The Geneva scoring system and the Wells system are two methodologies that have been used in lieu of or as an adjunct to “clinical judgment.” The former requires arterial blood gases and the latter has as criteria “other diagnosis more likely than pulmonary embolus” that can be problematic and difficult to standardize.
This article presents a revised Geneva scoring system based solely on elements of the history and physical examination. The elements were derived retrospectively from a prior different study on diagnostic strategies for pulmonary thromboembolism (PTE). A different prospective study on PTE was utilized for the validation arm of this study. By logistical regression analysis the following eight elements were incorporated into the revised Geneva score: Age greater than 65 (1 point), previous deep venous thrombosis or pulmonary embolism (3 points), surgery or fracture within one month (2 points), active malignant condition (2 points), unilateral lower limb pain (3 points), hemoptysis (2 points), heart rate 75 to 94 beats/min (3 points) or heart rate 95 beats /minute or more (5 points), and pain on lower limb palpation and unilateral edema (4 points). The prevalence for pulmonary embolism was as follows: low probability or 8% (0 to 3 points), intermediate probability or 28% (4 to 10 points), and high probability or 74% (equal or greater than 11 points).
Significance for hospitalists: This scoring system is not validated a management system per se. However in the imperfect world of clinical reasoning it can help reinforce a thoughtful decision not to embark on the diagnostic path for pulmonary embolism, with its own inherent risks.
Metoprolol after Vascular Surgery
Yang H, Raymer K, Butler R, et al. The effects of perioperative beta-blockade: results of metoprolol after vascular surgery (MaVS) study, a randomized controlled trial. Am Heart J. 2006 Nov;152(5):983-990. Comment in Am Heart J. 2006 Nov;152(5):815-818. McCullough PA. Failure of beta-blockers in the reduction of perioperative events: where did we go wrong? Am Heart J. 2006 Nov;152(5):815-818. Comment in: Am Heart J. 2006 Nov;152(5):983-990.
Hospitalists are frequently consulted regarding perioperative risk assessment and reduction for patients undergoing non-cardiac surgery. Over the last decade and supported by a few studies, the perioperative use of beta-blocker therapy has resolved the uncertainty frequently encountered. The McFalls study in 2004 showed no benefit to routine coronary revascularization for patients undergoing vascular surgery deemed at risk for myocardial ischemia.1 This provided further confidence for those of us supplying these preoperative assessments. However, the Lindenauer study in 2005 (a retrospective cohort analysis) was the first indication that perioperative beta blockade could be harmful.2 Lower-risk patients based on the revised cardiovascular index (RCRI) score actually did worse when treated. Still the ACC guidelines published in 2006 suggested perioperative beta blockers be considered for lower risk patients undergoing vascular surgery.3
This study is a randomized placebo-controlled trial of perioperative beta-blocker therapy in 500 treatment-naïve patients undergoing vascular surgery. Metoprolol was started two hours before surgery and continued for one week. Cardiovascular endpoints included cardiac death, arrhythmia requiring treatment, acute myocardial infarction or acute coronary syndrome, and congestive heart failure. No benefit was found for treatment with metoprolol regardless of the number of Revised Cardiac Risk Index (RCRI) factors present. No excess adverse outcomes were noted for therapy although intraoperative bradycardia and hypotension were significantly increased in the active treatment group.
In the accompanying editorial McCullough discusses possible reasons and implications of these findings. In fact, two other trials have reported similar findings. In contrast to the older trials suggesting a benefit to perioperative beta blockade these newer trials are larger and have a stronger design. He also notes that the patients in the more recent trials are more likely to have prior revascularization and hence are less prone to demand-type events, reflective of the type of insult beta blockade would most likely be helpful in preventing. These events may be more closely allied with plaque destabilization of subcritical lesions, with factors such as perioperative hypercoagulability and perhaps inflammation being more important. In this regard it is notable that recent trials on the perioperative use of statins have demonstrated favorable results, with these agents presumably acting to promote plaque stability, the so-called “pleiotropic” function of statins.