Asad Mehdi, MD

Outline A Diagnostic Approach to Pulmonary Embolism Clinical Presentation Risk Stratification Wells Criteria Geneva Rule PIOPED Approach PERC Score

Risk Factors Virchow’s Triad Alterations in blood flow Factors in vessel wall Factors affecting properties of blood

Clinical Presentation - History Dyspnea Chest Pain – Pleuritic Cough Hemoptysis

Clinical Presentation - Physical Fever – 14% Hypoxia Cyanosis Tachypnea Tachycardia

Clinical Presentation - Other ECG S1Q3T3 – 20% Sinus Tachycardia 8-69% RBBB RAD Right Heart Strain ECHO McConnell’s Sign – 77% sens 94% spec Acute PE

Diagnostic Approach Wells Criteria Suspect DVT PE #1 Diagnosis Tachycardia Immobilization/Surgery Hx of DVT/PE Hemoptysis Malignancy

Diagnostic - Wells Interpretation Traditional Score >6.0 High probability – 59% Score 2.0 to 6.0 Moderate probability – 29% Score <2.0 Low probability – 15% Stein PD, Woodard PK, Weg JG, Wakefield TW, Tapson VF, Sostman HD, Sos TA, Quinn DA, Leeper KV, Hull RD, Hales CA, Gottschalk A, Goodman LR, Fowler SE, Buckley JD (2007). "Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II Investigators". Radiology 242 (1): 15–21 Alternative Score > 4 PE likely Score 4 or less PE unlikely

Diagnostic Approach Geneva Score Original 7 risk factors Revised 8 risk factors Simplified 8 risk factors Klok FA, Mos IC, Nijkeuter M, et al. (October 2008). "Simplification of the revised Geneva score for assessing clinical probability of pulmonary embolism". Archives of Internal Medicine 168 (19): 2131–6.

Diagnostic Approach Simplified Geneva Score Age >65 Previous DVT or PE Surgery or fracture within 1 month Active malignancy Unilateral lower limb pain Hemoptysis Pain on deep vein palpation of lower limb and unilateral edema HR – HR > 94

Diagnostic - Geneva Interpretation Revised <3 - low probability (8%) intermediate probability (28%) >11 - high probability (74%) Le Gal G, Righini M, Roy PM, et al. (February 2006). "Prediction of pulmonary embolism in the emergency department: the revised Geneva score". Annals of Internal Medicine 144 (3): 165–71. Righini M, Le Gal G, Aujesky D, et al. (April 2008). "Diagnosis of pulmonary embolism by multidetector CT alone or combined with venous ultrasonography of the leg: a randomised non-inferiority trial". Lancet 371 (9621): 1343–52. Simplified <2 - unlikely to have a PE >2 - likely to have a PE <2 & normal D-Dimer – 3% "Geneva Scoring for Pulmonary Embolism Simplified Further. Physician's First Watch October 29, 2008"

Wells and Geneva Numbers Wells Traditional Score >6.0 High probability – 59% Score 2.0 to 6.0 Moderate probability – 29% Score <2.0 Low probability – 15% Geneva Revised Score > 11 High probability – 74% Score 4 – 10 Intermediate probability – 28% Score <3 low probability -8%

Diagnostic - PIOPED Low probability D-Dimer Negative Positive  MDCT sensitivity of 83% & specificity of 96% Moderate probability D-Dimer Negative Positive  MDCT sensitivity of 83% & specificity of 96% miss 5% High probability MDCT Positive Negative  additional tests Stein PD, Woodard PK, Weg JG, Wakefield TW, Tapson VF, Sostman HD, Sos TA, Quinn DA, Leeper KV, Hull RD, Hales CA, Gottschalk A, Goodman LR, Fowler SE, Buckley JD (2007). "Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II Investigators". Radiology 242 (1): 15–21. Stein PD, Fowler SE, Goodman LR, et al. (2006). "Multidetector computed tomography for acute pulmonary embolism". N. Engl. J. Med. 354 (22): 2317–27.

Ruling Out - PERC Low Risk Sensitivity 97.4% - specificity 21.9% Hypoxia - Sa0 2 <95% Unilateral leg swelling Hemoptysis Prior DVT or PE Recent surgery or trauma Age >50 Hormone use Tachycardia Kline, JA; Mitchell, AM; Kabrhel, C; Richman, PB; Courtney, DM (2004). "Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism". Journal of Thrombosis and Haemostasis 2 (8): 1247–1255. Kline, JA; Courtney, DM; Kabrhel, C; Moore, CL; Smithline, HA; Plewa, MC; Richman, PB; O'neil, BJ et al. (2008). "Prospective multicenter evaluation of the pulmonary embolism rule-out criteria". Journal of Thrombosis and Haemostasis 6 (5): 772–780.

Conclusion Suspicion for PE via Clinical Presentation Virchow’s Triad Risk Stratify via Well’s or Geneva Low vs Moderate vs High If Low Probability use PERC Use PIOPED Diagnostic Approach D-Dimer vs MDCT

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