Geneva Score (Revised) for Pulmonary Embolism

id

1750

full_title

Geneva Score (Revised) for Pulmonary Embolism

short_title

Geneva Score (Revised)

med_description

Objectifies risk of PE, like Wells' score.

description

The Geneva Score (Revised) For Pulmonary Embolism Objectifies risk of PE, like Wells’ score.

keywords

prediction pulmonary embolism, rule out PE, geneva calculator, geneva risk, rule out geneva, geneva embolism, geneva score, geneva pulmonary embolism, geneva pulmonary embolism risk, geneva pulmonary embolism calc, geneva PE risk, geneva rule out PE, geneva prognosis PE, geneva prognosis, geneva px, PE px, PE prognosis, PE calc, pe risk calc, pe risk px, pe risk prognosis

complaint

[ "Chest Pain", "Palpitations", "Shortness of Breath", "Syncope" ]

formula

evidence

Original study

• Created from multicenter prospective analysis.
• Included all patients with suspicion of pulmonary embolism.
• All included patients were assigned a pre-test probability by using the Geneva Prediction Rule. Patients then got:
1. d-dimer,
2. compression US and helical CT scan if d-dimer positive and low risk, and
3. pulmonary angiography if high probability.
• V/Q or angiography were performed on inconclusive CTs.
• All patients had 3 month follow up. The risk was 1.0% for PE in those who did not get therapy after initial workup.
• The score was derived by univariate analysis to predict variables and computed cutoffs for low, medium and high risk.
• Low was determined to be 9.0%, intermediate 27.5% and high 71.7% prevalence.
• Overall prevalence of PE was 23%.
• Performed an internal validation on 10 random groups, performing a regression analysis on 9 groups, and then applied the prediction to the 10th group. This process was rotated and repeated 10 times. Afterward, they performed an eternal validation on 3 ED sites. Low risk had an prevalence of 7.9%, intermediate was 28.5% and high was 73.7% with overall prevalence of 25.5%. In the low risk group, incidence of missed PE of 1%.

Validation studies

• In 2007 the rGeneva was applied retrospectively to a convenience sample cohort that was getting CT for rule out PE who had already been risk stratified with Wells. The frequency of PE was compared to the original Geneva score dataset (Klok FA 2007).
• 300 patients were included. Incidence of PE overall was 16%.
• 157 (52.3%) of patients were low risk based on Geneva, 136 (45.3%) were intermediate and 7 (2.3%) were high. The incidence of PE in these groups was 8.3%, 22.8% and 71.4% respectively. There was no statistical difference between these results and the original rGeneva dataset from the derivation study.
• 134 (44.7%) of these patients had a different level of risk stratification when comparing Geneva and Wells, and this was 97% of the time due to the subjective element of the Wells PE rule. 15 patients with PE were classified as lower-risk by Geneva when compared to Wells, 5 vice versa.
• 233 patients had a Wells of <4 and got a d-dimer. Of these, no patients classified as low or intermediate by Geneva score with a normal d-dimer had a PE on 3 month followup.
• A 2010 meta-analysis found that the rGeneva score as well as Wells, Geneva score and Charlotte rule were of the highest level of validation according to methodology.
• A 2013 retrospective study by Penaloza et al demonstrated that gestalt may be superior to all clinical decision rules.

measurements

[]

information

The Revised Geneva scores, along with the Wells’ PE criteria are the most commonly used scores to evaluate for pulmonary embolism. Some physicians prefer the Revised Geneva score because of its objectivity, since the Wells’ score heavily weighs the subjective "PE Is #1 Diagnosis, or Equally Likely" value.

Interestingly, Penaloza et. al's study (see below) comparing Wells to Revised Geneva to clinician gestalt found that clinician gestalt faired comparably (and possibly even favorably) to these scores as well.

Why is the original Geneva Score not used or included on MDCalc? It requires both a chest x-ray and arterial blood gas and has fallen out of favor given the need for this testing and interpretation of it prior to being able to apply the rule.

refrences

{ "Clinical Practice Guidelines": [], "Manufacturer Website": [], "Original/Primary Reference": [ { "href": "https://www.ncbi.nlm.nih.gov/pubmed/16461960", "text": "Le Gal G, Righini M, Roy PM, Sanchez O, Aujesky D, Bounameaux H, Perrier A. Prediction of pulmonary embolism in the emergency department: the revised Geneva score. Ann Intern Med. 2006 Feb 7;144(3):165-71. PubMed PMID: 16461960." } ], "Other References": [], "Outcomes": [], "Validation": [ { "href": "https://www.ncbi.nlm.nih.gov/pubmed/20149072", "text": "Ceriani E, Combescure C, Le Gal G, Nendaz M, Perneger T, Bounameaux H, Perrier A, Righini M. Clinical prediction rules for pulmonary embolism: a systematic review and meta-analysis. J Thromb Haemost. 2010 May;8(5):957-70. doi:10.1111/j.1538-7836.2010.03801.x. Epub 2010 Feb 2. Review. PubMed PMID: 20149072." }, { "href": "https://www.ncbi.nlm.nih.gov/pubmed/17973649", "text": "Klok FA, Kruisman E, Spaan J, Nijkeuter M, Righini M, Aujesky D, Roy PM, Perrier A, Le Gal G, Huisman MV. Comparison of the revised Geneva score with the Wells rule for assessing clinical probability of pulmonary embolism. J Thromb Haemost. 2008 Jan;6(1):40-4. Epub 2007 Oct 29. PubMed PMID: 17973649." }, { "href": "https://www.ncbi.nlm.nih.gov/pubmed/23433653", "text": "Penaloza A, Verschuren F, Meyer G, Quentin-Georget S, Soulie C, Thys F, Roy PM. Comparison of the unstructured clinician gestalt, the wells score, and the revised Geneva score to estimate pretest probability for suspected pulmonary embolism. Ann Emerg Med. 2013 Aug;62(2):117-124.e2. doi: 10.1016/j.annemergmed.2012.11.002. Epub 2013 Feb 21. PubMed PMID: 23433653." } ], "Validations": [] }

pearls

The Revised Geneva Score (rGeneva) risk-stratifies patients for pulmonary embolism (PE).

• The original Geneva score was criticised for inclusion of both a Chest X-ray and arterial blood gas to be applied; the rGeneva does not include these.
• rGeneva is not meant to diagnose but to guide workup and testing by predicting pre-test probability of PE.

usecase

The rGeneva can risk-stratify patients into low, intermediate, or high risk based on history and physical exam alone. Many use it as an alternative to the Wells’ PE criteria to determine those patients that are low enough risk to rule out pulmonary embolism with a d-dimer serum test and avoid the use of CT angiography and ultrasound.

reasons

The rGeneva score does not require imaging or serum studies for risk stratification. The rGeneva score does not require clinical gestalt (present inWells’ PE criteriaand often subjective) for risk stratification. Physicians continue to have a low threshold for the workup of pulmonary embolism. The rGeneva score aids in the reduction of unnecessary imaging studies by identifying low risk patients who can be ruled out for PE with a d-dimer serum test.One study suggested a clinical decision rule + d-dimer protocol could reduce imaging by 30%. One study suggested a clinical decision rule + d-dimer protocol could reduce imaging by 30%.

next_advice

The rGeneva score is an accepted alternative to the Wells’ PE criteria used to risk-stratify patients with concern for PE. This tool does not incorporate gestalt, which some would argue is better than any clinical decision rule.

next_actions

• No decision rule should trump clinical gestalt. High clinical suspicion for PE should warrant imaging regardless of Geneva score.
• Never delay resuscitative efforts for diagnostic testing, especially in the unstable patient.
• History and exam should always be performed prior to diagnostic testing.

next_management

In the setting of concern for possible PE:

• The patient is considered low risk (Score 0-3), <10% incidence of PE.
• The patient is considered intermediate risk (Score 4-10).
  • If d-dimer testing is negative, consider stopping workup.
  • If d-dimer testing is positive, consider CT and US.
    • If CT is inconclusive, consider V/Q scan or angiography.
• If the patient is considered high risk (score 11+, >60% incidence of PE), consider CT and US.
  • If imaging is negative consider angiography.

diseases

[ "Pulmonary Embolism" ]

instructions

published

2022-04-21T20:29:00.201Z

purpose

[ "Diagnosis", "Rule Out" ]

search_terms

[ "pe", "revised geneva", "dvt", "wells", "geneva score", "pulmonary embolism", "pe risk", "geneva pulmonary embolism" ]

seo

{ "keywords_en": "prediction pulmonary embolism, rule out PE, geneva calculator, geneva risk, rule out geneva, geneva embolism, geneva score, geneva pulmonary embolism, geneva pulmonary embolism risk, geneva pulmonary embolism calc, geneva PE risk, geneva rule out PE, geneva prognosis PE, geneva prognosis, geneva px, PE px, PE prognosis, PE calc, pe risk calc, pe risk px, pe risk prognosis", "meta_description_en": "The Geneva Score (Revised) For Pulmonary Embolism Objectifies risk of PE, like Wells’ score." }

specialty

[ "Cardiology", "Critical Care", "Emergency Medicine", "Hematology and Oncology", "Hospitalist Medicine", "Internal Medicine", "OB-Gyn", "Orthopedics", "Pulmonology", "Surgery (General)" ]

departments

[ "Cardiac", "Hematologic", "Respiratory" ]

tags

[]

version_number

1

versions

[]

related

[ { "calcId": 347, "short_title_en": "PERC Rule", "slug": "perc-rule-pulmonary-embolism" }, { "calcId": 115, "short_title_en": "Wells' Score for PE", "slug": "wells-criteria-pulmonary-embolism" }, { "calcId": 10138, "short_title_en": "Age-Adjusted D-dimer", "slug": "age-adjusted-d-dimer-venous-thromboembolism-vte" } ]

ismed

true

section

[ "whenToUseViewed", "pearlsPitfallsViewed", "whyUseViewed", "nextStepsViewed", "evidenceViewed" ]

cleaned_departments

[ "cardiology", "hematology", "pulmonology" ]

cleaned_use

[ "The rGeneva can risk-stratify patients into low, intermediate, or high risk based on history and physical exam alone. Many use it as an alternative to theWells’ PE criteriato determine those patients that are low enough risk to rule out pulmonary embolism with a d-dimer serum test and avoid the use of CT angiography and ultrasound." ]

pub

true