Comparative Validation of Two-Tier Wells and Revised Geneva Clinical Decision Rules in Emergency Department Patients with Suspected Pulmonary Embolism: A Retrospective Study
Seyed Reza Ahmadi Koupaei, Ahmad Bagheri Moghaddam, Ashkan Torshizian, Maziar Malek Mahmoodi, Seyed Reza Habibzadeh, Elnaz Vafadar MoradiAbstract
Background:
Pulmonary embolism (PE) is a potentially life-threatening condition with nonspecific clinical presentations. Scores such as the Wells rule and the revised Geneva score (RGS) are widely used to guide diagnostic strategies. The study aimed to validate and compare the diagnostic performance of the Wells rule and RGS in patients with suspected PE.
Materials and Methods:
This retrospective observational study was conducted in the emergency departments of two tertiary academic hospitals between June 2016 and 2017. Adult patients who underwent computed tomographic pulmonary angiography (CTPA) for suspected acute PE were included. The Wells rule and RGS were retrospectively calculated using clinical information available at the time of CTPA request. Patients were classified into “PE likely” and “PE unlikely” categories using validated two-tier thresholds. Diagnostic performance was assessed using sensitivity, specificity, predictive values, and receiver operating characteristic curve analysis.
Results:
Of 475 included patients, PE was confirmed in 140 (29.5%). Using original thresholds, the Wells rule demonstrated higher specificity but lower sensitivity compared with the RGS, with 27% and 19% of PE cases misclassified as “PE unlikely,” respectively. Overall discriminative ability was similar (Wells area under the receiver operating characteristic curve [AUROC]: 0.683; RGS AUROC: 0.668). The optimal Wells cutoff in this cohort (>1) differed from the originally proposed threshold, whereas the RGS optimal cutoff aligned with prior literature.
Conclusion:
When applied at original thresholds, the RGS classified patients with suspected PE more safely than the Wells rule. After optimization, both clinical decision-making rules demonstrated comparable diagnostic performance. Prospective multicenter studies incorporating standardized D-dimer testing are warranted to confirm these findings.