What Are the Parameters That Should Inform Gestalt as a Clinical Decision Strategy for Pulmonary Embolism?

Abstract

The limitations of clinical decision rules 1 are exemplified by the performance of the Wells criteria in primary care. 2 The latter study enrolled 598 patients in whom the general practitioner considered that pulmonary embolism might be present. Suspicion of pulmonary embolism was based on the presence of 1 or more of the following symptoms: unexplained (sudden) dyspnea, deterioration in existing dyspnea, pleuritic pain, and unexplained cough. After recording the Wells score, the primary care doctor was required to refer the patient to secondary care for further evaluation. An eventual diagnosis was made on 73 patients. Pulmonary embolism was ruled out in 525 subjects, including 93 with Wells score amounting to >4, which is defined as making pulmonary embolism likely. Some of the patients who did not have pulmonary embolism with Wells score amounting to > 4 had pneumonia in association with a raised D-dimer level. 2 An important caveat to unstructured diagnostic evaluation is that gestalt is operator-dependent and not necessarily also dependent on awareness of atypical symptoms of pulmonary embolism such as abdominal pain 3,4 and ST segment elevation, 5 so as to mitigate the risk of inappropriate laparotomy 3 or inappropriate coronary angiography. 5 In 1957, pulmonary embolism-related abdominal pain was documented as having a 12% prevalence among 90 patients with pulmonary embolism. 3 More recently, 9.5% of 40 patients with pulmonary embolism were documented as having presented with abdominal pain in the absence of concurrent chest pain or dyspnea. 4 A recent review of the world literature documented 34 cases of pulmonary embolism-related electrocardiographic ST segment elevation in the absence of thrombotic coronary artery occlusion or thrombotic coronary artery occlusion attributable to paradoxical embolism. 5 The Wells score amounted to < 2 in 44.4% of the 27 patients in whom that parameter was measured. 5 Gestalt should, therefore, be informed, not only by awareness of classical symptoms and signs of pulmonary embolism but also by awareness of atypical clinical stigmata, exemplified by pulmonary embolism-related abdominal pain, 3,4 pulmonary embolism-related ST segment elevation, 5 and the association of pulmonary embolismrelated abdominal pain and pulmonary embolism-related ST segment elevation. 6