Betrouwbaarheid klinische beslisregels bij diagnostiek van acute longembolie

Objective

To directly compare the performance of four clinical decision rules (CDRs) (Wells rule, revised Geneva score, simplified Wells rule and simplified revised Geneva score) in combination with D-dimer testing in excluding acute pulmonary embolism (PE).

Design

Prospective cohort study.

Method

In patients with suspected PE, the clinical probability of PE was assessed on the basis of the results of the CDRs and D-dimer test results using a computer program which calculated all CDRs and indicated the next diagnostic step. The CDRs results were compared using the outcome measure ‘PE’ assessed by CT-scanning or by the occurrence of venous thromboembolism or PE during a 3-month follow-up period after excluding PE.

Results

A total of 807 consecutive patients with suspected PE were included. PE prevalence was 23%. The number of patients categorised as ‘PE unlikely’ ranged from 62% (simplified Wells rule) to 72% (Wells rule). This CDR result combined with a normal D-dimer level excluded PE, which was the case in 22-24% of patients. There was no difference between the CDRs in the number of missed PEs (1 missed (0.5-0.6%); upper 95% CI: 2.9-3.1%). Although 30% of the patients had discordant CDR outcomes, PE was missed in none of the patients with discordant CDRs and a normal D-dimer result.

Conclusion

All four CDRs show similar performance for exclusion of acute PE in combination with a normal D-dimer level. In addition this prospective study indicates that also the simplified scores can be used in clinical practice.

Conflict of interest: the institution of M.V. Huisman received research grants from Bayer, Actelion and Boehringer Ingelheim; H. ten Cate received payment for lectures from Boehringer, Bayer and Glaxo-Smith-Kline. Financial support for this article: none declared.