Simplified PESI (sPESI) and Hestia scores identified similar numbers of patients with pulmonary embolism as low risk. Both groups had similar 30-day all-cause mortality. However, interobserver reliability was better with sPESI.
In this retrospective review, age-adjusted, clinical probability-adjusted, and standard D-dimer approaches had similar NPVs (99.7%, 99.1%, 100% respectively). Clinical probability-adjusted D-dimer has potential to exclude PE in more patients without imaging, but use caution before applying this to practice until prospectively validated.
If clinical gestalt for PE is low, use PERC to rule out PE. If not ruled out, use a validated tool to determine pretest probability of PE: Wells, Revised Geneva, or simplified versions of either score. If non-high or "unlikely" pretest probability, order D-dimer, adjusting for age (<500 or <age x 10). If D-dimer is negative, PE is ruled out. If positive, order CT pulmonary angiogram.