Performance of the revised Geneva score in patients with a delayed suspicion of pulmonary embolism

To the Editor: Establishing a prompt diagnosis of acute pulmonary embolism is a diagnostic challenge, as the clinical presentation ranges from haemodynamic shock to very subtle symptoms mimicking those of other cardiovascular or pulmonary diseases [1]. This diverse presentation facilitates diagnostic delay and, consequently, also a delay in treatment initiation, which might be an important prognostic indicator for patients with acute pulmonary embolism [1]. The standard diagnostic algorithm for suspected acute pulmonary embolism consists of sequential pre-test probability determination, D-dimer testing and computed tomography pulmonary angiography (CTPA) [2]. The pre-test probability can be estimated using a validated clinical decision rule (CDR), such as the Wells score and the revised Geneva score (RGS) [3, 4]. In addition to an excellent sensitivity and specificity, the main advantage of this diagnostic algorithm is that 20–30% of all patients with a clinical suspicion can be managed without CTPA, since an unlikely clinical probability in combination with a normal high-sensitive D-dimer test result has been shown to accurately rule out acute symptomatic pulmonary embolism [5]. The significance of the appropriate use of this diagnostic management strategy in patients with suspected pulmonary embolism has been highlighted by a prospective cohort study [6]. In patients with inappropriate diagnostic management, the diagnostic failure rate was 7.7%, compared to 1.2% for those patients in whom pulmonary embolism was ruled out according to the strategy (p<0.001). Importantly, symptoms suggestive of pulmonary embolism that could also be ascribed to underlying cardiopulmonary diseases ( e.g. heart failure or chronic lung disease) were identified as an important factor …