Articles7 February 2006
    Author, Article, and Disclosure Information

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


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


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


    Emergency departments of 3 university hospitals in Europe.


    Consecutive patients admitted for clinically suspected pulmonary embolism.


    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.


    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 (≥11 points).


    Interobserver agreement for the score items was not studied.


    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.


    • 1. Wells PSAnderson DRRodger MStiell IDreyer JFBarnes Det alExcluding 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 Med2001;135:98-107. [PMID: 11453709] LinkGoogle Scholar
    • 2. Musset DParent FMeyer GMaître SGirard PLeroyer Cet alDiagnostic strategy for patients with suspected pulmonary embolism: a prospective multicentre outcome study. Lancet2002;360:1914-20. [PMID: 12493257] CrossrefMedlineGoogle Scholar
    • 3. Perrier ABounameaux HCost-effective diagnosis of deep vein thrombosis and pulmonary embolism. Thromb Haemost2001;86:475-87. [PMID: 11487038] CrossrefMedlineGoogle Scholar
    • 4. British Thoracic Society guidelines for the management of suspected acute pulmonary embolism. Thorax2003;58:470-83. [PMID: 12775856] CrossrefMedlineGoogle Scholar
    • 5. Guidelines on diagnosis and management of acute pulmonary embolism.Task Force on Pulmonary Embolism, European Society of Cardiology. Eur Heart J2000;21:1301-36. [PMID: 10952823] CrossrefMedlineGoogle Scholar
    • 6. Kruip MJLeclercq MGvan der Heul CPrins MHBüller HRDiagnostic strategies for excluding pulmonary embolism in clinical outcome studies.A systematic review. Ann Intern Med2003;138:941-51. [PMID: 12809450] LinkGoogle Scholar
    • 7. Perrier ARoy PMAujesky DChagnon IHowarth NGourdier ALet alDiagnosing pulmonary embolism in outpatients with clinical assessment, D-dimer measurement, venous ultrasound, and helical computed tomography: a multicenter management study. Am J Med2004;116:291-9. [PMID: 14984813] CrossrefMedlineGoogle Scholar
    • 8. Perrier ADesmarais SMiron MJde Moerloose PLepage RSlosman Det alNon-invasive diagnosis of venous thromboembolism in outpatients. Lancet1999;353:190-5. [PMID: 9923874] CrossrefMedlineGoogle Scholar
    • 9. Kelly JHunt BJA clinical probability assessment and D-dimer measurement should be the initial step in the investigation of suspected venous thromboembolism. Chest2003;124:1116-9. [PMID: 12970044] CrossrefMedlineGoogle Scholar
    • 10. Perrier ANendaz MRSarasin FPHowarth NBounameaux HCost-effectiveness analysis of diagnostic strategies for suspected pulmonary embolism including helical computed tomography. Am J Respir Crit Care Med2003;167:39-44. [PMID: 12502474] CrossrefMedlineGoogle Scholar
    • 11. Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). The PIOPED Investigators. JAMA1990;263:2753-9. [PMID: 2332918] CrossrefMedlineGoogle Scholar
    • 12. Perrier ABounameaux HMorabia Ade Moerloose PSlosman DDidier Det alDiagnosis of pulmonary embolism by a decision analysis-based strategy including clinical probability, D-dimer levels, and ultrasonography: a management study. Arch Intern Med1996;156:531-6. [PMID: 8604959] CrossrefMedlineGoogle Scholar
    • 13. Wells PSAnderson DRRodger MGinsberg JSKearon CGent Met alDerivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer. Thromb Haemost2000;83:416-20. [PMID: 10744147] CrossrefMedlineGoogle Scholar
    • 14. Wicki JPerneger TVJunod AFBounameaux HPerrier AAssessing clinical probability of pulmonary embolism in the emergency ward: a simple score. Arch Intern Med2001;161:92-7. [PMID: 11146703] CrossrefMedlineGoogle Scholar
    • 15. Chagnon IBounameaux HAujesky DRoy PMGourdier ALCornuz Jet alComparison of two clinical prediction rules and implicit assessment among patients with suspected pulmonary embolism. Am J Med2002;113:269-75. [PMID: 12361811] CrossrefMedlineGoogle Scholar
    • 16. Perrier ARoy PMSanchez OLe Gal GMeyer GGourdier ALet alMultidetector-row computed tomography in suspected pulmonary embolism. N Engl J Med2005;352:1760-8. [PMID: 15858185] CrossrefMedlineGoogle Scholar
    • 17. Cockcroft DWGault MHPrediction of creatinine clearance from serum creatinine. Nephron1976;16:31-41. [PMID: 1244564] CrossrefMedlineGoogle Scholar
    • 18. Hersh ALStefanick MLStafford RSNational use of postmenopausal hormone therapy: annual trends and response to recent evidence. JAMA2004;291:47-53. [PMID: 14709575] CrossrefMedlineGoogle Scholar
    • 19. McNeil BJHanley JAFunkenstein HHWallman JPaired receiver operating characteristic curves and the effect of history on radiographic interpretation. CT of the head as a case study. Radiology1983;149:75-7. [PMID: 6611955] CrossrefMedlineGoogle Scholar
    • 20. Wasson JHSox HCClinical prediction rules.Have they come of age? [Editorial]. JAMA1996;275:641-2. [PMID: 8594248] CrossrefMedlineGoogle Scholar
    • 21. Wyatt JCAltman DGCommentary: prognostic models: clinically useful or quickly forgotten? BMJ1995;311:1539-41. CrossrefGoogle Scholar
    • 22. Wasson JHSox HCNeff RKGoldman LClinical prediction rules.Applications and methodological standards. N Engl J Med1985;313:793-9. [PMID: 3897864] CrossrefMedlineGoogle Scholar
    • 23. Wells PSGinsberg JSAnderson DRKearon CGent MTurpie AGet alUse of a clinical model for safe management of patients with suspected pulmonary embolism. Ann Intern Med1998;129:997-1005. [PMID: 9867786] LinkGoogle Scholar
    • 24. Stein PDHull RDPatel KCOlson REGhali WABrant Ret alD-dimer for the exclusion of acute venous thrombosis and pulmonary embolism: a systematic review. Ann Intern Med2004;140:589-602. [PMID: 15096330] LinkGoogle Scholar