous thromboembolism'''''
 |-
-|History of prior [[DVT]] or [[PE]]
+|style="font-size: 100; padding: 0 5px; background: #F5F5F5" align=left |History of prior [[DVT]] or [[PE]]
-|style="text-align:center"|2.0
+|style="font-size: 100; padding: 0 5px; background: #F5F5F5" align=left | 2.0
 |-
-!colspan=2|Previous surgery
+|style="padding: 0 5px; font-size: 100%; background: #B8B8B8; width: 70%" align=left colspan=2 |'''''Previous surgery'''''
 |-
-|Recent surgery within 4 weeks
+|style="font-size: 100; padding: 0 5px; background: #F5F5F5" align=left |Recent surgery within 4 weeks
-|style="text-align:center"|3.0
+|style="font-size: 100; padding: 0 5px; background: #F5F5F5" align=left |3.0
 |-
-!colspan=2|Heart rate
+|style="padding: 0 5px; font-size: 100%; background: #B8B8B8; width: 70%" align=left colspan=2 |'''''Heart rate'''''
 |-
-|[[Heart rate]] >100 beats per minute
+|style="font-size: 100; padding: 0 5px; background: #F5F5F5" align=left |[[Heart rate]] >100 beats per minute
-|style="text-align:center"|1.0
+|style="font-size: 100; padding: 0 5px; background: #F5F5F5" align=left | 1.0
 |-
-!colspan=2|PaCO<sub>2</sub> (partial pressure of CO<sub>2</sub> in arterial blood)
+|style="padding: 0 5px; font-size: 100%; background: #B8B8B8; width: 70%" align=left colspan=2 |'''''PaCO<sub>2</sub> (partial pressure of CO<sub>2</sub> in arterial blood)'''''
 |-
-|<35mmHg
+|style="font-size: 100; padding: 0 5px; background: #F5F5F5" align=left |<35 mmHg (<4.8 kPa)
-|style="text-align:center"|2.0
+|style="font-size: 100; padding: 0 5px; background: #F5F5F5" align=left | 2.0
 |-
-|35-39mmHg
+|style="font-size: 100; padding: 0 5px; background: #F5F5F5" align=left |35-39 mmHg (4.8-5.19 kPa)
-|style="text-align:center"|1.0
+|style="font-size: 100; padding: 0 5px; background: #F5F5F5" align=left | 1.0
 |-
-!colspan=2|PaO<sub>2</sub> (partial pressure of O<sub>2</sub> in arterial blood)
+|style="padding: 0 5px; font-size: 100%; background: #B8B8B8; width: 70%" align=left colspan=2 |'''''PaO<sub>2</sub> (partial pressure of O<sub>2</sub> in arterial blood)'''''
 |-
-|<49mmHg
+|style="font-size: 100; padding: 0 5px; background: #F5F5F5" align=left |<49 mmHg (<6.5 kPa)
-|style="text-align:center"|4.0
+|style="font-size: 100; padding: 0 5px; background: #F5F5F5" align=left | 4.0
 |-
-|49-59mmHg
+|style="font-size: 100; padding: 0 5px; background: #F5F5F5" align=left |49-59 mmHg (6.5-7.99 kPa)
-|style="text-align:center"|3.0
+|style="font-size: 100; padding: 0 5px; background: #F5F5F5" align=left | 3.0
 |-
-|60-71mmHg
+|style="font-size: 100; padding: 0 5px; background: #F5F5F5" align=left |60-71 mmHg (8-9.49 kPa)
-|style="text-align:center"|2.0
+|style="font-size: 100; padding: 0 5px; background: #F5F5F5" align=left | 2.0
 |-
-|72-82mmHg
+|style="font-size: 100; padding: 0 5px; background: #F5F5F5" align=left |72-82 mmHg (9.5-10.99 kPa)
-|style="text-align:center"|1.0
+|style="font-size: 100; padding: 0 5px; background: #F5F5F5" align=left | 1.0
 |-
-!colspan=2|Chest X-ray findings
+|style="padding: 0 5px; font-size: 100%; background: #B8B8B8; width: 70%" align=left colspan=2 |'''''Chest X-ray findings'''''
 |-
-|Band [[atelectasis]]
+|style="font-size: 100; padding: 0 5px; background: #F5F5F5" align=left |Band [[atelectasis]]
-|style="text-align:center"|1.0
+|style="font-size: 100; padding: 0 5px; background: #F5F5F5" align=left | 1.0
 |-
-|Elevation of hemidiaphragm
+|style="font-size: 100; padding: 0 5px; background: #F5F5F5" align=left |Elevation of hemidiaphragm
-|style="text-align:center"|1.0
+|style="font-size: 100; padding: 0 5px; background: #F5F5F5" align=left | 1.0
 |}
-=====Interpretation:=====
+=====Interpretation of the [[Geneva Score]]=====
-The score obtained correlates to the probability of the patient suffering from pulmonary embolism (the lower the score, the lower the probability).
+Shown below is the interpretation of the [[Geneva score]]:<ref name="pmid11146703">{{cite journal| author=Wicki J, Perneger TV, Junod AF, Bounameaux H, Perrier A| title=Assessing clinical probability of pulmonary embolism in the emergency ward: a simple score. | journal=Arch Intern Med | year= 2001 | volume= 161 | issue= 1 | pages= 92-7 | pmid=11146703 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11146703  }} </ref>
-:* Score < 5 points - low probability of PE.
+* Score ≤ 4 points: low probability of [[PE]] (~10%)
-:* Score 5 to 8 points - moderate probability of PE.
+* Score 5 to 8 points: moderate probability of [[PE]] (~38%)
-:* Score > 8 points - high probability of PE.
+* Score ≥ 9 points: high probability of [[PE]] (~81%)
-===Revised Geneva Score===
+==== Revised [[Geneva Score]] ====
-Recently in 2006, the revised Geneva score was introduced with a more standardized, sustained internal and external validation that may be used for the prediction of pulmonary embolism.<ref name="pmid16461960">{{cite journal |author=Le Gal G, Righini M, Roy PM, Sanchez O, Aujesky D, Bounameaux H, Perrier A |title=Prediction of pulmonary embolism in the emergency department: the revised Geneva score |journal=Ann. Intern. Med. |volume=144 |issue=3 |pages=165–71 |year=2006 |month=February |pmid=16461960 |doi= |url= |accessdate=2012-04-26}}</ref> This simplified scoring system has shown to be as effective as the Wells score.<ref name="pmid18424324">{{cite journal |author=Righini M, Le Gal G, Aujesky D, Roy PM, Sanchez O, Verschuren F, Rutschmann O, Nonent M, Cornuz J, Thys F, Le Manach CP, Revel MP, Poletti PA, Meyer G, Mottier D, Perneger T, Bounameaux H, Perrier A |title=Diagnosis of pulmonary embolism by multidetector CT alone or combined with venous ultrasonography of the leg: a randomised non-inferiority trial |journal=Lancet |volume=371 |issue=9621 |pages=1343–52 |year=2008 |month=April |pmid=18424324 |doi=10.1016/S0140-6736(08)60594-2 |url=http://linkinghub.elsevier.com/retrieve/pii/S0140-6736(08)60594-2 |accessdate=2012-04-26}}</ref>
+Recently in 2006, the revised [[Geneva score]] was introduced with a more standarized and simplified algorithm to help predict the probability that a patient has a [[pulmonary embolism]].<ref name="pmid16461960">{{cite journal |author=Le Gal G, Righini M, Roy PM, Sanchez O, Aujesky D, Bounameaux H, Perrier A |title=Prediction of pulmonary embolism in the emergency department: the revised Geneva score |journal=Ann. Intern. Med. |volume=144 |issue=3 |pages=165–71 |year=2006 |month=February |pmid=16461960 |doi= |url= |accessdate=2012-04-26}}</ref>
-=====Variables:=====
+=====Calculation of the Revised Geneva Score=====
-The revised score uses 8 parameters, excluding the assessment of [[ABG|arterial blood gas sample]] for the diagnosis of PE.
-{| class=wikitable border=1
+'''[[Revised Geneva score calculator]]'''
-!Variable
-!Score
+{|
+|style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |Variable
+|style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |Score
 |-
-|Age 65 years or over
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |Age more than 65 years
-|style="text-align:center"|1.0
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |1.0
 |-
-|Previous history of [[DVT]] or [[PE]]
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |Prior history of [[DVT]] or [[PE]]
-|style="text-align:center"|3.0
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |3.0
 |-
-|[[Surgery]] or [[fracture]] within 1 month
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |[[Surgery]] under general [[anesthesia]] or [[fracture]] of the lower limbs within the last month
-|style="text-align:center"|2.0
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |2.0
 |-
-|[[Malignancy|Active malignant condition]]
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |[[Malignancy|Active malignant condition]] (currently active or cured less than 1 year ago)
-|style="text-align:center"|2.0
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |2.0
 |-
-|Unilateral lower limb pain
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |[[Unilateral]] lower limb [[pain]]
-|style="text-align:center"|3.0
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |3.0
 |-
-|[[Haemoptysis]]
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |[[Hemoptysis]]
-|style="text-align:center"|2.0
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |2.0
 |-
-|[[Heart rate]] 75 to 94 beats per minute
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |[[Heart rate]] 75 to 94 beats per minute
-|style="text-align:center"|3.0
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |3.0
 |-
-|[[Heart rate]] 95 or more beats per minute
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |[[Heart rate]] 95 or more beats per minute
-|style="text-align:center"|5.0
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |5.0
 |-
-|Pain on deep palpation of lower limb and unilateral edema
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |Pain on deep palpation of lower limb and [[unilateral]] edema
-|style="text-align:center"|4.0
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |4.0
 |}
-=====Interpretation:=====
+=====Interpretation of the Revised [[Geneva Score]]=====
-The score obtained correlates to probability of PE and is summarized below:
+* Score 0-3 points: lower probability of [[PE]] (8%)
-:* Score 0 to 3 points - lower probability (8%).
+* Score 4-10 points: intermediate probability of [[PE]] (28%)
-:* Score 4 to 10 points - intermediate probability (28%).
+* Score ≥ 11 points: higher probability of [[PE]] (74%)
-:* Score 11 points or more - higher probability (74%).
-===Simplified Geneva Score<ref name="pmid18955643">{{cite journal |author=Klok FA, Mos IC, Nijkeuter M, Righini M, Perrier A, Le Gal G, Huisman MV |title=Simplification of the revised Geneva score for assessing clinical probability of pulmonary embolism |journal=Arch. Intern. Med. |volume=168 |issue=19 |pages=2131–6 |year=2008 |month=October |pmid=18955643 |doi=10.1001/archinte.168.19.2131 |url=http://archinte.ama-assn.org/cgi/pmidlookup?view=long&pmid=18955643 |accessdate=2012-04-30}}</ref>===
+==== Simplified [[Geneva Score]]====
-The simplified scoring system replaced the weighted scores for each parameter with a 1 point score for each parameter present, to reduce the likelihood of error when the score is used in clinical settings. The simplified Geneva score does not lead to a decrease in diagnostic utility in evaluating patients for a PE when compared to previous Geneva scores.
+A one-point simplified scoring system replaced the previously weighted scores for each parameter. This was done to reduce the likelihood of error when the score is used in clinical settings. The simplified [[Geneva score]] does not lead to a decrease in diagnostic utility when compared to the previous [[Geneva scores]].<ref name="pmid18955643">{{cite journal |author=Klok FA, Mos IC, Nijkeuter M, Righini M, Perrier A, Le Gal G, Huisman MV |title=Simplification of the revised Geneva score for assessing clinical probability of pulmonary embolism |journal=Arch. Intern. Med. |volume=168 |issue=19 |pages=2131–6 |year=2008 |month=October |pmid=18955643 |doi=10.1001/archinte.168.19.2131 |url=http://archinte.ama-assn.org/cgi/pmidlookup?view=long&pmid=18955643 |accessdate=2012-04-30}}</ref>
-=====Variables:=====
+=====Calculation of the Simplified [[Geneva Score]]=====
-{| class=wikitable border=1
-!Variable
+'''[[Simplified Geneva Score calculator]]'''
-!Score
+{|
+|style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |Variable
+|style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |Score
 |-
-|Age >65
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |Age >65
-|style="text-align:center"|1.0
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |1.0
 |-
-|Previous history of [[DVT]] or [[PE]]
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |Previous history of [[DVT]] or [[PE]]
-|style="text-align:center"|1.0
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |1.0
 |-
-|[[Surgery]] or [[fracture]] within 1 month
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |[[Surgery]] under general [[anesthesia]] or [[fracture]] of the lower limbs within the last month
-|style="text-align:center"|1.0
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |1.0
 |-
-|[[Malignancy|Active malignancy]]
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |[[Malignancy|Active malignant condition]] (currently active or cured less than 1 year ago)
-|style="text-align:center"|1.0
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |1.0
 |-
-|Unilateral lower limb pain
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |[[Unilateral]] lower limb pain
-|style="text-align:center"|1.0
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |1.0
 |-
-|[[Hemoptysis]]
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |[[Hemoptysis]]
-|style="text-align:center"|1.0
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |1.0
 |-
-|Pain on deep vein palpation of lower limb and unilateral edema
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |[[Heart rate]] 75 to 94 bpm
-|style="text-align:center"|1.0
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |1.0
 |-
-|[[Heart rate]] 75 to 94 bpm
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |[[Heart rate]] greater than 94 bpm*
-|style="text-align:center"|1.0
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |<nowiki>+1</nowiki>
 |-
-|[[Heart rate]] greater than 94 bpm*
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |Pain on deep [[vein]] palpation of lower limb and [[unilateral]] [[edema]]
-|style="text-align:center"|<nowiki>+1</nowiki>
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |1.0
 |-
 |colspan=2|<nowiki>*</nowiki> <span style="font-size:85%">Heart rates of 75 to 94 bpm receive 1 point, while heart rates higher than 94bpm receive a further point (i.e. 2 points in total)</span>
 |}
-=====Interpretation:=====
+=====Interpretation of the Simplified [[Geneva Score]]=====
-Decreased likelihood of developing PE if the score is 2 or below.
+======Trichotomous Use of the Simplified Revised [[Geneva Score]]======
+* Score 0-1 points: low probability of [[PE]] (7.7%)
+* Score 2-4 points: intermediate probability of [[PE]] (29.4%)
+* Score ≥5 points: high probability of [[PE]] (64.3%)
+======Dichotomous Use of the Simplified Revised [[Geneva Score]]======
+* Score 0-2 points: [[PE]] is unlikely (11.5%)
+* Score ≥3 points: [[PE]] is likely (41.6%)
-===PE Rule-out Criteria (PERC)===
+== PE Rule-Out Criteria (PERC) ==
-*The Pulmonary Embolism Rule-out Criteria, or PERC rule, helps to evaluate patients in whom pulmonary embolism is suspected, but is unlikely.
+*The Pulmonary Embolism Rule-out Criteria, or [[PERC rule]], helps to evaluate patients in whom [[pulmonary embolism]] is suspected, but is unlikely.<ref name="pmid15304025">{{cite journal| author=Kline JA, Mitchell AM, Kabrhel C, Richman PB, Courtney DM| title=Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. | journal=J Thromb Haemost | year= 2004 | volume= 2 | issue= 8 | pages= 1247-55 | pmid=15304025 | doi=10.1111/j.1538-7836.2004.00790.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15304025  }} </ref>
-*Unlike the Wells Score and Geneva score, which are [[clinical prediction rules]] intended to risk stratify patients with suspected PE, '''''the PERC rule is designed to rule out the risk of PE in low-risk patients stratified clinically by the physicians; hence, to prevent unnecessary diagnostic testing in this patient population.'''''<ref name="pmid18272098">{{cite journal |author=Wolf SJ, McCubbin TR, Nordenholz KE, Naviaux NW, Haukoos JS |title=Assessment of the pulmonary embolism rule-out criteria rule for evaluation of suspected pulmonary embolism in the emergency department |journal=[[The American Journal of Emergency Medicine]] |volume=26 |issue=2 |pages=181–5 |year=2008 |month=February |pmid=18272098 |doi=10.1016/j.ajem.2007.04.026 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-6757(07)00307-5 |accessdate=2012-04-30}}</ref>
+*Unlike the [[Wells Score]] and [[Geneva score]], which are clinical prediction rules intended to risk stratify patients with suspected [[PE]], the [[PERC]] rule is designed to rule out the risk of [[PE]] in low-risk patients stratified clinically by the physicians; hence, to prevent unnecessary diagnostic testing in this patient population.<ref name="pmid18272098">{{cite journal |author=Wolf SJ, McCubbin TR, Nordenholz KE, Naviaux NW, Haukoos JS |title=Assessment of the pulmonary embolism rule-out criteria rule for evaluation of suspected pulmonary embolism in the emergency department |journal=[[The American Journal of Emergency Medicine]] |volume=26 |issue=2 |pages=181–5 |year=2008 |month=February |pmid=18272098 |doi=10.1016/j.ajem.2007.04.026 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-6757(07)00307-5 |accessdate=2012-04-30}}</ref>
-*In 2008, Kline et al, demonstrated that the PERC rule had a sensitivity of 97.4%, specificity of 21.9% and a false negative rate of 1.0% when used as a diagnostic test. The study further concluded that among patients with low suspicion for PE, a negative PERC rule reduced the probability of [[VTE]] to below 2% and in about 20% of outpatients with suspected PE.<ref name="pmid18318689">{{cite journal |author=Kline JA, Courtney DM, Kabrhel C, Moore CL, Smithline HA, Plewa MC, Richman PB, O'Neil BJ, Nordenholz K |title=Prospective multicenter evaluation of the pulmonary embolism rule-out criteria |journal=J. Thromb. Haemost. |volume=6 |issue=5 |pages=772–80 |year=2008 |month=May |pmid=18318689 |doi=10.1111/j.1538-7836.2008.02944.x |url=http://dx.doi.org/10.1111/j.1538-7836.2008.02944.x |accessdate=2012-04-26}}</ref> On the similar lines, among the low pretest probability population, Wolf et al, demonstrated that the use of PERC-approach had a high negative predictive value and sensitivity, but a low positive predictive value and specificity.<ref name="pmid18272098">{{cite journal |author=Wolf SJ, McCubbin TR, Nordenholz KE, Naviaux NW, Haukoos JS |title=Assessment of the pulmonary embolism rule-out criteria rule for evaluation of suspected pulmonary embolism in the emergency department |journal=Am J Emerg Med |volume=26 |issue=2 |pages=181–5 |year=2008 |month=February |pmid=18272098 |doi=10.1016/j.ajem.2007.04.026 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-6757(07)00307-5 |accessdate=2011-12-19}}</ref> On the contrary, among patients with a higher prevalence of PE (>20%), the PERC based approach has shown to have significantly poor predictive value.<ref name="pmid21091866">{{cite journal |author=Hugli O, Righini M, Le Gal G, Roy PM, Sanchez O, Verschuren F, Meyer G, Bounameaux H, Aujesky D |title=The pulmonary embolism rule-out criteria (PERC) rule does not safely exclude pulmonary embolism |journal=J. Thromb.Haemost. |volume=9 |issue=2 |pages=300–4 |year=2011 |month=February |pmid=21091866 |doi=10.1111/j.1538-7836.2010.04147.x |url=http://dx.doi.org/10.1111/j.1538-7836.2010.04147.x |accessdate=2011-12-19}}</ref>
+*In 2008, Kline et al, demonstrated that the [[PERC]] rule had a [[sensitivity]] of 97.4%, [[specificity]] of 21.9% and a [[false negative rate]] of 1.0% when used as a diagnostic test. The study further concluded that among patients with low suspicion for [[PE]], a negative [[PERC]] rule reduced the probability of [[VTE]] to below 2% and in about 20% of outpatients with suspected [[PE]].<ref name="pmid18318689">{{cite journal |author=Kline JA, Courtney DM, Kabrhel C, Moore CL, Smithline HA, Plewa MC, Richman PB, O'Neil BJ, Nordenholz K |title=Prospective multicenter evaluation of the pulmonary embolism rule-out criteria |journal=J. Thromb. Haemost. |volume=6 |issue=5 |pages=772–80 |year=2008 |month=May |pmid=18318689 |doi=10.1111/j.1538-7836.2008.02944.x |url=http://dx.doi.org/10.1111/j.1538-7836.2008.02944.x |accessdate=2012-04-26}}</ref> On the similar lines, among the low pretest probability population, Wolf et al, demonstrated that the use of [[PERC]]-approach had a high [[negative predictive value]] and [[sensitivity]], but a low [[positive predictive value]] and [[specificity]].<ref name="pmid18272098">{{cite journal |author=Wolf SJ, McCubbin TR, Nordenholz KE, Naviaux NW, Haukoos JS |title=Assessment of the pulmonary embolism rule-out criteria rule for evaluation of suspected pulmonary embolism in the emergency department |journal=Am J Emerg Med |volume=26 |issue=2 |pages=181–5 |year=2008 |month=February |pmid=18272098 |doi=10.1016/j.ajem.2007.04.026 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-6757(07)00307-5 |accessdate=2011-12-19}}</ref> On the contrary, among patients with a higher [[prevalence]] of [[PE]] (>20%), the PERC based approach has shown to have significantly poor predictive value.<ref name="pmid21091866">{{cite journal |author=Hugli O, Righini M, Le Gal G, Roy PM, Sanchez O, Verschuren F, Meyer G, Bounameaux H, Aujesky D |title=The pulmonary embolism rule-out criteria (PERC) rule does not safely exclude pulmonary embolism |journal=J. Thromb.Haemost. |volume=9 |issue=2 |pages=300–4 |year=2011 |month=February |pmid=21091866 |doi=10.1111/j.1538-7836.2010.04147.x |url=http://dx.doi.org/10.1111/j.1538-7836.2010.04147.x |accessdate=2011-12-19}}</ref>
-{| class=wikitable border=1
+{| style="cellpadding=0; cellspacing= 0; width: 600px;"
-!Variables
+|-
+| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Variables in PERC'''<ref name="pmid15304025">{{cite journal| author=Kline JA, Mitchell AM, Kabrhel C, Richman PB, Courtney DM| title=Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. | journal=J Thromb Haemost | year= 2004 | volume= 2 | issue= 8 | pages= 1247-55 | pmid=15304025 | doi=10.1111/j.1538-7836.2004.00790.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15304025  }} </ref>
 |-
-|Age less than 50 years
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |Age less than 50 years?
 |-
-|[[Hemoptysis]]
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |No [[hemoptysis]]?
 |-
-|Estrogen use
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |No [[estrogen]] use?
 |-
-|Prior history of [[DVT]] or [[PE]]
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |No prior history of [[DVT]] or [[PE]]?
 |-
-|Unilateral leg swelling
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |No [[unilateral]] leg [[swelling]]?
 |-
-|Surgery or trauma requiring hospitalization within the past four weeks
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |No [[surgery]] or trauma requiring hospitalization within the past four weeks?
 |-
-|Heart rate less than 100 bpm
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |[[Heart rate]] less than 100 bpm?
 |-
-|Oxyhemoglobin saturation ≥95 percent
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |[[Oxyhemoglobin]] saturation ≥95 percent?
 |-
 |}
-=====Interpretation:=====
+====Interpretation of [[PERC]]====
-To rule-out pulmonary embolism based on PERC rule, the answer to every variable mentioned above should be ''No''.
+If the answer to every question above is yes, then a [[pulmonary embolism]] can be ruled out according to the [[PERC]] rule.<ref name="pmid15304025">{{cite journal| author=Kline JA, Mitchell AM, Kabrhel C, Richman PB, Courtney DM| title=Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected [[pulmonary embolism]]. | journal=J Thromb Haemost | year= 2004 | volume= 2 | issue= 8 | pages= 1247-55 | pmid=15304025 | doi=10.1111/j.1538-7836.2004.00790.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15304025  }} </ref>
-==Summary of PE Clinical Probability based on Clinical Prediction Rules==
+==Pulmonary Embolism Severity Index (PESI) Score==
+The Pulmonary Embolism Severity Index ([[PESI]]) score aims to stratify patients with [[PE]] into classes of increasing rate of mortality and adverse outcomes.<ref name="pmid16020800">{{cite journal| author=Aujesky D, Obrosky DS, Stone RA, Auble TE, Perrier A, Cornuz J et al.| title=Derivation and validation of a prognostic model for pulmonary embolism. | journal=Am J Respir Crit Care Med | year= 2005 | volume= 172 | issue= 8 | pages= 1041-6 | pmid=16020800 | doi=10.1164/rccm.200506-862OC | pmc=PMC2718410 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16020800  }} </ref>
+===Calculation of [[PESI]] Score===
+{| style="cellpadding=0; cellspacing= 0; width: 600px;"
+|-
+| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Age, per yr''' || style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center | '''Age, in yr'''
+|-
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |Male sex ||style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |10
+|-
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |[[Cancer]] || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |30
+|-
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |[[Heart failure]] || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |10
+|-
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |Chronic [[lung]] disease|| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |10
+|-
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |[[Pulse]] ≥110 beat/min|| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |20
+|-
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |Systolic [[blood pressure]] <100 mmHg ||style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |30
+|-
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |[[Respiratory rate]] ≥30/min || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |20
+|-
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |[[Temperature]] <36 ||style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |20
+|-
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |[[Altered mental status]] || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |60
+|-
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |Arterial [[oxygen saturation]] <90% || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |20
+|}
+===Interpretation of [[PESI]] Score===
+{| style="cellpadding=0; cellspacing= 0; width: 600px;"
+|-
+| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Class''' ||style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center | '''Score'''|| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Class–specific 30-day mortality'''
+|-
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |Class I, very low risk ||style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |≤65|| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |1.1%
+|-
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |Class II, low risk || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |65-85|| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |3.1%
+|-
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |Class III, intermediate risk ||style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |86-105||style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |6.5%
+|-
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |Class IV, high risk ||style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |106-125||style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |10.4%
+|-
+|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |Class V, very high risk || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |>125 ||style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |24.5%
+|}
+==YEARS Algorithm==
+A comparison of the YEARS to the original Wells found that the YEARS is more sensitive, less specific, and a very similar [[Diagnostic_test | Youden's J index or Gain in Certainty]]<ref name="pmid32079894">{{cite journal| author=Abdelaal Ahmed Mahmoud M Alkhatip A, Donnelly M, Snyman L, Conroy P, Hamza MK, Murphy I | display-authors=etal| title=YEARS Algorithm Versus Wells' Score: Predictive Accuracies in Pulmonary Embolism Based on the Gold Standard CT Pulmonary Angiography. | journal=Crit Care Med | year= 2020 | volume= 48 | issue= 5 | pages= 704-708 | pmid=32079894 | doi=10.1097/CCM.0000000000004271 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32079894  }} </ref>.
+The YEARS algorithm uses the following three clinical variables:
+# clinical signs of deep vein thrombosis (as swelling and edema)
+# hemoptysis
+# whether the physician considers PE to be "the most probable diagnosis."
+The YEARS algorithm excludes PE in patients who either had:
+* A d-dimer level less than 1,000 ng/mL and no clinical variables of YEARS
+* OR
+* d-dimer level less than 500 ng/mL and one or more YEARS items
+A cluster-randomized, crossover comparison of the YEARS to a strategy of "all patients underwent D-dimer testing with the threshold set at the age-adjusted level" found similar clinical outcomes but less chest imaging with the YEARS algorithm<ref name="pmid34874418">{{cite journal| author=Freund Y, Chauvin A, Jimenez S, Philippon AL, Curac S, Fémy F | display-authors=etal| title=Effect of a Diagnostic Strategy Using an Elevated and Age-Adjusted D-Dimer Threshold on Thromboembolic Events in Emergency Department Patients With Suspected Pulmonary Embolism: A Randomized Clinical Trial. | journal=JAMA | year= 2021 | volume= 326 | issue= 21 | pages= 2141-2149 | pmid=34874418 | doi=10.1001/jama.2021.20750 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34874418  }} </ref>.
+== Summary of PE Clinical Probability based on Clinical Prediction Rules ==
 {|style="width:75%; height:100px" border="1"
 |style="height:100px"; border="1" bgcolor="DarkGray" align="center"| '''Clinical Prediction Rules'''
-|style="height:100px"; border="1" bgcolor="DarkGray" colspan="3" align="center"| '''Clinical Probability of PE'''
+|style="height:100px"; border="1" bgcolor="DarkGray" colspan="3" align="center"| '''Clinical Probability of [[PE]]'''
 |-
 |style="height:100px";  border="1" bgcolor="DarkGray" align="center"|
@@ Line 268: / Line 335: @@
 |-
 |-
-| Empirical<ref name="pmid10739372">{{cite journal |author=Sanson BJ, Lijmer JG, Mac Gillavry MR, Turkstra F, Prins MH, Büller HR |title=Comparison of a clinical probability estimate and two clinical models in patients with suspected pulmonary embolism. ANTELOPE-Study Group |journal=[[Thrombosis and Haemostasis]] |volume=83 |issue=2 |pages=199–203 |year=2000 |month=February |pmid=10739372 |doi= |url=http://www.schattauer.de/index.php?id=1268&L=1&pii=th00020199&no_cache=1 |accessdate=2012-04-30}}</ref><ref name="pmid11146703">{{cite journal |author=Wicki J, Perneger TV, Junod AF, Bounameaux H, Perrier A |title=Assessing clinical probability of pulmonary embolism in the emergency ward: a simple score |journal=[[Archives of Internal Medicine]] |volume=161 |issue=1 |pages=92–7 |year=2001 |month=January |pmid=11146703 |doi= |url=http://archinte.ama-assn.org/cgi/pmidlookup?view=long&pmid=11146703 |accessdate=2012-04-30}}</ref><ref name="pmid2332918">{{cite journal |author= |title=Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). The PIOPED Investigators |journal=[[JAMA : the Journal of the American Medical Association]] |volume=263 |issue=20 |pages=2753–9 |year=1990 |pmid=2332918 |doi= |url= |accessdate=2012-04-30}}</ref>
+| Empirical<ref name="pmid11146703">{{cite journal |author=Wicki J, Perneger TV, Junod AF, Bounameaux H, Perrier A |title=Assessing clinical probability of pulmonary embolism in the emergency ward: a simple score |journal=[[Archives of Internal Medicine]] |volume=161 |issue=1 |pages=92–7 |year=2001 |month=January |pmid=11146703 |doi= |url=http://archinte.ama-assn.org/cgi/pmidlookup?view=long&pmid=11146703 |accessdate=2012-04-30}}</ref>
-| align="center" | 10
+| align="center" | ~10
-| align="center" | 31
+| align="center" | ~33
-| align="center" | 61
+| align="center" | ~66
 |-
 |-
-| Extended Wells Score<ref name="pmid10739372">{{cite journal |author=Sanson BJ, Lijmer JG, Mac Gillavry MR, Turkstra F, Prins MH, Büller HR |title=Comparison of a clinical probability estimate and two clinical models in patients with suspected pulmonary embolism. ANTELOPE-Study Group |journal=[[Thrombosis and Haemostasis]] |volume=83 |issue=2 |pages=199–203 |year=2000 |month=February |pmid=10739372 |doi= |url=http://www.schattauer.de/index.php?id=1268&L=1&pii=th00020199&no_cache=1 |accessdate=2012-04-30}}</ref><ref name="pmid11453709">{{cite journal |author=Wells PS, Anderson DR, Rodger M, Stiell I, Dreyer JF, Barnes D, Forgie M, Kovacs G, Ward J, Kovacs MJ |title=Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer |journal=[[Annals of Internal Medicine]] |volume=135 |issue=2 |pages=98–107 |year=2001 |month=July |pmid=11453709 |doi= |url=http://www.annals.org/cgi/pmidlookup?view=long&pmid=11453709 |accessdate=2012-04-30}}</ref><ref name="pmid9867786">{{cite journal |author=Wells PS, Ginsberg JS, Anderson DR, Kearon C, Gent M, Turpie AG, Bormanis J, Weitz J, Chamberlain M, Bowie D, Barnes D, Hirsh J |title=Use of a clinical model for safe management of patients with suspected pulmonary embolism |journal=[[Annals of Internal Medicine]] |volume=129 |issue=12 |pages=997–1005 |year=1998 |month=December |pmid=9867786 |doi= |url= |accessdate=2012-04-30}}</ref>
+| Extended [[Wells Score]]<ref name="pmid10739372">{{cite journal |author=Sanson BJ, Lijmer JG, Mac Gillavry MR, Turkstra F, Prins MH, Büller HR |title=Comparison of a clinical probability estimate and two clinical models in patients with suspected pulmonary embolism. ANTELOPE-Study Group |journal=[[Thrombosis and Haemostasis]] |volume=83 |issue=2 |pages=199–203 |year=2000 |month=February |pmid=10739372 |doi= |url=http://www.schattauer.de/index.php?id=1268&L=1&pii=th00020199&no_cache=1 |accessdate=2012-04-30}}</ref><ref name="pmid11453709">{{cite journal |author=Wells PS, Anderson DR, Rodger M, Stiell I, Dreyer JF, Barnes D, Forgie M, Kovacs G, Ward J, Kovacs MJ |title=Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer |journal=[[Annals of Internal Medicine]] |volume=135 |issue=2 |pages=98–107 |year=2001 |month=July |pmid=11453709 |doi= |url=http://www.annals.org/cgi/pmidlookup?view=long&pmid=11453709 |accessdate=2012-04-30}}</ref><ref name="pmid9867786">{{cite journal |author=Wells PS, Ginsberg JS, Anderson DR, Kearon C, Gent M, Turpie AG, Bormanis J, Weitz J, Chamberlain M, Bowie D, Barnes D, Hirsh J |title=Use of a clinical model for safe management of patients with suspected pulmonary embolism |journal=[[Annals of Internal Medicine]] |volume=129 |issue=12 |pages=997–1005 |year=1998 |month=December |pmid=9867786 |doi= |url= |accessdate=2012-04-30}}</ref>
 | align="center" | 4
-| align="center" | 30
+| align="center" | 20
 | align="center" | 68
 |-
 |-
-| Simplified Wells Score<ref name="pmid10739372">{{cite journal |author=Sanson BJ, Lijmer JG, Mac Gillavry MR, Turkstra F, Prins MH, Büller HR |title=Comparison of a clinical probability estimate and two clinical models in patients with suspected pulmonary embolism. ANTELOPE-Study Group |journal=[[Thrombosis and Haemostasis]] |volume=83 |issue=2 |pages=199–203 |year=2000 |month=February |pmid=10739372 |doi= |url=http://www.schattauer.de/index.php?id=1268&L=1&pii=th00020199&no_cache=1 |accessdate=2012-04-30}}</ref><ref name="pmid10744147">{{cite journal |author=Wells PS, Anderson DR, Rodger M, Ginsberg JS, Kearon C, Gent M, Turpie AG, Bormanis J, Weitz J, Chamberlain M, Bowie D, Barnes D, Hirsh J |title=Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer |journal=[[Thrombosis and Haemostasis]] |volume=83 |issue=3 |pages=416–20 |year=2000 |month=March |pmid=10744147 |doi= |url=http://www.schattauer.de/index.php?id=1268&L=1&pii=th00030416&no_cache=1 |accessdate=2012-04-30}}</ref><ref name="pmid12361811">{{cite journal |author=Chagnon I, Bounameaux H, Aujesky D, Roy PM, Gourdier AL, Cornuz J, Perneger T, Perrier A |title=Comparison of two clinical prediction rules and implicit assessment among patients with suspected pulmonary embolism |journal=[[The American Journal of Medicine]] |volume=113 |issue=4 |pages=269–75 |year=2002 |month=September |pmid=12361811 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0002934302012123 |accessdate=2012-04-30}}</ref>
+| Simplified [[Wells Score]]<ref name="pmid10739372">{{cite journal |author=Sanson BJ, Lijmer JG, Mac Gillavry MR, Turkstra F, Prins MH, Büller HR |title=Comparison of a clinical probability estimate and two clinical models in patients with suspected pulmonary embolism. ANTELOPE-Study Group |journal=[[Thrombosis and Haemostasis]] |volume=83 |issue=2 |pages=199–203 |year=2000 |month=February |pmid=10739372 |doi= |url=http://www.schattauer.de/index.php?id=1268&L=1&pii=th00020199&no_cache=1 |accessdate=2012-04-30}}</ref><ref name="pmid10744147">{{cite journal |author=Wells PS, Anderson DR, Rodger M, Ginsberg JS, Kearon C, Gent M, Turpie AG, Bormanis J, Weitz J, Chamberlain M, Bowie D, Barnes D, Hirsh J |title=Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer |journal=[[Thrombosis and Haemostasis]] |volume=83 |issue=3 |pages=416–20 |year=2000 |month=March |pmid=10744147 |doi= |url=http://www.schattauer.de/index.php?id=1268&L=1&pii=th00030416&no_cache=1 |accessdate=2012-04-30}}</ref><ref name="pmid12361811">{{cite journal |author=Chagnon I, Bounameaux H, Aujesky D, Roy PM, Gourdier AL, Cornuz J, Perneger T, Perrier A |title=Comparison of two clinical prediction rules and implicit assessment among patients with suspected pulmonary embolism |journal=[[The American Journal of Medicine]] |volume=113 |issue=4 |pages=269–75 |year=2002 |month=September |pmid=12361811 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0002934302012123 |accessdate=2012-04-30}}</ref>
 | align="center" | 15
 | align="center" | 29
@@ Line 286: / Line 353: @@
 |-
 |-
-| Original Geneva Score<ref name="pmid11146703">{{cite journal |author=Wicki J, Perneger TV, Junod AF, Bounameaux H, Perrier A |title=Assessing clinical probability of pulmonary embolism in the emergency ward: a simple score |journal=[[Archives of Internal Medicine]] |volume=161 |issue=1 |pages=92–7 |year=2001 |month=January |pmid=11146703 |doi= |url=http://archinte.ama-assn.org/cgi/pmidlookup?view=long&pmid=11146703 |accessdate=2012-04-30}}</ref><ref name="pmid12361811">{{cite journal |author=Chagnon I, Bounameaux H, Aujesky D, Roy PM, Gourdier AL, Cornuz J, Perneger T, Perrier A |title=Comparison of two clinical prediction rules and implicit assessment among patients with suspected pulmonary embolism |journal=[[The American Journal of Medicine]] |volume=113 |issue=4 |pages=269–75 |year=2002 |month=September |pmid=12361811 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0002934302012123 |accessdate=2012-04-30}}</ref>
+| Original [[Geneva Score]]<ref name="pmid11146703">{{cite journal| author=Wicki J, Perneger TV, Junod AF, Bounameaux H, Perrier A| title=Assessing clinical probability of pulmonary embolism in the emergency ward: a simple score. | journal=Arch Intern Med | year= 2001 | volume= 161 | issue= 1 | pages= 92-7 | pmid=11146703 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11146703  }} </ref>
-| align="center" | 11
+| align="center" | 10
 | align="center" | 38
-| align="center" | 79
+| align="center" | 81
 |-
 |-
-| Revised Geneva Score<ref name="pmid16461960">{{cite journal |author=Le Gal G, Righini M, Roy PM, Sanchez O, Aujesky D, Bounameaux H, Perrier A |title=Prediction of pulmonary embolism in the emergency department: the revised Geneva score |journal=[[Annals of Internal Medicine]] |volume=144 |issue=3 |pages=165–71 |year=2006 |month=February |pmid=16461960 |doi= |url= |accessdate=2012-04-30}}</ref>
+| Revised [[Geneva Score]]<ref name="pmid16461960">{{cite journal |author=Le Gal G, Righini M, Roy PM, Sanchez O, Aujesky D, Bounameaux H, Perrier A |title=Prediction of pulmonary embolism in the emergency department: the revised Geneva score |journal=Ann. Intern. Med. |volume=144 |issue=3 |pages=165–71 |year=2006 |month=February |pmid=16461960 |doi= |url= |accessdate=2012-04-26}}</ref>
 | align="center" | 8
-| align="center" | 29
+| align="center" | 28
 | align="center" | 74
 |-
 |}
-{{cquote|
+Based on pooled study data. Adapted from Recommendations of The PIOPED II Investigators.<ref name="pmid17145249">[[Template:cite journal|{{cite journal ]]|author=Stein PD, Woodard PK, Weg JG, Wakefield TW, Tapson VF, Sostman HD, Sos TA, Quinn DA, Leeper KV, Hull RD, Hales CA, Gottschalk A, Goodman LR, Fowler SE, Buckley JD |title=Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II investigators |journal=[[The American Journal of Medicine|[[The American Journal of Medicine]]]] |volume=119 |issue=12 |pages=1048–55 |year=2006 |month=December |pmid=17145249 |doi=10.1016/j.amjmed.2006.05.060 |url=[http://linkinghub.elsevier.com/retrieve/pii/S0002-9343%2806%2900779-0 http://linkinghub.elsevier.com/retrieve/pii/S0002-9343(06)00779-0] |accessdate=2012-04-30}}</ref>
-''Based on pooled study data. Adapted from Recommendations of The PIOPED II Investigators.''<ref name="pmid17145249">{{cite journal |author=Stein PD, Woodard PK, Weg JG, Wakefield TW, Tapson VF, Sostman HD, Sos TA, Quinn DA, Leeper KV, Hull RD, Hales CA, Gottschalk A, Goodman LR, Fowler SE, Buckley JD |title=Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II investigators |journal=[[The American Journal of Medicine]] |volume=119 |issue=12 |pages=1048–55 |year=2006 |month=December |pmid=17145249 |doi=10.1016/j.amjmed.2006.05.060 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002-9343(06)00779-0 |accessdate=2012-04-30}}</ref>}}
-==ESC Guideline Recommendations <ref name="pmid18757870">{{cite journal |author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P, Bengel F, Brady AJ, Ferreira D, Janssens U, Klepetko W, Mayer E, Remy-Jardin M, Bassand JP |title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC) |journal=Eur. Heart J. |volume=29|issue=18 |pages=2276–315 |year=2008 |month=September |pmid=18757870 |doi=10.1093/eurheartj/ehn310|url=http://eurheartj.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=18757870 |accessdate=2011-12-07}}</ref>==
-===Suspected Non High-risk PE Patients===
+==2008 Guidelines on the Diagnosis and Management of [[Acute]] [[Pulmonary Embolism]]- The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)(DO NOT EDIT)<ref name="pmid18757870">{{cite journal |author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P, Bengel F, Brady AJ, Ferreira D, Janssens U, Klepetko W, Mayer E, Remy-Jardin M, Bassand JP |title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC) |journal=Eur. Heart J. |volume=29|issue=18|pages=2276–315 |year=2008 |month=September |pmid=18757870 |doi=10.1093/eurheartj/ehn310|url=http://eurheartj.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=18757870 |accessdate=2011-12-07}}</ref>==
-{{cquote|
-====[[European society of cardiology#Classes of Recommendations|Class I]]====
-'''1.''' In non-high-risk PE, basing the diagnostic strategy on clinical probability assessed either implicitly or using a validated [[clinical prediction rule|prediction rule]] is recommended. ''([[European society of cardiology#Level of Evidence|Level of Evidence: A]])''
-'''2.''' The use of validated criteria for diagnosing PE is recommended. Validated criteria according to clinical probability of PE (low, intermediate or high) are detailed below. ''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])''}}
+The clinical predictive scores of [[PE]] are important in the interpretation of the different diagnostic modalities used to diagnose the disease. The combination of the pre-test probability and the tests results helps in the inclusion/exclusion of PE.
-====Exclusion Criteria for PE====
+====Exclusion Criteria for [[PE]]====
 {|style="width:75%; height:100px" border="1"
 |style="height:100px"; style="width:25%" border="1" bgcolor="DarkGray" align="center"| '''Diagnostic Criteria'''
-|style="height:100px"; style="width:75%" border="1" bgcolor="DarkGray" colspan="3" align="center"| '''Clinical Probability of PE'''
+|style="height:100px"; style="width:75%" border="1" bgcolor="DarkGray" colspan="3" align="center"| '''Clinical Probability of [[PE]]'''
 |-
 |style="height:100px"; style="width:75%" border="1" bgcolor="DarkGray" align="center"|
@@ Line 322: / Line 383: @@
 |-
 |-
-| Normal [[Pulmonary embolism CT pulmonary angiography|pulmonary angiogram]].
+| Normal [[pulmonary angiogram]]
 |bgcolor="PaleTurquoise" align="center"| '''+'''
 |bgcolor="PaleTurquoise" align="center"| '''+'''
@@ Line 328: / Line 389: @@
 |-
 |-
-| [[Pulmonary embolism laboratory tests#D-dimers|D-dimer]]: Negative result, highly sensitive assay.
+| [[Pulmonary embolism laboratory tests#D-dimers|D-dimer]]: Negative result, highly sensitive assay
 |bgcolor="PaleTurquoise" align="center"| '''+'''
 |bgcolor="PaleTurquoise" align="center"| '''+'''
@@ Line 334: / Line 395: @@
 |-
 |-
-|[[Pulmonary embolism laboratory tests#D-dimers|D-dimer]]: Negative result, moderately sensitive assay.
+|[[Pulmonary embolism laboratory tests#D-dimers|D-dimer]]: Negative result, moderately sensitive assay
 |bgcolor="PaleTurquoise" align="center"| '''+'''
 |bgcolor="Pink" align="center"| '''-'''
@@ Line 340: / Line 401: @@
 |-
 |-
-| [[Pulmonary embolism ventilation/perfusion scan|V/Q Scan]]: Normal lung scan.
+| [[Pulmonary embolism ventilation/perfusion scan|V/Q Scan]]: Normal [[lung]] scan
 |bgcolor="PaleTurquoise" align="center"| '''+'''
 |bgcolor="PaleTurquoise" align="center"| '''+'''
@@ Line 346: / Line 407: @@
 |-
 |-
-| [[Pulmonary embolism ventilation/perfusion scan|V/Q Scan]]: Non-diagnostic lung scan<sup>a</sup>.
+| [[Pulmonary embolism ventilation/perfusion scan|V/Q Scan]]: Non-diagnostic lung scan<sup>a</sup>
 |bgcolor="PaleTurquoise" align="center"| '''+'''
 |bgcolor="Pink" align="center"| '''-'''
@@ Line 352: / Line 413: @@
 |-
 |-
-| [[Pulmonary embolism ventilation/perfusion scan|V/Q Scan]]: Non-diagnostic lung scan<sup>a</sup> and negative proximal [[Pulmonary embolism ultrasonography|compression venous ultrasonography]].
+| [[Pulmonary embolism ventilation/perfusion scan|V/Q Scan]]: Non-diagnostic lung scan<sup>a</sup> and negative [[proximal]] [[compression venous ultrasonography]]
 |bgcolor="PaleTurquoise" align="center"| '''+'''
 |bgcolor="PaleTurquoise" align="center"| '''+'''
@@ Line 358: / Line 419: @@
 |-
 |-
-| [[Pulmonary embolism CT|Chest CT]]: Normal single-detector CT and negative proximal [[Pulmonary embolism ultrasonography|compression venous ultrasonography]].
+| [[Pulmonary embolism CT|Chest CT]]: Normal single-detector [[CT]] and negative [[proximal]] [[compression venous ultrasonography]]
 |bgcolor="PaleTurquoise" align="center"| '''+'''
 |bgcolor="PaleTurquoise" align="center"| '''+'''
@@ Line 364: / Line 425: @@
 |-
 |-
-| [[Pulmonary embolism CT|Chest CT]]: Normal multi-detector CT alone.
+| [[Pulmonary embolism CT|Chest CT]]: Normal multi-detector [[CT]] alone
 |bgcolor="PaleTurquoise" align="center"| '''+'''
 |bgcolor="PaleTurquoise" align="center"| '''+'''
@@ Line 374: / Line 435: @@
 {|style="width:75%; height:100px" border="1"
 |style="height:100px"; style="width:25%" border="1" bgcolor="DarkGray" align="center"| '''Diagnostic Criteria'''
-|style="height:100px"; style="width:75%" border="1" bgcolor="DarkGray" colspan="3" align="center"| '''Clinical Probability of PE'''
+|style="height:100px"; style="width:75%" border="1" bgcolor="DarkGray" colspan="3" align="center"| '''Clinical Probability of [[PE]]'''
 |-
 |style="height:100px"; style="width:75%" border="1" bgcolor="DarkGray" align="center"|
@@ Line 382: / Line 443: @@
 |-
 |-
-| [[Pulmonary embolism CT pulmonary angiography|Pulmonary angiogram]] showing PE.
+| [[Pulmonary angiogram]] showing PE
 |bgcolor="PaleTurquoise" align="center"| '''+'''
 |bgcolor="PaleTurquoise" align="center"| '''+'''
@@ Line 388: / Line 449: @@
 |-
 |-
-| High-probability [[Pulmonary embolism ventilation/perfusion scan|V/Q Scan]].
+| High-probability [[Pulmonary embolism ventilation/perfusion scan|V/Q Scan]]
 |bgcolor="LightYellow" align="center"| '''±'''
 |bgcolor="PaleTurquoise" align="center"| '''+'''
@@ Line 394: / Line 455: @@
 |-
 |-
-| [[Pulmonary embolism ultrasonography|Compression venous ultrasonography]] showing proximal [[DVT]].
+| [[Compression venous ultrasonography]] showing [[proximal]] [[DVT]]
 |bgcolor="PaleTurquoise" align="center"| '''+'''
 |bgcolor="PaleTurquoise" align="center"| '''+'''
@@ Line 400: / Line 461: @@
 |-
 |-
-| [[Pulmonary embolism CT|Chest CT]]: Single or multi-detector helical CT showing PE (at least segmental).
+| [[Pulmonary embolism CT|Chest CT]]: Single or multi-detector helical [[CT]] showing [[PE]] (at least segmental)
 |bgcolor="LightYellow" align="center"| '''±'''
 |bgcolor="PaleTurquoise" align="center"| '''+'''
@@ Line 406: / Line 467: @@
 |-
 |-
-| [[Pulmonary embolism CT|Chest CT]]: Single or multi-detector helical CT showing sub-segmental PE.
+| [[Pulmonary embolism CT|Chest CT]]: Single or multi-detector helical [[CT]] showing sub-segmental [[PE]]
 |bgcolor="LightYellow" align="center"| '''±'''
 |bgcolor="LightYellow" align="center"| '''±'''
@@ Line 413: / Line 474: @@
 |}
-<sup>a</sup>low or intermediate probability lung scan according to the PIOPED classification.
+<sup>a</sup>low or intermediate probability lung scan according to the PIOPED classification
 {|
@@ Line 428: / Line 489: @@
 {{cquote|
-''Adapted from 2008 ESC guidelines on the diagnosis and management of acute pulmonary embolism.''}}
+''Adapted from 2008 ESC guidelines on the diagnosis and management of [[acute]] [[pulmonary embolism]].''}}
-==Guideline Resources==
-[http://eurheartj.oxfordjournals.org/content/29/18/2276.long Guidelines on the diagnosis and management of acute pulmonary embolism. The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology]<ref name="pmid18757870">{{cite journal |author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P, Bengel F, Brady AJ, Ferreira D, Janssens U, Klepetko W, Mayer E, Remy-Jardin M, Bassand JP |title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC) |journal=[[European Heart Journal]] |volume=29 |issue=18 |pages=2276–315 |year=2008 |month=September |pmid=18757870 |doi=10.1093/eurheartj/ehn310 |url=http://eurheartj.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=18757870 |accessdate=2012-04-26}}</ref>
 ==References==
-{{reflist|2}}
+{{Reflist|2}}
+{{WH}}
+{{WS}}
 [[Category:Hematology]]
@@ Line 440: / Line 500: @@
 [[Category:Cardiology]]
 [[Category:Emergency medicine]]
+[[Category:Intensive care medicine]]
-{{WH}}
-{{WS}}