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Evidence summaries

Clinical Gestalt and Clinical Prediction Rules in the Diagnosis of Pulmonary Embolism

Both clinical gestalt of more experienced clinicians and clinical prediction rules used by both experienced and less-experienced clinicians appear to be able to determine whether patients have a low, moderate, or high pre-test probability of pulmonary embolism (PE). Level of evidence: "B"

A systematic review 1 including 16 studies with a total of 8306 subjects was abstracted in DARE.

Clinical gestalt. The proportion of patients in each pre-test category that actually had PE varied from 8 to 19% (low), 26 to 47% (moderate) and 46 to 91% (high) across studies. The LR was 0.25 (95% CI: 0.14, 0.45) for low pre- test probability, 0.92 (95% CI: 0.71, 1.2) for moderate pre-test probability and 4.7 (95% CI: 2.3, 9.7) for high pre-test probability.

Clinical prediction rules. The proportion of patients in each pre-test category that actually had PE varied from 3 to 28% (low), 16 to 46% (moderate) and 38 to 98% (high) across studies. The LR was 0.12 (95% CI: 0.05, 0.31) for low pre-test probability, 1.1 (95% CI: 0.76, 1.6) for moderate pre-test probability and 23 (95% CI: 7.6, 69) for high pre-test probability.

Comment: The quality of evidence is downgraded by inconsistency (heterogeneity in interventions and outcomes). There was no direct comparison of the accuracy of clinical prediction rules and clinical gestalt. The authors recommend that clinical prediction rules should be used because they can be used accurately by less-experienced clinicians.

    References

    • Chunilal SD, Eikelboom JW, Attia J, Miniati M, Panju AA, Simel DL, Ginsberg JS. Does this patient have pulmonary embolism? JAMA 2003Dec 3;290(21):2849-58. [PubMed] [DARE]

Primary/Secondary Keywords