MDCalc

4-Level Pulmonary Embolism Clinical Probability Score (4PEPS)

Rules out PE based on clinical criteria.

The timing of vital sign values were not formally assessed by this study; we recommend using clinician judgment to assess which vital sign should be used for the 4PEPS score.

years
Sex
Chronic respiratory disease
Heart rate <80
Chest pain AND acute dyspnea
Current estrogen use
Prior history of
Syncope
Immobility within the last four weeks
Surgery, lower limb plaster cast, or bedridden >3 days for acute medical condition within the last four weeks
O2 saturation <95%
Calf pain and/or unilateral lower limb edema
is the most likely diagnosis

Result:

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Advice

The results of this tool should not replace clinical judgment; always consider individual patient context and atypical presentations.

Management
  • Suggested management based on clinical probability results:
    • Very low (<0): PE can be ruled out based on clinical criteria without further testing.
    • Low (0-5): Check a D-dimer level. If <1.0 μg/mL, PE can be ruled out. Otherwise, proceed to imaging.
    • Moderate (6-12): Check a D-dimer level. If <0.5 μg/mL OR <(age x 0.01) μg/mL, PE can be ruled out. Otherwise, proceed to imaging.
    • High (≥13): Proceed to imaging.
  • If results suggests very-low or low probability but clinical suspicion remains high, consider imaging or use Wells' or YEARS as confirmation.
  • If results suggest moderate or high probability but suspicion is low, re-examine whether "PE most likely" was scored appropriately; consider alternative diagnoses before imaging.
Critical Actions

D-Dimer Assay Considerations

  • The 1000 μg/mL threshold for the low-clinical pretest probability tier assumes a quantitative assay with specific calibration.

  • Not all D-dimer assays are interchangeable at this threshold; verify local assay characteristics.

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