Ruling Out Pulmonary Embolism in the Primary Care Setting

Pete Yunyongying

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Jun 1, 2018 Issue

Point-of-Care Guides

Ruling Out Pulmonary Embolism in the Primary Care Setting

PETE YUNYONGYING, MD, Augusta University/University of Georgia Medical Partnership, Athens, Georgia

Am Fam Physician. 2018 Jun 1;97(11):750-752.

Author disclosure: No relevant financial affiliations.

Clinical Question

What is the best approach to evaluate patients with suspected pulmonary embolism (PE) in the outpatient primary care setting?

Evidence Summary

Acute PE accounts for one out of 400 to 1,500 adult presentations to the emergency department,1 with a 30-day mortality rate of 5.4%.2 Chronic thromboembolic pulmonary hypertension further adds to morbidity in 4.8% of patients who survive PE.3 However, PE has a highly variable presentation.

Many clinical decision rules exist to estimate the patient's risk level based on certain clinical characteristics and subsequently guide the evaluation of suspected PE. These include the Wells score, Geneva score, Pisa model, and Pulmonary Embolism Rule-out Criteria (PERC). Each of the rules has advantages and disadvantages (eTable A). A primary care protocol that uses three of these rules to rule out PE is presented in Table 1.4

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eTABLE A

Summary of Clinical Decision Rules for the Diagnosis of Acute Pulmonary Embolism

Clinical decision rule	Multiple validated versions?	Number of characteristics	Characteristics that are not history or physical examination findings	Attributes requiring subjective judgments?	Validated in outpatient emergency department?	Validated in primary care?	Comments
Geneva score	Yes	8	None	No	Yes	Yes	Versions: original, revised, simplified revised
Pisa model	Yes	11	Chest radiograph or electrocardiogram	No	Yes	No	—
Pulmonary Embolism Rule-out Criteria	Yes	8	None	No	Yes	No	Combine with other clinical decision rules per American College of Physicians
Wells score	Yes	7	None	Yes	Yes	Yes (Netherlands)	Versions: original, modified, simplified
Wells + ultrasonography	No	7	Point-of-care ultrasonography	No	Yes	No	—

eTABLE A

Summary of Clinical Decision Rules for the Diagnosis of Acute Pulmonary Embolism

Clinical decision rule	Multiple validated versions?	Number of characteristics	Characteristics that are not history or physical examination findings	Attributes requiring subjective judgments?	Validated in outpatient emergency department?	Validated in primary care?	Comments
Geneva score	Yes	8	None	No	Yes	Yes	Versions: original, revised, simplified revised
Pisa model	Yes	11	Chest radiograph or electrocardiogram	No	Yes	No	—
Pulmonary Embolism Rule-out Criteria	Yes	8	None	No	Yes	No	Combine with other clinical decision rules per American College of Physicians
Wells score	Yes	7	None	Yes	Yes	Yes (Netherlands)	Versions: original, modified, simplified
Wells + ultrasonography	No	7	Point-of-care ultrasonography	No	Yes	No	—

Enlarge Print

TABLE 1.

A Primary Care Protocol to Rule Out Pulmonary Embolism

Wells score		Geneva score		PERC

Clinical characteristics	Points	Clinical characteristics	Points	Clinical characteristics
Previous PE or DVT	1	Previous PE or DVT	1	No history of venous thromboembolism
Surgery or immobilization within four weeks of presentation	1	Surgery or fracture of the lower limbs within one month of presentation	1	No surgery or trauma within four weeks
Hemoptysis	1	Hemoptysis	1	Initial oxygen saturation > 94% on room air
Clinical signs of DVT	1	Pain on lower limb deep venous palpation and unilateral edema	1	No hemoptysis
Alternative diagnosis less likely than PE	1	Unilateral lower limb pain	1	No unilateral leg swelling
Active cancer	1	Active cancer	1	No estrogen use
Heart rate > 100 beats per minute	1	Heart rate		Initial heart rate < 100 beats per minute
Total:	______	75 to 94 beats per minute	1
		≥ 95 beats per minute	2	Age < 50 years
		Age > 65 years	1
		Total:	______
Interpretation: Patients with fewer than 2 points on the Wells score or 2 points or fewer on the Geneva score have a low risk of PE. Absence of PE should be confirmed using the PERC or d-dimer testing. If either is negative, PE is ruled out.				Interpretation: PE is ruled out in patients with all of the above characteristics.

DVT = deep venous thrombosis; PE = pulmonary embolism; PERC = Pulmonary Embolism Rule-out Criteria.

Adapted with permission from Raja AS, Greenberg JO, Qaseem A, et al. Evaluation of patients with suspected acute pulmonary embolism: best practice advice from the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. 2015;163(9):701–711.

TABLE 1.

A Primary Care Protocol to Rule Out Pulmonary Embolism

Wells score		Geneva score		PERC

Clinical characteristics	Points	Clinical characteristics	Points	Clinical characteristics
Previous PE or DVT	1	Previous PE or DVT	1	No history of venous thromboembolism
Surgery or immobilization within four weeks of presentation	1	Surgery or fracture of the lower limbs within one month of presentation	1	No surgery or trauma within four weeks
Hemoptysis	1	Hemoptysis	1	Initial oxygen saturation > 94% on room air
Clinical signs of DVT	1	Pain on lower limb deep venous palpation and unilateral edema	1	No hemoptysis
Alternative diagnosis less likely than PE	1	Unilateral lower limb pain	1	No unilateral leg swelling
Active cancer	1	Active cancer	1	No estrogen use
Heart rate > 100 beats per minute	1	Heart rate		Initial heart

Address correspondence to Pete Yunyongying, MD, at pete.yunyongying@carle.com. Reprints are not available from the author.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Kline JA, Kabrhel C. Emergency evaluation for pulmonary embolism, part 1: clinical factors that increase risk. J Emerg Med. 2015;48(6):771–780....

2. Pollack CV, Schreiber D, Goldhaber SZ, et al. Clinical characteristics, management, and outcomes of patients diagnosed with acute pulmonary embolism in the emergency department: initial report of EMPEROR (multicenter emergency medicine pulmonary embolism in the real world registry). J Am Coll Cardiol. 2011;57(6):700–706.

3. Guérin L, Couturaud F, Parent F, et al. Prevalence of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism. Prevalence of CTEPH after pulmonary embolism. Thromb Haemost. 2014;112(3):598–605.

4. Raja AS, Greenberg JO, Qaseem A, et al. Evaluation of patients with suspected acute pulmonary embolism: best practice advice from the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. 2015; 163(9):701–711.

5. Wells PS, Anderson DR, Rodger M, et al. 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. 2001;135(2):98–107.

6. Kline JA. Diagnosis and exclusion of pulmonary embolism [published ahead of print March 8, 2010]. Thromb Res. http://www.thrombosisresearch.com/article/S0049-3848(17)30358-4/fulltext (login required). Accessed November 6, 2017.

7. Gibson NS, Sohne M, Kruip MJ, et al.; Christopher study investigators. Further validation and simplification of the Wells clinical decision rule in pulmonary embolism. Thromb Haemost. 2008;99(1):229–234.

8. Nazerian P, Volpicelli G, Gigli C, et al.; Ultrasound Wells Study Group. Diagnostic performance of Wells score combined with point-of-care lung and venous ultrasound in suspected pulmonary embolism. Acad Emerg Med. 2017;24(3):270–280.

9. Kline JA, Webb WB, Jones AE, Hernandez-Nino J. Impact of a rapid rule-out protocol for pulmonary embolism on the rate of screening, missed cases, and pulmonary vascular imaging in an urban US emergency department. Ann Emerg Med. 2014;44(5):490–502.

10. Miniati M, Bottai M, Monti S, Salvadori M, Serasini L, Passera M. Simple and accurate prediction of the clinical probability of pulmonary embolism. Am J Respir Crit Care Med. 2008;178(3):290–294.

11. Miniati M, Monti S, Bottai M. A structured clinical model for predicting the probability of pulmonary embolism. Am J Med. 2003;114(3):173–179.

12. Duoma RA, Mos IC, Erkens PM, et al.; Prometheus Study Group. Performance of 4 clinical decision rules in the diagnostic management of acute pulmonary embolism: a prospective cohort study. Ann Int Med. 2011;154(11):709–718.

13. Shen JH, Chen HL, Chen JR, Xing JL, Gu P, Zhu BF. Comparison of the Wells score with the revised Geneva score for assessing suspected pulmonary embolism: a systematic review and meta-analysis. J Thromb Thrombolysis. 2016;41(3):482–492.

14. Hendriksen JM, Geersing GJ, Lucassen WA, et al. Diagnostic prediction models for suspected pulmonary embolism: systematic review and independent external validation in primary care. BMJ. 2015;351:h4438.

This guide is one in a series that offers evidence-based tools to assist family physicians in improving their decision making at the point of care.

This series is coordinated by Mark H. Ebell, MD, MS, Deputy Editor for Evidence-Based Medicine.

A collection of Point-of-Care Guides published in AFP is available at https://www.aafp.org/afp/poc.

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