Prediction of pulmonary embolism in the emergency department: the revised Geneva score

Abstract

Background: Diagnosis of pulmonary embolism requires clinical probability assessment. Implicit assessment is accurate but is not standardized, and current prediction rules have shortcomings.

Objective: To construct a simple score based entirely on clinical variables and independent from physicians' implicit judgment.

Design: Derivation and external validation of the score in 2 independent management studies on pulmonary embolism diagnosis.

Setting: Emergency departments of 3 university hospitals in Europe.

Patients: Consecutive patients admitted for clinically suspected pulmonary embolism.

Measurements: Collected data included demographic characteristics, risk factors, and clinical signs and symptoms suggestive of venous thromboembolism. The variables statistically significantly associated with pulmonary embolism in univariate analysis were included in a multivariate logistic regression model. Points were assigned according to the regression coefficients. The score was then externally validated in an independent cohort.

Results: The score comprised 8 variables (points): age older than 65 years (1 point), previous deep venous thrombosis or pulmonary embolism (3 points), surgery or fracture within 1 month (2 points), active malignant condition (2 points), unilateral lower limb pain (3 points), hemoptysis (2 points), heart rate of 75 to 94 beats/min (3 points) or 95 beats/min or more (5 points), and pain on lower-limb deep venous palpation and unilateral edema (4 points). In the validation set, the prevalence of pulmonary embolism was 8% in the low-probability category (0 to 3 points), 28% in the intermediate-probability category (4 to 10 points), and 74% in the high-probability category (> or =11 points).

Limitations: Interobserver agreement for the score items was not studied.

Conclusions: The proposed score is entirely standardized and is based on clinical variables. It has sustained internal and external validation and should now be tested for clinical usefulness in an outcome study.