Clinical probability of pulmonary embolism: Comparison of different scoring systems

A cross-sectional analysis of four common clinical decision rules for pulmonary embolism, Mashhad, Iran

Introduction

Pulmonary embolism (PE) is a potentially fatal condition. Several non-invasive clinical decision rules (CDRs) were developed for the safe exclusion of PE. All CDRs used to safely rule out PE have been created and tested within hospital or acute care environments. However, CDRs that are designed in one specific setting may not perform as effectively when used in a different setting. In this study, we aimed to compare the performance of four common CDRs; Wells Score, Simplified Wells Score, revised Geneva Score, and simplified revised Geneva Score.

Methods

This was a cross-sectional study in which patients suspected of PE presenting to Imam Reza Hospital or Ghaem Hospital were recruited from September 23, 2013, to March 19, 2016 in Mashhad, Iran. The specificity, sensitivity, and accuracy were utilized as metrics to compare the CDRs in our region.

Results

Two hundred and forty patients were included in the study. The mean age of patients was 57.91±19.97 years, and 54.16% of them (n=130) were female. 120 patients were confirmed to have PE with CT angiography. Wells score showed the highest sensitivity (90.4%) and revised Geneva score represented the highest specificity (84.9%). The highest accuracy belongs to the simplified Wells score (62.3%).

Conclusion

In this study, we demonstrated that the Wells criteria with its high sensitivity, can be used as a score for screening, and the revised Geneva score with its high specificity, can be used in the second stage for healthy people who have been diagnosed as unhealthy by the Wells score.

Evaluation of the modified Wells score in predicting venous thromboembolic disease in patients with tuberculosis or HIV in a South African setting

Background

There is paucity of data on the modified Wells score (MWS) utility on patients with venous thromboembolism (VTE) in a South African setting where there is a high burden of HIV and tuberculosis (TB). This study analyses the performance of this score in HIV/TB-infected patients compared with non-infected patients.

Objectives

To assess the performance of the MWS as an additional risk factor for VTE in hospitalised patients with a high burden of HIV/TB infections.

Method

This study was a retrospective cross-sectional cohort analysis of the utility of the MWS in 156 HIV/TB-infected and non-infected adult patients diagnosed with VTE on compression ultrasonography (CUS) or computed tomography pulmonary angiography (CTPA) in a medical inpatient setting over six months. Patients with HIV and/or TB were assessed as having an additional risk factor (1 point for each), and this was compared with the MWS. A McNeymar’s paired sample chi-squared test was used to compare the sensitivity of this score against the MWS.

Results

Of the 156 patients with VTE who were enrolled, HIV was the commonest risk factor (42.31%) with TB accounting for 10.90% of cases. When the MWS adjusted for HIV/TB was used, the sensitivity increased from 25% to 100% for the HIV–/TB+ category, it increased from 77.36% to 98.11% in the HIV+/TB– category and it increased from 84.62% to 92.95% in the HIV+/TB+ category. These differences were statistically significant at P < 0.05 in all categories.

Conclusion

The MWS performs better when the infectivity of HIV/TB is included as an additional risk factor in the score.

A comparative analysis of the diagnostic performances of four clinical probability models for acute pulmonary embolism in a sub-Saharan African population: a cross-sectional study

Background

The diagnosis of acute pulmonary embolism (PE) is one of the most challenging in emergency settings where prompt and accurate decisions need to be taken for life-saving purposes. Here, the assessment of the clinical probability of PE is a paramount step in its diagnosis. Although clinical probability models (CPM) for PE are routinely used in emergency departments (EDs) of low-resource settings, few studies have cited their diagnostic performances in sub-Saharan Africa (SSA). We aimed to comparatively assess the accuracy of four CPM in the diagnosis of acute PE in sub-Saharan Africans.

Methods

We carried out a cross-sectional study to compare the sensitivity, specificity, positive and negative predictive values and accuracy of four CPM namely; the Wells, simplified Wells, revised Geneva and the simplified revised Geneva (SRG) Scores to computed tomography pulmonary angiography (CTPA) in all adults patients with suspected PE admitted to the EDs of the Gynaeco-obstetric and Paediatric Hospital of Yaoundé and the Yaoundé Central Hospital in Cameroon between January 1, 2017 and April 30, 2018.

Results

In total, we enrolled 30 patients with clinical suspicion of acute PE. PE was confirmed on CTPA in 16 (53.3%) cases. Their mean age was 53.7 ± 15.5 years and 36.7% were males. All four scores had a diagnostic performance superior to 50% in all criteria assessed. The simplified Wells score had the highest sensitivity (62.5%) followed by the Wells score (56.3%). The SRG score had the highest specificity (71.4%). The score with highest PPV was the SRG score (66.7%) and that with the highest NPV was the Wells score (56.3%). Overall the models with the highest accuracies were the Wells and SRG scores (60% for each).

Conclusion

All CPM had a suboptimal diagnostic performance, perhaps highlighting the need of a more optimal CPM for acute PE in SSA. However, the Wells and the SRG scores appeared to be most accurate than the other two scores in the ED. Hence, both or either of them may be used in first intention to predict PE and guide which ED patients should undergo further investigations in an emergency SSA setting.

Clinical Update. Clinical Presentations of Pulmonary Embolism in the Emergency Department

Pulmonary embolism (PE) is one of the most severe conditions encountered in the emergency department (ED) and one of the leading causes of cardiovascular morbidity and mortality, especially in patients presenting with hemodynamic instability, right ventricular dysfunction, or necessitating cardiopulmonary resuscitation. The early recognition and treatment of PE is essential, as many studies demonstrated that mortality rates drop significantly if adequate therapy is administered from the early stages. The aim of this update is to summarize the various patterns of PE presentations in the ED.