Pulmonary Embolism is Enigmatic Problem in Emergency Service: Performance of Wells Score, Geneva Score and Other Test for PE

Year 2017, Volume: 2 Issue: 1, 36 - 44, 22.05.2017

Aynur Yurtseven , Mehmet Tatlı Ismail Altintop

Abstract

Background

Pulmonary
embolism which is an mysterious and difficult disease to diagnose is the third
most common cause of death from cardiovascular disease. Despite recent clinical
studies and technological development, pulmonary embolism diagnosing is hard
and complicated. Diagnosis of pulmonary embolism starts with physcians
suspicion. Firstly, assessment of clinical pre-test probability is important. Clinical
pre-test probability is based on assessment of whether symptoms and signs are
typical for pulmonary embolism. Geneva score and  Wells score are most known pre-tests. The
revised Geneva score, a standardized clinical decision rule in the diagnosis of
pulmonary embolism (PE). The Wells score is widely used for the assessment of
pretest probability of pulmonary embolism (PE). The revised Geneva score is a
fully standardized clinical decision rule. We compared the predictive accuracy
of these two pre-test probabilities.

Methods:

In 119 consecutive
patients, the clinical probability of PE was assessed prospectively by the
Wells rule and retrospectively using the revised Geneva score. Patients
comprised a random sample from a single center, participating in a large
prospective multicenter diagnostic study.

Results:

The
overall prevalence of PE was 31%. The prevalence of PE in the low-probability,
intermediate-probability and high-probability categories are grouped by the revised
Geneva score.  After three months of
followup, any patient categorised into the low or intermediate clinical
probability category by the revised Geneva score. Normal D-dimer result was
diagnosed with acute venous thromboembolism. When we compare Geneva and Wells
scores, their predictive values were similar for PE group. Predictive values of
Geneva scores for PE and non-PE were not importantly different (p=0.169), but
Wells scores were importantly higher for PE group (p=0.006).

Conclusions:

This
study recommends that the performance of the revised Geneva score is equal to
that of the Wells score. In addition, it appears safe to exclude PE in patients
by the combination of a low or intermediate clinical probability by the revised
Geneva score and a normal D-dimer. Determining clinical probability is the main
step for diagnosis. High D-dimer value is important for clinical suspicion, but
low values can’t eliminate the diagnosis. Also we showed that Wells score’s
predictive value was higher than Genova score but predictions of mortality were
similar. Both clinical risk classification and laboratory results must be
evaluated  together with Genova score in
suspected PE cases. In our population, the Wells score appeared to be more
accurate than the simplified revised Geneva score. Patient outcomes should be examined in
a prospective study.

Keywords

Pulmonary embolism, geneva score, wells score

References

• Chen JSH, Xing JCJ. Comparison of the Wells score with the revised Geneva score for assessing suspected pulmonary embolism : a systematic review and meta-analysis. J Thromb Thrombolysis. 2015;
• 2. Benson CB, Khorasani R. in the Inpatient Setting. 2015;2445:1–6.
• 3. Goldhaber SZ, Bounameaux H. Pulmonary embolism and deep vein thrombosis. Lancet. 2012;379(9828):1835–46.
• 4. Klok FA, Kruisman E, Spaan J, Nijkeuter M, Righini M, Aujesky D. Comparison of the revised Geneva score with the Wells rule for assessing clinical probability of pulmonary embolism. 2008;(October 2007):40–4.
• 5. Penaloza A, Verschuren F, Meyer G, Quentin-georget S, Soulie C. Comparison of the Unstructured Clinician Gestalt , the Wells Score , and the Revised Geneva Score to Estimate Pretest Probability for Suspected Pulmonary Embolism. YMEM. 2013;62(2):117–124.e2.
• 6. Morgenthaler TI, Ryu JH. Clinical characteristics of fatal pulmonary embolism in a referral hospital. In: Mayo Clinic Proceedings. Elsevier; 1995. p. 417–24.
• 7. Lapner ST, Kearon C. Clinical review. 2013;757(February):1–9.
• 8. Klings ES, Machado RF, Barst RJ, Morris CR, Mubarak KK, Gordeuk VR, et al. An official American Thoracic Society clinical practice guideline: diagnosis, risk stratification, and management of pulmonary hypertension of sickle cell disease. Am J Respir Crit Care Med. 2014;189(6):727–40.
• 9. Bĕlohlávek J, Dytrych V, Linhart A. Pulmonary embolism, part I: Epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis and nonthrombotic pulmonary embolism. Exp Clin Cardiol. 2013;18(2):129.
• 10. Güzel A, Yavuz Y, Sisman B, Duran L, Altuntas M, Murat N. A Retrospective Evaluation of Patients Admitted to Emergency Departments with Pulmonary Thromboembolism. J Acad Emerg Med. 2015;14(1):8.