Pulmonary Embolism Clinical Prediction Rules
Pulmonary Embolism (PE): Clinical Prediction Rules
Note: These rules should be used with caution, because none of these scoring protocols are perfect. For instance, in a very recent publication of the Journal of Thrombosis and Haemostasis, the authors found that the PERC rule may not actually safely exclude PEs.
Pulmonary Embolism Rule-out Criteria (PERC) Rule
Kline et al. J Thromb Haem 2004; Kline et al. J Thromb Haem 2008
- Age <50 years
- Heart rate <100 bpm
- Room air oxygen saturation ≥95%
- No prior DVT or PE
- No recent trauma or surgery (4 weeks)
- No hemoptysis
- No exogenous estrogen
- No clinical signs suggestive of DVT
If all 8 present: Only 1% risk for venous thromboembolism (VTE) at 45 days.
Wells' Score
Wells et al. Thromb Haemost; Wells et al. Ann Intern Med
| Clinical Finding or Risk Factor | Points |
|---|---|
| Clinical signs and symptoms of DVT | +3 |
| PE is #1 diagnosis, or equally likely | +3 |
| Heart rate > 100 bpm | +1.5 |
| Immobilization for ≥ 3 days, or Surgery in ≤ 4 wks | +1.5 |
| Previous, objectively diagnosed PE or DVT | +1.5 |
| Hemoptysis | +1 |
| Malignancy with treatment within 6 months, or palliative | +1 |
| Total # Wells points | Risk for PE at 3 months |
|---|---|
| <2 | 1.3% |
| 2-6 | 16.2% |
| >6 | 40.6% |
| ≤4 and neg D-Dimer | 0.5% non-fatal VTE [Van Belle, 2006] |
Simplified Geneva Score
Klok FA et al. Arch Intern Med 2008
| Clinical Finding or Risk Factor | Points |
|---|---|
| Age > 65 years | +1 |
| Previous DVT or PE | +1 |
| Surgery (general anesthesia) or fracture (lower limbs) ≤ 1 month | +1 |
| Active malignancy (solid or hematologic, 1 currently active or considered cured < 1 year) | +1 |
| Unilateral lower-limb pain | +1 |
| Hemoptysis | +1 |
| Heart rate ≥ 75 bpm | +1 |
| Unilateral edema | +1 |
| Pain on lower-limb deep venous palpation | +4 |
| Total # of points | Incidence of PE |
|---|---|
| 0-1 | 7.7% |
| 2-4 | 29.4% |
| 5-7 | 64.3% |
References
- Klok FA et al.Simplification of the revised Geneva score for assessing clinical probability of pulmonary embolism. Arch Intern Med 2008 [PubMed]
- Wells 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. [PubMed]
- Van Belle et al. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography.JAMA 2006 [PubMed]
- Hugli O, Righini M, Le Gal G, Roy PM, Sanchez O, Verschuren F, Meyer G, Bounameaux H, Aujesky D.The pulmonary embolism rule-out criteria (PERC) rule does not safely exclude pulmonary embolism.J Thromb Haemost. 2011 Feb;9(2):300-4. [PubMed]
- Kline et al. Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism.J Thromb Haem 2004. [PubMed]
- Kline et al. Prospective multicenter evaluation of the pulmonary embolism rule-out criteria. J Thromb Haem 2008. [PubMed]
- Wells et al.Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer. Thromb Haemost 2000 [PubMed]
