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    Geneva Score (Revised) for Pulmonary Embolism

    Objectifies risk of PE, like Wells’ score.
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    When to Use
    Pearls/Pitfalls
    Why 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 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.

    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
    • The rGeneva score does not require imaging or serum studies for risk stratification
    • The rGeneva score does not require clinical gestalt (present in Wells’ PE criteria and 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%.

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    Next Steps
    Evidence
    Creator Insights

    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.

    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

    Critical 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.

    Facts & Figures

    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.

    Evidence Appraisal

    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.

    Literature

    Validation

    Research PaperCeriani 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.Research PaperKlok 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.Research PaperPenaloza 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.
    Dr. Grégoire Le Gal

    About the Creator

    Grégoire Le Gal, MD, PhD, is a professor in the Division of Hematology at the University of Ottawa, a physician in the Thrombosis Program at Ottawa Hospital, and a Senior Scientist in the Ottawa Hospital Research Institute, Clinical Epidemiology Program. He has 185 peer-reviewed publications and research interests include the diagnosis and management of venous thromboembolism (VTE) and the derivation and validation of clinical decision rules for VTE.

    To view Dr. Grégoire Le Gal's publications, visit PubMed

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