• Renée A Douma, Inge C M Mos, Petra M G Erkens, Tessa A C Nizet, Marc F Durian, Marcel M Hovens, Anja A van Houten, Herman M A Hofstee, Frederikus A Klok, Hugo ten Cate, Erik F Ullmann, Harry R Büller, Pieter W Kamphuisen, Menno V Huisman, and Prometheus Study Group.
• Academic Medical Center, Amsterdam, the Netherlands.
• Ann. Intern. Med. 2011 Jun 7;154(11):709-18.

BackgroundSeveral clinical decision rules (CDRs) are available to exclude acute pulmonary embolism (PE), but they have not been directly compared.ObjectiveTo directly compare the performance of 4 CDRs (Wells rule, revised Geneva score, simplified Wells rule, and simplified revised Geneva score) in combination with d-dimer testing to exclude PE.DesignProspective cohort study.Setting7 hospitals in the Netherlands.Patients807 consecutive patients with suspected acute PE.InterventionThe clinical probability of PE was assessed by using a computer program that calculated all CDRs and indicated the next diagnostic step. Results of the CDRs and d-dimer tests guided clinical care.MeasurementsResults of the CDRs were compared with the prevalence of PE identified by computed tomography or venous thromboembolism at 3-month follow-up.ResultsPrevalence of PE was 23%. The proportion of patients categorized as PE-unlikely ranged from 62% (simplified Wells rule) to 72% (Wells rule). Combined with a normal d-dimer result, the CDRs excluded PE in 22% to 24% of patients. The total failure rates of the CDR and d-dimer combinations were similar (1 failure, 0.5% to 0.6% [upper-limit 95% CI, 2.9% to 3.1%]). Even though 30% of patients had discordant CDR outcomes, PE was not detected in any patient with discordant CDRs and a normal d-dimer result.LimitationManagement was based on a combination of decision rules and d-dimer testing rather than only 1 CDR combined with d-dimer testing.ConclusionAll 4 CDRs show similar performance for exclusion of acute PE in combination with a normal d-dimer result. This prospective validation indicates that the simplified scores may be used in clinical practice.Primary Funding SourceAcademic Medical Center, VU University Medical Center, Rijnstate Hospital, Leiden University Medical Center, Maastricht University Medical Center, Erasmus Medical Center, and Maasstad Hospital.

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