Diagnosis

Review: Gestalt or clinical decision rules have limited sensitivity and specificity for detecting acute PE
Question
In patients with suspected acute pulmonary embolism (PE), what is the accuracy of gestalt and clinical decision rules (CDRs) for detecting PE?

Lucassen W, Geersing GJ, Erkens PM, et al. Clinical decision rules for excluding pulmonary embolism: a meta-analysis. Ann Intern Med. 2011;155:448-60.

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In patients with suspected acute pulmonary embolism, gestalt and clinical decision rules have limited sensitivity and specificity for detecting pulmonary embolism. Source of funding: Dutch Heart Foundation. For correspondence: Dr. W. Lucassen, Academic Medical Center, Amsterdam, The Netherlands. E-mail w.a.lucassen@amc.uva.nl. I

Review scope
Included studies evaluated gestalt or CDRs for estimating probability of PE in patients 16 years of age with suspected acute PE, enrolled patients consecutively, blinded assessors to results of Ddimer testing or pulmonary vascular imaging, used an appropriate reference standard to confirm diagnosis of PE (or deep venous thrombosis as a surrogate for PE), had 45 days of follow-up for patients with negative test results and no pulmonary imaging, included > 50 patients with confirmed PE if a decision rule was being derived, and provided sufficient data to create 2 2 tables. Gestalt estimates were unstructured and based on patient history, physical examination with or without basic laboratory tests, chest radiographs, or electrocardiographs. Decision rule estimates were structured and based on multivariate logistic regression models. Outcomes were pooled sensitivity, specificity, and likelihood ratios (calculated from data in article).

Commentary
In patients with suspected PE, it is excluded much more often than it is confirmed. Imaging all suspected cases would be expensive and confers risks associated with exposure to radiation and intravenous contrast agents. A negative, sensitive D-dimer assay can exclude PE without imaging in patients with sufficiently low pretest probability (PTP) of disease (1). Substantial research has focused on assessing PTP for PE, evaluating both subjective clinical impression (gestalt) and more objective CDRs. The relative merits of these approaches continue to be debated, and the large number of different CDRs and frequent revisions to existing CDRs may be confusing to clinicians. Moreover, there is discordance between practice guidelines, such as those of the European Society of Cardiology and the American College of Emergency Physicians, about PTP assessment (1, 2). The meta-analysis by Lucassen and colleagues brings some clarity to the issue. Although the included studies were heterogeneous because accuracy and management studies were analyzed together and prevalence of PE varied, analytic techniques were used to address these issues. The study is limited by lack of individual patient data for meta-analysis and lack of assessment for publication bias. Finally, the failure rate of combining D-dimer testing with intermediate PTP was not analyzed. The most important finding is that any of the approaches, including gestalt, can be used with D-dimer testing to exclude PE in low PTP patients. The authors also suggest that the approach used should be determined by local prevalence of PE, although it is uncertain whether clinicians can easily access such information. Gestalt may lead to more imaging than the Wells rule with a cutpoint 4. The Wells rule with a cutpoint 4 should not be combined with less-sensitive, qualitative D-dimer testing. Scott M. Stevens, MD Intermountain Medical Center Murray, Utah, USA
References 1. Torbicki A, Perrier A, Konstantinides S, et al; ESC Committee for Practice Guidelines (CPG). Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J. 2008;29:2276-315. 2. American College of Emergency Physicians Clinical Policies Subcommittee on Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Suspected Pulmonary Embolism, Fesmire FM, Brown MD, et al. Critical issues in the evaluation and management of adult patients presenting to the emergency department with suspected pulmonary embolism. Ann Emerg Med. 2011;57:628-52. 2012 American College of Physicians JC1-11

Review methods
MEDLINE and EMBASE/Excerpta Medica (both to Jun 2011), and reference lists were searched for original, prospective studies published in English, French, German, Italian, Spanish, or Dutch. Investigators were contacted. 52 studies (n = 55 268, mean or median age 45 y to 72 y, 47% to 74% women) met the selection criteria: 19 evaluated gestalt; 26 the Wells or simplified Wells rule; 12 the Geneva, revised Geneva, or simplified revised Geneva rule; 4 the Pisa or revised Pisa rule; 3 the Charlotte rule; and 3 the Pulmonary Embolism Rule-out Criteria. Data for rules evaluated in 4 studies were pooled using random-effects bivariate analysis that simultaneously modeled sensitivity and specificity pairs. 20 studies that combined gestalt or CDRs with D-dimer testing are not reported here.

Main results
Prevalence of PE ranged from 4% to 44%. Pooled sensitivities and specificities are shown in the Table. Studies were heterogeneous for sensitivity and specificity (data not reported). Wells rule with a cutpoint 4 differed from other diagnostic tools for sensitivity and specificity (P < 0.01), and Wells rule with a cutpoint < 2 had higher specificity than the revised Geneva rule (P = 0.026).

Pooled diagnostic characteristics of gestalt or clinical decision rules for detecting pulmonary embolism (PE)*
Diagnostic tool
Gestalt Wells rule, cutpoint < 2 Wells rule, cutpoint 4 Geneva rule Revised Geneva rule

Number of Prevalence Sensitivity studies (n) of PE (95% CI)

15 (27 374) 19 (20 146) 11 (9659) 5 (2702) 4 (2159) 17% 15% 16% 29% 24% 85% (78 to 90) 84% (78 to 89) 60% (49 to 69) 84% (81 to 87) 91% (73 to 98)

Specificity (CI) +LR LR

51% (39 to 63) 58% (52 to 65) 80% (75 to 84) 50% (29 to 72) 37% (22 to 55) 1.73 2.00 3.00 1.68 1.44 0.29 0.28 0.50 0.32 0.24

*Diagnostic terms defined in Glossary. Only rules evaluated in 4 studies are reported here. LRs calculated on the basis of pooled sensitivity and specificity.

17 January 2012 | ACP Journal Club | Volume 156 Number 1