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Performance of 4 clinical decision rules in the diagnostic management of acute pulmonary embolism: a prospective cohort study.
Ann Intern Med. 2011 Jun 07; 154(11):709-18.AIM

Abstract

BACKGROUND

Several clinical decision rules (CDRs) are available to exclude acute pulmonary embolism (PE), but they have not been directly compared.

OBJECTIVE

To directly compare the performance of 4 CDRs (Wells rule, revised Geneva score, simplified Wells rule, and simplified revised Geneva score) in combination with d-dimer testing to exclude PE.

DESIGN

Prospective cohort study.

SETTING

7 hospitals in the Netherlands.

PATIENTS

807 consecutive patients with suspected acute PE.

INTERVENTION

The clinical probability of PE was assessed by using a computer program that calculated all CDRs and indicated the next diagnostic step. Results of the CDRs and d-dimer tests guided clinical care.

MEASUREMENTS

Results of the CDRs were compared with the prevalence of PE identified by computed tomography or venous thromboembolism at 3-month follow-up.

RESULTS

Prevalence of PE was 23%. The proportion of patients categorized as PE-unlikely ranged from 62% (simplified Wells rule) to 72% (Wells rule). Combined with a normal d-dimer result, the CDRs excluded PE in 22% to 24% of patients. The total failure rates of the CDR and d-dimer combinations were similar (1 failure, 0.5% to 0.6% [upper-limit 95% CI, 2.9% to 3.1%]). Even though 30% of patients had discordant CDR outcomes, PE was not detected in any patient with discordant CDRs and a normal d-dimer result.

LIMITATION

Management was based on a combination of decision rules and d-dimer testing rather than only 1 CDR combined with d-dimer testing.

CONCLUSION

All 4 CDRs show similar performance for exclusion of acute PE in combination with a normal d-dimer result. This prospective validation indicates that the simplified scores may be used in clinical practice.

PRIMARY FUNDING SOURCE

Academic Medical Center, VU University Medical Center, Rijnstate Hospital, Leiden University Medical Center, Maastricht University Medical Center, Erasmus Medical Center, and Maasstad Hospital.

Authors+Show Affiliations

Academic Medical Center, Amsterdam, the Netherlands.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Comparative Study
Journal Article
Multicenter Study
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

21646554

Citation

Douma, Renée A., et al. "Performance of 4 Clinical Decision Rules in the Diagnostic Management of Acute Pulmonary Embolism: a Prospective Cohort Study." Annals of Internal Medicine, vol. 154, no. 11, 2011, pp. 709-18.
Douma RA, Mos IC, Erkens PM, et al. Performance of 4 clinical decision rules in the diagnostic management of acute pulmonary embolism: a prospective cohort study. Ann Intern Med. 2011;154(11):709-18.
Douma, R. A., Mos, I. C., Erkens, P. M., Nizet, T. A., Durian, M. F., Hovens, M. M., van Houten, A. A., Hofstee, H. M., Klok, F. A., ten Cate, H., Ullmann, E. F., Büller, H. R., Kamphuisen, P. W., & Huisman, M. V. (2011). Performance of 4 clinical decision rules in the diagnostic management of acute pulmonary embolism: a prospective cohort study. Annals of Internal Medicine, 154(11), 709-18. https://doi.org/10.7326/0003-4819-154-11-201106070-00002
Douma RA, et al. Performance of 4 Clinical Decision Rules in the Diagnostic Management of Acute Pulmonary Embolism: a Prospective Cohort Study. Ann Intern Med. 2011 Jun 7;154(11):709-18. PubMed PMID: 21646554.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Performance of 4 clinical decision rules in the diagnostic management of acute pulmonary embolism: a prospective cohort study. AU - Douma,Renée A, AU - Mos,Inge C M, AU - Erkens,Petra M G, AU - Nizet,Tessa A C, AU - Durian,Marc F, AU - Hovens,Marcel M, AU - van Houten,Anja A, AU - Hofstee,Herman M A, AU - Klok,Frederikus A, AU - ten Cate,Hugo, AU - Ullmann,Erik F, AU - Büller,Harry R, AU - Kamphuisen,Pieter W, AU - Huisman,Menno V, AU - ,, PY - 2011/6/8/entrez PY - 2011/6/8/pubmed PY - 2011/8/13/medline SP - 709 EP - 18 JF - Annals of internal medicine JO - Ann Intern Med VL - 154 IS - 11 N2 - BACKGROUND: Several clinical decision rules (CDRs) are available to exclude acute pulmonary embolism (PE), but they have not been directly compared. OBJECTIVE: To directly compare the performance of 4 CDRs (Wells rule, revised Geneva score, simplified Wells rule, and simplified revised Geneva score) in combination with d-dimer testing to exclude PE. DESIGN: Prospective cohort study. SETTING: 7 hospitals in the Netherlands. PATIENTS: 807 consecutive patients with suspected acute PE. INTERVENTION: The clinical probability of PE was assessed by using a computer program that calculated all CDRs and indicated the next diagnostic step. Results of the CDRs and d-dimer tests guided clinical care. MEASUREMENTS: Results of the CDRs were compared with the prevalence of PE identified by computed tomography or venous thromboembolism at 3-month follow-up. RESULTS: Prevalence of PE was 23%. The proportion of patients categorized as PE-unlikely ranged from 62% (simplified Wells rule) to 72% (Wells rule). Combined with a normal d-dimer result, the CDRs excluded PE in 22% to 24% of patients. The total failure rates of the CDR and d-dimer combinations were similar (1 failure, 0.5% to 0.6% [upper-limit 95% CI, 2.9% to 3.1%]). Even though 30% of patients had discordant CDR outcomes, PE was not detected in any patient with discordant CDRs and a normal d-dimer result. LIMITATION: Management was based on a combination of decision rules and d-dimer testing rather than only 1 CDR combined with d-dimer testing. CONCLUSION: All 4 CDRs show similar performance for exclusion of acute PE in combination with a normal d-dimer result. This prospective validation indicates that the simplified scores may be used in clinical practice. PRIMARY FUNDING SOURCE: Academic Medical Center, VU University Medical Center, Rijnstate Hospital, Leiden University Medical Center, Maastricht University Medical Center, Erasmus Medical Center, and Maasstad Hospital. SN - 1539-3704 UR - https://www.unboundmedicine.com/medline/citation/21646554/Performance_of_4_clinical_decision_rules_in_the_diagnostic_management_of_acute_pulmonary_embolism:_a_prospective_cohort_study_ L2 - https://www.acpjournals.org/doi/10.7326/0003-4819-154-11-201106070-00002?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub=pubmed DB - PRIME DP - Unbound Medicine ER -