Safe exclusion of pulmonary embolism using the Wells rule and qualitative D-dimer testing in primary care: prospective cohort study
Geert-Jan Geersing,Petra M. G. Erkens,Wim A M Lucassen,Harry R. Büller,Hugo ten Cate,Arno W. Hoes,Karel G.M. Moons,Martin H. Prins,Ruud Oudega,Henk van Weert,Henri E J H Stoffers +10 more
TLDR
A Wells score of ≤4 combined with a negative qualitative D-dimer test result can safely and efficiently exclude pulmonary embolism in primary care.Abstract:
Objective To validate the use of the Wells clinical decision rule combined with a point of care D-dimer test to safely exclude pulmonary embolism in primary care.
Design Prospective cohort study.
Setting Primary care across three different regions of the Netherlands (Amsterdam, Maastricht, and Utrecht).
Participants 598 adults with suspected pulmonary embolism in primary care.
Interventions Doctors scored patients according to the seven variables of the Wells rule and carried out a qualitative point of care D-dimer test. All patients were referred to secondary care and diagnosed according to local protocols. Pulmonary embolism was confirmed or refuted on the basis of a composite reference standard, including spiral computed tomography and three months’ follow-up.
Main outcome measures Diagnostic accuracy (sensitivity and specificity), proportion of patients at low risk (efficiency), number of missed patients with pulmonary embolism in low risk category (false negative rate), and the presence of symptomatic venous thromboembolism, based on the composite reference standard, including events during the follow-up period of three months.
Results Pulmonary embolism was present in 73 patients (prevalence 12.2%). On the basis of a threshold Wells score of ≤4 and a negative qualitative D-dimer test result, 272 of 598 patients were classified as low risk (efficiency 45.5%). Four cases of pulmonary embolism were observed in these 272 patients (false negative rate 1.5%, 95% confidence interval 0.4% to 3.7%). The sensitivity and specificity of this combined diagnostic approach was 94.5% (86.6% to 98.5%) and 51.0% (46.7% to 55.4%), respectively.
Conclusion A Wells score of ≤4 combined with a negative qualitative D-dimer test result can safely and efficiently exclude pulmonary embolism in primary care.read more
Citations
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Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis (TRIPOD): explanation and elaboration.
Karel G.M. Moons,Douglas G. Altman,Johannes B. Reitsma,John P. A. Ioannidis,Petra Macaskill,Ewout W. Steyerberg,Andrew J. Vickers,David F. Ransohoff,Gary S. Collins +8 more
TL;DR: In virtually all medical domains, diagnostic and prognostic multivariable prediction models are being developed, validated, updated, and implemented with the aim to assist doctors and individuals in estimating probabilities and potentially influence their decision making.
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2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism
Stavros Konstantinides,Adam Torbicki,David Fitzmaurice,Simón J,R. Gibbs,Menno V. Huisman,Marc Humbert,John Lekakis,Nicolas Meneveau,Lars Hvilsted Rasmussen,Thomas H. Schindler,Anton Vonk Noordegraaf,José Luis Zamorano,Maurizio Zompatori +13 more
TL;DR: Guidelines summarize and evaluate all available evidence at the time of the writing process, on a particular issue with the aim of assisting health professionals in selecting the best management strategies for an individual patient, with a given condition, taking into account the impact on outcome.
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2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European respiratory society (ERS)
Stavros Konstantinides,Guy Meyer,Cecilia Becattini,Héctor Bueno,Geert-Jan Geersing,Veli-Pekka Harjola,Menno V. Huisman,Marc Humbert,Catriona Jennings,David Jiménez,Nils Kucher,Irene M. Lang,Mareike Lankeit,Roberto Lorusso,Lucia Mazzolai,Nicolas Meneveau,Fionnuala Ní Áinle,Paolo Prandoni,Piotr Pruszczyk,Marc Philip Righini,Adam Torbicki,Eric Van Belle,José Luis Zamorano +22 more
TL;DR: Guidelines summarize and evaluate available evidence with the aim of assisting health professionals in proposing the best management strategies for an individual patient with a given condition.
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2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS) : The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC)
Stavros Konstantinides,Guy Meyer,Cecilia Becattini,Héctor Bueno,Geert-Jan Geersing,Veli-Pekka Harjola,Menno V. Huisman,Marc Humbert,Catriona Jennings,David Jiménez,Nils Kucher,Irene M. Lang,Mareike Lankeit,Roberto Lorusso,Lucia Mazzolai,Nicolas Meneveau,Fionnuala Ní Áinle,Paolo Prandoni,Piotr Pruszczyk,Marc Philip Righini,Adam Torbicki,Eric Van Belle,José Luis Zamorano +22 more
TL;DR: New ESCardio Guidelines for the Diagnosis and Management of Acute PulmonaryEmbolism developed in collaboration with EuroRespSoc are available.
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STARD 2015 guidelines for reporting diagnostic accuracy studies: explanation and elaboration
Jérémie F. Cohen,Jérémie F. Cohen,Daniël A. Korevaar,Douglas G. Altman,David E. Bruns,Constantine Gatsonis,Lotty Hooft,Les Irwig,Deborah Levine,Johannes B. Reitsma,Henrica C.W. de Vet,Patrick M.M. Bossuyt +11 more
TL;DR: The rationale for each of the 30 items on the STARD 2015 checklist is clarified, and what is expected from authors in developing sufficiently informative study reports is described.
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