Finalement, la composante implicite dans l’évaluation de la probabilité clinique pré-test d’embolie pulmonaire semble indispensable. Qu’elle soit utilisée avec le SGR ou avec PERC, il est nécessaire qu’elle soit enseignée. Naturellement, la capacité à évaluer correctement la probabilité clinique pré-test semble s’améliorer avec l’expérience du médecin (14,34,35).
L’item subjectif du score de Wells s’en approche et pourrait être un outil d’enseignement de la PCI (24,25).
D’autre part, dans l’étude « Pretest risk assessment in suspected acute pulmonary embolism » de Weiss (36), 72.5% des médecins interrogés préféraient une approche non structurée de l’évaluation de la probabilité clinique pré-test. En effet, c’est une méthode facilement accessible et simple d’utilisation. Les scores de prédiction nécessitent d’être parfaitement connus pour être utilisés correctement.
Pour finir, quelle que soit la méthode utilisée, il est nécessaire d’estimer et de tracer la
CONCLUSION
Notre étude ne permet pas de démontrer une performance significativement plus importante de la PCG face au SGR et à la PCI. Bien que la PCG soit plus facilement reproductible, il semblerait que la PCI soit à privilégier. Il est nécessaire que cette dernière soit enseignée et encouragée afin de rendre plus performante la stratégie diagnostique.
BIBLIOGRAPHIE
1. West J, Goodacre S, Sampson F. The value of clinical features in the diagnosis of acute pulmonary embolism: systematic review and meta-analysis. QJM Mon J Assoc Physicians.
2007 Dec;100(12):763–9.
2. Konstantinides SV, Torbicki A, Agnelli G, Danchin N, Fitzmaurice D, Galiè N, et al. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2014 Nov 14;35(43):3033–69, 3069a–3069k.
3. Moores LK, King CS, Holley AB. Current approach to the diagnosis of acute nonmassive pulmonary embolism. Chest. 2011;140(2):509–18.
4. PIOPED Investigators. Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). JAMA. 1990 May 23;263(20):2753–9.
5. Roy P-M, Meyer G, Vielle B, Le Gall C, Verschuren F, Carpentier F, et al. Appropriateness of diagnostic management and outcomes of suspected pulmonary embolism. Ann Intern Med. 2006 Feb 7;144(3):157–64.
6. Roy P-M, Colombet I, Durieux P, Chatellier G, Sors H, Meyer G. Systematic review and meta-analysis of strategies for the diagnosis of suspected pulmonary embolism. BMJ.
2005 Jul 30;331(7511):259.
7. Le Gal G, Righini M, Roy P-M, Sanchez O, Aujesky D, Bounameaux H, et al. Prediction of pulmonary embolism in the emergency department: the revised Geneva score. Ann Intern Med. 2006 Feb 7;144(3):165–71.
8. Wells PS, Anderson DR, Rodger M, Ginsberg JS, Kearon C, Gent M, et al. Derivation of a simple clinical model to categorize patients probability of pulmonary embolism:
increasing the models utility with the SimpliRED D-dimer. Thromb Haemost. 2000 Mar;83(3):416–20.
9. Ceriani E, Combescure C, Le Gal G, Nendaz M, Perneger T, Bounameaux H, et al. Clinical prediction rules for pulmonary embolism: a systematic review and meta-analysis. J Thromb Haemost JTH. 2010 May;8(5):957–70.
10. Douma RA, Mos ICM, Erkens PMG, Nizet TAC, Durian MF, Hovens MM, et al. Performance of 4 clinical decision rules in the diagnostic management of acute pulmonary embolism: a prospective cohort study. Ann Intern Med. 2011 Jun 7;154(11):709–18.
13. Perrier A, Roy P-M, Aujesky D, Chagnon I, Howarth N, Gourdier A-L, et al. Diagnosing pulmonary embolism in outpatients with clinical assessment, D-dimer measurement, venous ultrasound, and helical computed tomography: a multicenter management study.
Am J Med. 2004 Mar 1;116(5):291–9.
14. Runyon MS, Webb WB, Jones AE, Kline JA. Comparison of the unstructured clinician estimate of pretest probability for pulmonary embolism to the Canadian score and the Charlotte rule: a prospective observational study. Acad Emerg Med Off J Soc Acad Emerg Med. 2005 Jul;12(7):587–93.
15. Kline JA, Stubblefield WB. Clinician gestalt estimate of pretest probability for acute coronary syndrome and pulmonary embolism in patients with chest pain and dyspnea.
Ann Emerg Med. 2014 Mar;63(3):275–80.
16. Rafaud P. Reproductibilité de la probabilité clinique implicite dans la suspicion d’embolie pulmonaire aux urgences. 2017.
17. Penaloza A, Soulié C, Moumneh T, Delmez Q, Ghuysen A, Kouri DE, et al. Pulmonary embolism rule-out criteria (PERC) rule in European patients with low implicit clinical probability (PERCEPIC): a multicentre, prospective, observational study. Lancet Haematol. 2017 Dec 1;4(12):e615–21.
18. DeLong ER, DeLong DM, Clarke-Pearson DL. Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach.
Biometrics. 1988 Sep;44(3):837–45.
19. Armstrong RA. When to use the Bonferroni correction. Ophthalmic Physiol Opt J Br Coll Ophthalmic Opt Optom. 2014 Sep;34(5):502–8.
20. Landis JR, Koch GG. The measurement of observer agreement for categorical data.
Biometrics. 1977 Mar;33(1):159–74.
21. Chagnon I, Bounameaux H, Aujesky D, Roy P-M, Gourdier A-L, Cornuz J, et al.
Comparison of two clinical prediction rules and implicit assessment among patients with suspected pulmonary embolism. Am J Med. 2002 Sep;113(4):269–75.
22. Klok FA, Mos ICM, Nijkeuter M, Righini M, Perrier A, Le Gal G, et al. Simplification of the revised Geneva score for assessing clinical probability of pulmonary embolism. Arch Intern Med. 2008 Oct 27;168(19):2131–6.
23. Righini M, Le Gal G, Perrier A, Bounameaux H. Effect of age on the assessment of clinical probability of pulmonary embolism by prediction rules. J Thromb Haemost JTH. 2004 Jul;2(7):1206–8.
24. Kabrhel C, McAfee AT, Goldhaber SZ. The contribution of the subjective component of the Canadian Pulmonary Embolism Score to the overall score in emergency department patients. Acad Emerg Med Off J Soc Acad Emerg Med. 2005 Oct;12(10):915–20.
25. Penaloza A, Mélot C, Dochy E, Blocklet D, Gevenois PA, Wautrecht J-C, et al. Assessment of pretest probability of pulmonary embolism in the emergency department by physicians in training using the Wells model. Thromb Res. 2007;120(2):173–9.
26. Penaloza A, Melot C, Motte S. Comparison of the Wells score with the simplified revised Geneva score for assessing pretest probability of pulmonary embolism. Thromb Res.
2011 Feb;127(2):81–4.
27. Freund Y, Cachanado M, Aubry A, Orsini C, Raynal P-A, Féral-Pierssens A-L, et al. Effect of the Pulmonary Embolism Rule-Out Criteria on Subsequent Thromboembolic Events Among Low-Risk Emergency Department Patients: The PROPER Randomized Clinical Trial.
JAMA. 2018 Feb 13;319(6):559–66.
28. Dachs RJ, Kulkarni D, Higgins GL. The Pulmonary Embolism Rule-Out Criteria rule in a community hospital ED: a retrospective study of its potential utility. Am J Emerg Med.
2011 Nov;29(9):1023–7.
29. Penaloza A, Kline J, Verschuren F, Courtney DM, Zech F, Derrien B, et al. European and American suspected and confirmed pulmonary embolism populations: comparison and analysis. J Thromb Haemost JTH. 2012 Mar;10(3):375–81.
30. Goldstein NM, Kollef MH, Ward S, Gage BF. The impact of the introduction of a rapid D-dimer assay on the diagnostic evaluation of suspected pulmonary embolism. Arch Intern Med. 2001 Feb 26;161(4):567–71.
31. Kabrhel C, Matts C, McNamara M, Katz J, Ptak T. A highly sensitive ELISA D-dimer increases testing but not diagnosis of pulmonary embolism. Acad Emerg Med Off J Soc Acad Emerg Med. 2006 May;13(5):519–24.
32. Pernod G, Caterino J, Maignan M, Tissier C, Kassis J, Lazarchick J, et al. D-Dimer Use and Pulmonary Embolism Diagnosis in Emergency Units: Why Is There Such a Difference in Pulmonary Embolism Prevalence between the United States of America and Countries Outside USA? PloS One. 2017;12(1):e0169268.
33. Kline JA, Mitchell AM, Kabrhel C, Richman PB, Courtney DM. Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. J Thromb Haemost JTH. 2004 Aug;2(8):1247–55.
34. Kabrhel C, Camargo CA, Goldhaber SZ. Clinical gestalt and the diagnosis of pulmonary embolism: does experience matter? Chest. 2005 May;127(5):1627–30.
35. Rosen MP, Sands DZ, Morris J, Drake W, Davis RB. Does a physician’s ability to accurately assess the likelihood of pulmonary embolism increase with training? Acad Med J Assoc Am Med Coll. 2000 Dec;75(12):1199–205.
36. Weiss CR, Haponik EF, Diette GB, Merriman B, Scatarige JC, Fishman EK. Pretest Risk Assessment in Suspected Acute Pulmonary Embolism. Acad Radiol. 2008 Jan 1;15(1):3–
14.