Assessing clinical probability of pulmonary embolism: prospective validation of the simplified Geneva score

The History of Diagnosing Venous Thromboembolism

An accurate and prompt diagnosis of deep vein thrombosis and/or pulmonary embolism is important to prevent serious complications and mortality. Because the clinical presentation of venous thromboembolism (VTE) is often nonspecific, objective testing by means of radiological imaging is required to confirm the diagnosis. Historically, a diagnosis of VTE involved invasive imaging techniques like contrast venography or conventional pulmonary angiography. Technological developments toward more accurate and less invasive diagnostics have driven the implementation of a variety of newer technologies over the past decades, as well as the derivation and validation of clinical decision rules (CDRs) that can be used to rule out VTE in combination with D-dimer blood tests. In this narrative review, we provide a historical overview of the most notable developments in the imaging techniques and CDRs for VTE diagnosis.

In-Hospital versus Out-of-Hospital Pulmonary Embolism: Clinical Characteristics, Biochemical Markers and Echocardiographic Indices

BACKGROUND

A significant proportion of pulmonary embolisms (PEs) occurs in patients during hospitalisation for another reason. However, limited data regarding differences between out-of-hospital PE (OHPE) and in-hospital PE (IHPE) is available. We aimed to compare these groups regarding their clinical characteristics, biochemical markers, and echocardiographic indices.

METHODS

This was a prospective, single-arm, single-centre study. Adult consecutive patients with non-COVID-related PE from September 2019 to March 2022 were included and followed up for 12 months.

RESULTS

The study included 180 (84 women) patients, with 89 (49.4%) suffering from IHPE. IHPE patients were older, they more often had cancer, were diagnosed earlier after the onset of symptoms, they had less frequent pain and higher values of high sensitivity troponin I and brain natriuretic peptide levels compared to OHPE patients. Echocardiographic right ventricular (RV) dysfunction was detected in similar proportions in the 2 groups. IHPE had increased in-hospital mortality (14.6% vs. 3.3%, p = 0.008) and similar post-discharge to 12-month mortality with OHPE patients.

CONCLUSIONS

In this prospective cohort study, IHPE differed from OHPE patients regarding age, comorbidities, symptoms, and levels of biomarkers associated with RV dysfunction. IHPE patients had higher in-hospital mortality compared to OHPE patients and a similar risk of death after discharge.

Developing a nomogram-based scoring model to estimate the risk of pulmonary embolism in respiratory department patients suspected of pulmonary embolisms

Objective

Pulmonary embolisms (PE) are clinically challenging because of their high morbidity and mortality. This study aimed to create a nomogram to accurately predict the risk of PE in respiratory department patients in order to enhance their medical treatment and management.

Methods

This study utilized a retrospective method to collect information on medical history, complications, specific clinical characteristics, and laboratory biomarker results of suspected PE patients who were admitted to the respiratory department at Affiliated Dongyang Hospital of Wenzhou Medical University between January 2012 and December 2021. This study involved a total of 3,511 patients who were randomly divided into a training group (six parts) and a validation group (four parts) based on a 6:4 ratio. The LASSO regression and multivariate logistic regression were used to develop a scoring model using a nomogram. The performance of the model was evaluated using receiver operating characteristic curve (AUC), calibration curve, and clinical decision curve.

Results

Our research included more than 50 features from 3,511 patients. The nomogram-based scoring model was established using six predictive features including age, smoke, temperature, systolic pressure, D-dimer, and fibrinogen, which achieved AUC values of 0.746 in the training cohort (95% CI 0.720-0.765) and 0.724 in the validation cohort (95% CI 0.695-0.753). The results of the calibration curve revealed a strong consistency between probability predicted by the nomogram and actual probability. The decision curve analysis (DCA) also demonstrated that the nomogram-based scoring model produced a favorable net clinical benefit.

Conclusion

In this study, we successfully developed a novel numerical model that can predict the risk of PE in respiratory department patients suspected of PE, which can not only appropriately select PE prevention strategies but also decrease unnecessary computed tomographic pulmonary angiography (CTPA) scans and their adverse effects.

A nomogram for predicting the risk of pulmonary embolism in neurology department suspected PE patients: A 10-year retrospective analysis

Objective

The purpose of this retrospective study was to establish a numerical model for predicting the risk of pulmonary embolism (PE) in neurology department patients.

Methods

A total of 1,578 subjects with suspected PE at the neurology department from January 2012 to December 2021 were considered for enrollment in our retrospective study. The patients were randomly divided into the training cohort and the validation cohort in the ratio of 7:3. The least absolute shrinkage and selection operator regression were used to select the optimal predictive features. Multivariate logistic regression was used to establish the numerical model, and this model was visualized by a nomogram. The model performance was assessed and validated by discrimination, calibration, and clinical utility.

Results

Our predictive model indicated that eight variables, namely, age, pulse, systolic pressure, hemoglobin, neutrophil count, low-density lipoprotein, D-dimer, and partial pressure of oxygen, were associated with PE. The area under the receiver operating characteristic curve of the model was 0.750 [95% confidence interval (CI): 0.721–0.783] in the training cohort and 0.742 (95% CI: 0.689–0.787) in the validation cohort, indicating that the model showed a good differential performance. A good consistency between the prediction and the real observation was presented in the training and validation cohorts. The decision curve analysis in the training and validation cohorts showed that the numerical model had a good net clinical benefit.

Conclusion

We established a novel numerical model to predict the risk factors for PE in neurology department suspected PE patients. Our findings may help doctors to develop individualized treatment plans and PE prevention strategies.

D-dimer Testing in Pulmonary Embolism with a Focus on Potential Pitfalls: A Narrative Review

D-dimer is a multifaceted biomarker of concomitant activation of coagulation and fibrinolysis, which is routinely used for ruling out pulmonary embolism (PE) and/or deep vein thrombosis (DVT) combined with a clinical pretest probability assessment. The intended use of the tests depends largely on the assay used, and local guidance should be applied. D-dimer testing may suffer from diagnostic errors occurring throughout the pre-analytical, analytical, and post-analytical phases of the testing process. This review aims to provide an overview of D-dimer testing and its value in diagnosing PE and discusses the variables that may impact the quality of its laboratory assessment.

The High Expression of Adhering and Circulating Integrin Serves as a Diagnostic Marker in Venous Thromboembolism

Objective

To investigate the diagnostic value of circulating integrins β1, 2, and 3 in venous thrombosis (VTE).

Materials and Methods

A total of 474 VTE patients and 306 patients with nonhigh risk for VTE as the control group were studied. Levels of adhering integrins β1, 2, and 3 were detected by flow cytometry. Levels of circulating integrins β1, 2, and 3 in serum were measured by enzyme-linked immunosorbent assay.

Results

We found that integrins β1, 2, and 3 were expressed highly both in serum and on the surface of leukocytes and platelets in venous thromboembolism. The levels of circulating integrins β1, 2, and 3 are positively correlated with adhering integrins. It showed excellent clinical diagnostic performance of circulating integrins β1, 2, and 3 in venous thromboembolism.

Conclusions

Integrin subunit β can be used as a diagnostic marker with high sensitivity and specificity for venous thromboembolism.

Diagnostic Value of Galectin-3 for Identifying Acute Pulmonary Embolism in the Emergency Department

BACKGROUND

Pulmonary embolism (PE) is a common disease associated with high mortality and morbidity. Diagnosing PE is challenging due to diverse clinical presentations and the lack of specific biomarkers.

OBJECTIVE

We hypothesized that plasma galectin-3 (Gal-3) levels might reflect the severity of acute PE and be useful for diagnostic assessment.

METHODS

In this prospective study, 150 patients (100 patients with PE and 50 control patients) were included. Patients were stratified into high-risk, medium-risk, and low-risk groups according to the Wells and revised Geneva scoring systems, and Gal-3 levels were compared among the groups. PE was diagnosed by means of computed tomography pulmonary angiography.

RESULTS

In this study, of the 100 PE patients included in the study, 69 patients recovered and were discharged and 31 patients died. Median Gal-3 value in the PE group was 27.0 ng/mL (range 11.5-35.0 ng/mL), whereas the median Gal-3 value in the control group was significantly lower at 8.8 ng/mL (range 1.0-21.0 ng/mL) (p < 0.001). When the Gal-3 values of the PE group and the control group were evaluated with the receiver operator characteristic curve, the area under the curve was calculated as 0.99 (95% confidence interval 0.979-1). At a Gal-3 cutoff value of 13.55 ng/mL, which was determined to be the most appropriate value for PE diagnosis, the sensitivity was 98% and the specificity was 92%.

CONCLUSIONS

A biomarker that rapidly and accurately diagnoses acute PE in the emergency department can be an extremely useful tool. We concluded that plasma Gal-3 levels can be regarded as a promising marker of acute PE.

Assessing the clinical probability of pulmonary embolism during pregnancy: The Pregnancy-Adapted Geneva (PAG) score

BACKGROUND

The diagnosis of pulmonary embolism (PE) in pregnant women represents an ongoing challenge. As in the general population, the first step in pregnant women with suspected PE consists of assessing clinical pre-test probability (PTP). However, no dedicated clinical decision rule has been developed in this population.

OBJECTIVE

To propose a new version of the Geneva score adapted to pregnant women with suspected PE.

METHODS

Data from a multicenter, prospective management outcome study including 395 women with suspected PE, in whom PTP was assessed using the Geneva score, were used. We first removed items which were present in none of the patients (cancer, age >65 years). Receiver operating characteristic (ROC) curve analysis was then performed for quantitative variables and the optimal threshold defined. The obtained Pregnancy-Adapted Geneva Score (PAG Score) comprised seven items, including an age 40 years or older and a heart rate >110 beats per minute.

RESULTS

The PAG Score showed a high discriminative power to identify patients with a low, intermediate, or high PTP, associated with increasing prevalence of PE, 2.3%, 11.6%, and 61.5%, respectively. The ROC curves showed an area under the curve of 0.795 for the PAG Score compared to 0.684 for the Geneva score.

CONCLUSION

In pregnant women with suspected PE, the PAG Score shows a high discriminative power to identify patients at low, intermediate, or high PTP. It has the strength of being a fully objective decision rule, is clinically relevant, easy to compute, and should now be tested in a prospective outcome study.

Previously undiagnosed scoliosis presenting as pleuritic chest pain in the emergency department - a case series and a validating retrospective audit

Background

Chest pain is one of the commonest presenting complaints in urgent/emergency care, with a lifelong prevalence of up to 25% in the adult population. Pleuritic chest pain is a subset of high investigation burden because of a diverse range of possible causes varying from simple musculoskeletal conditions to pulmonary embolism.

Case series

Among otherwise fit and healthy adult patients presenting in our emergency department with sudden onset of unilateral pleuritic chest pain, within 1 month we identified a cohort of five patients with pin-point tenderness in one specific costo-sternal joint often with referred pain to the back. All cases had apparent and, previously undiagnosed mild/moderate scoliosis.

Methods

To confirm and validate the observed association between scoliosis and pleuritic chest pain, a retrospective audit was designed and performed using the hospital’s electronic medical record system to reassess all consecutive adult chest pain patients.

Results

The Odds Ratio for having chest pain with scoliosis was 30.8 [95%CI 1.71–553.37], twenty times higher than suggested by prevalence data.

Discussion

In scoliosis the pathologic lateral curvature of the spine adversely affects the functional anatomy of both the spine and ribcage. In our hypothesis the chest wall asymmetry enables minor slip/subluxation of a rib either in the costo-sternal and/or costovertebral junction exerting direct pressure on the intercostal nerve causing pleuritic pain.

Conclusion

Thorough physical examination of the anterior and posterior chest wall is key to identify underlying scoliosis in otherwise fit patients presenting with sudden onset of pleuritic pain. Incorporating assessment for scoliosis in the low-risk chest pain protocols/tools may help reducing the length of stay in the emergency department and, facilitate speedy but safe discharge with increased patient satisfaction.

Pulmonary embolism: update on management and controversies

Pulmonary embolism is a common and potentially fatal cardiovascular disorder that must be promptly diagnosed and treated. The diagnosis, risk assessment, and management of pulmonary embolism have evolved with a better understanding of efficient use of diagnostic and therapeutic options. The use of either clinical probability adjusted or age adjusted D-dimer interpretation has led to a reduction in diagnostic imaging to exclude pulmonary embolism. Direct oral anticoagulation therapies are safe, effective, and convenient treatments for most patients with acute venous thromboembolism, with a lower risk of bleeding than vitamin K antagonists. These oral therapeutic options have opened up opportunities for safe outpatient management of pulmonary embolism in selected patients. Recent clinical trials exploring the use of systemic thrombolysis in intermediate to high risk pulmonary embolism suggest that this therapy should be reserved for patients with evidence of hemodynamic compromise. The role of low dose systemic or catheter directed thrombolysis in other patient subgroups is uncertain. After a diagnosis of pulmonary embolism, all patients should be assessed for risk of recurrent venous thromboembolism to guide duration of anticoagulation. Patients with a venous thromboembolism associated with a strong, transient, provoking risk factor can safely discontinue anticoagulation after three months of treatment. Patients with an ongoing strong risk factor, such as cancer, or unprovoked events are at increased risk of recurrent events and should be considered for extended treatment. The use of a risk prediction score can help to identify patients with unprovoked venous thromboembolism who can benefit from extended duration therapy. Despite major advances in the management of pulmonary embolism, up to half of patients report chronic functional limitations. Such patients should be screened for chronic thromboembolic pulmonary hypertension, but only a small proportion will have this as the explanation of their symptoms. In the remaining patients, future studies are needed to understand the pathophysiology and explore interventions to improve quality of life.

The diagnostic value of D-dimer with simplified Geneva score (SGS) pre-test in the diagnosis of pulmonary embolism (PE)

Background

Pulmonary embolism (PE) is the third most common cardiovascular syndrome with an average annual incidence rate of 77 per 100,000 population in the worldwide. The diagnose algorithms for suspected PE are generally include clinical scoring assessment and plasma D-dimer evaluation, patients with high risk of PE require computed tomographic pulmonary angiogram (CTPA) detection for confirmation.

Methods

In this retrospective analysis, 1035 patients with suspected PE were recruited. All the patients were clinically received simplified Geneva score (SGS) pre-test, determination of plasma D-dimer level, and CTPA detection. All enrolled patients were grouped according to the CTPA results: PE patients and non-PE patients. Then, receiver operating characteristic (ROC) curve were constructed to determine the optimal D-dimer cutoff point value which is based on Yonden’s index (YI).

Results

294 (28.4%) patients were confirmed with PE and 741(71.6%) individuals were regarded as non-PE cases by CTPA detection. Using the SGS pre-test, 829 (80.1%) patients were classified PE-unlikely (SGS ≤ 2) and 206 (19.9%) patients were PE-likely (SGS ≥ 3). Patients with D-dimer levels above 1.96 mg/L had a significant risk to suffer from PE (area under curve (AUC), 0.707; 95% CI, 0.678–0.735; p < 0.05). Meanwhile, in patients with SGS ≥ 3, the D-dimer cutoff point value moved to 2.2 mg/L (AUC, 0.644; 95% CI, 0.574–0.709; p < 0.05).

Conclusion

D-dimer test in combination with SGS pre-test could improve the accuracy of PE diagnosis. Patients with D-dimer levels over 1.96 mg/L (4 times of the normal level) have a significant risk for PE. In patients with SGS ≥ 3, the D-dimer cutoff point concentration for PE risk moves to the levels of 2.2 mg/L.

Age-adjusted D-dimer cutoff for the diagnosis of pulmonary embolism: A cost-effectiveness analysis

BACKGROUND

In patients with suspected pulmonary embolism (PE) and a non-high pretest probability, the use of an age-adjusted D-dimer cutoff (AADD, <500 ng/mL up to 50 years, then

METHODS

We created a decision tree to compare the use of the AADD with the standard D-dimer cutoff. The model included short-term venous thromboembolism-related events and long-term complications, their associated morbidity/mortality, and costs. Probabilities were derived from published literature and the ADJUST-PE study, and costs from US estimates. The time horizon was lifetime, with a health care system perspective.

RESULTS

Using the AADD cutoff, compared with the standard cutoff, was associated with a loss of 0.0001 quality-adjusted life-years (QALY) and an average cost reduction of $33.4. The decremental cost-effectiveness ratio (DCER) was +$282 881/lost QALY (95% confidence interval from +$43 209/lost QALY to a dominant strategy). The probability that the use of the AADD cutoff was either dominant or gained >$200 000/lost QALY was 79.4%. In sensitivity analyses, the DCER became <+$200 000/lost QALY only if, among patients with D-dimer below the AADD cutoff, the mortality of an undiagnosed PE was >6% or the prevalence of PE was >0.6%.

CONCLUSIONS

The AADD cutoff results in a clinically nonsignificant decrease in QALY but important costs reductions. It is a decrementally cost-effective innovation, with a potential of cost savings of >$80 million per year for the United States health care system.

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Key Words

• biomarker
• cost-benefit analysis
• diagnosis
• fibrin fragment D
• pulmonary embolism

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MESH Headings

• Angiography
• Cost-Benefit Analysis
• Fibrin Fibrinogen Degradation Products
• Humans
• Pulmonary Embolism/diagnosis

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Affiliation(s)

Marc Blondon Division of Angiology and Haemostasis, Faculty of Medicine and Geneva University Hospitals, Geneva, Switzerland
Gregoire Le Gal Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
Guy Meyer Department of Respiratory Disease, Hôpital Européen Georges Pompidou, APHP, Paris, France Université Paris Descartes, Paris, France
Marc Righini Division of Angiology and Haemostasis, Faculty of Medicine and Geneva University Hospitals, Geneva, Switzerland
Helia Robert-Ebadi Division of Angiology and Haemostasis, Faculty of Medicine and Geneva University Hospitals, Geneva, Switzerland

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Advances in the diagnosis of acute pulmonary embolism

Venous thromboembolism is a common disease which remains underdiagnosed because of nonspecific presentations which can range from asymptomatic incidental imaging findings to sudden death. Symptoms can overlap with comorbid cardiopulmonary disease, and risk factors that offer clues to the clinician are not always present. The diagnostic approach can vary depending on the specific clinical presentation, but ruling in the diagnosis nearly always depends on lung imaging. Overuse of diagnostic testing is another recognized problem; a cautious, evidence-based approach is required, although physician gestalt must be acknowledged. The following review offers an approach to the diagnosis of acute pulmonary embolism based on the assessment of symptoms, signs, risk factors, laboratory findings, and imaging studies.

[ESC guidelines 2019 on diagnostics and management of acute pulmonary embolism]

This article on the new European Society of Cardiology (ESC) guidelines for diagnostics and management of acute pulmonary embolism (PE) focusses on new or changed recommendations compared to the previous version of the guidelines from 2014. The current risk-adjusted management algorithm for acute PE includes the clinical severity, aggravating comorbid conditions and right ventricular dysfunction. For low-risk patients early discharge and outpatient treatment are possible, whereas for high-risk patients reperfusion treatment and hemodynamic support have to be considered, depending on the hemodynamic situation and contraindications in the individual patient. Effective therapeutic anticoagulation for at least 3 months is recommended for all patients with PE. Potential indicators for extended anticoagulation are given in the guidelines (class I or class IIa recommendations). New oral anticoagulants (NOAC) are the first choice for anticoagulation in preference to vitamin K antagonists (VKA); however, they are not recommended in patients with severe renal dysfunction, during pregnancy or lactation and in patients with antiphospholipid antibody syndrome. Furthermore, a new algorithm for the follow-up after acute PE is proposed in the guidelines. In cases of symptomatic persistent pulmonary hypertension (PH) the transfer to a specialized center is recommended.

D-dimer: Preanalytical, analytical, postanalytical variables, and clinical applications

D-dimer is a soluble fibrin degradation product deriving from the plasmin-mediated degradation of cross-linked fibrin. D-dimer can hence be considered a biomarker of activation of coagulation and fibrinolysis, and it is routinely used for ruling out venous thromboembolism (VTE). D-dimer is increasingly used to assess the risk of VTE recurrence and to help define the optimal duration of anticoagulation treatment in patients with VTE, for diagnosing disseminated intravascular coagulation, and for screening medical patients at increased risk of VTE. This review is aimed at (1) revising the definition of D-dimer; (2) discussing preanalytical variables affecting the measurement of D-dimer; (3) reviewing and comparing assay performance and some postanalytical variables (e.g. different units and age-adjusted cutoffs); and (4) discussing the use of D-dimer measurement across different clinical settings.