RU2596056C1 - Method for clinical assessment of probability non-massive pulmonary artery thromboembolia in patients receiving menopausal hormone therapy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine and can be used for clinical assessment of probability of developing non-massive pulmonary artery thromboembolia (PATE) in patients, receiving menopausal hormone therapy. Clinical signs are determined and following signs are assessed in points: existence of receiving menopausal hormonal therapy agents, appearance on ECG signs of pulmonary heart, presence in Doppler echocardiography signs of right ventricular dysfunction detection in x-ray image of chest signs of pulmonary heart, presence of congenital or acquired disorders hemostasis, from laboratory indicators, such as homocysteine, presence of blood markers of APL syndrome, product of dehydration of fibrin D-dimer above 500 ng/ml, change on side of coagulation system (coagulation and/or platelet haemostasis), occurrence of signs of chronic venous insufficiency for period of using menopausal hormonal therapy, presence of metabolic syndrome, absence of any of following clinical signs is evaluated as 0 points. Obtained points are summed up. If total score is more than 19 a high probability of developing non-massive PATE is determined. If total score ranges from 13 to 18 - moderate probability of developing PATE. If total score is less than 12 - low clinical probability of non-massive PATE.

EFFECT: method improves accuracy and information value of detection of non-massive PATE in females, receiving menopausal hormonal therapy.

1 cl, 2 tbl

Description

The invention relates to medicine and can be used to clinically determine the likelihood of developing non-massive pulmonary artery thromboembolism (PE) in patients taking menopausal hormone therapy.

Preparations of menopausal hormone therapy (MHT) in recent decades have been widely used throughout the world as a means of improving the quality of life in a woman's menopause. Unfortunately, MHT drugs were not safe for thrombotic complications. One of them is non-massive pulmonary embolism - a common but difficult to diagnose cardiovascular pathology, characterized by pronounced polymorphism of clinical manifestations and the absence of pathognomonic symptoms, often occurring under the "mask" of various diseases. The main causes of non-massive pulmonary embolism include congenital (antiphospholipid syndrome, antithrombin deficiency, protein C deficiency, protein S deficiency, Leiden mutation, prothrombin G20210A gene mutation, hyperhomocysteinemia and others) and acquired hemostatic disorders, impaired hemodynamics and damage to the vascular wall, and MHT increases the risk of pulmonary embolism by 2–9 times. Unfortunately, studies on congenital disorders of hemostasis are not part of the standards for examining women, and their cost is high, so you need to get all the information about the patient's hemostasis and hemodynamics from routine examination methods, as well as their overall analysis. The alertness of doctors of all specialties regarding non-massive pulmonary thromboembolism, especially in women taking hormone therapy, is necessary.

One way to solve the problem of increasing the efficiency of clinical diagnosis of pulmonary embolism is a clinical assessment of the likelihood of pulmonary embolism, based on a combined assessment of risk factors for pulmonary embolism and some clinical signs. There are several ways to assess the clinical likelihood of developing pulmonary embolism by assessing risk factors and clinical symptoms, which use a scoring of the contribution of each trait. The most famous scales are Wells [4] and Geneva [5].

The most common definition of the likelihood of pulmonary embolism is using the Wells scale (2001), according to which the following indicators are evaluated in points: clinical symptoms of deep vein thrombosis of the lower extremities; Pulmonary embolism is more likely than other pathologies; tachycardia> 100 beats / min; immobilization or surgery over the past 3 days; history of deep vein thrombosis of the lower extremities or pulmonary embolism in history; hemoptysis; oncological pathology at the present time or up to 6 months old and the diagnostic indicator is calculated by their sum. This scale is quite easy to use, but has several disadvantages. Firstly, it does not take into account some important clinical manifestations, such as respiratory (shortness of breath, dissatisfaction with inspiration, sudden cough or bronchial obstruction syndrome), cardiac (chest pain, tachycardia) and neurological (dizziness, weakness, loss of consciousness) symptoms. Secondly, a low probability of another diagnosis is mentioned as a criterion. This criterion is not clear enough and serves as a source of errors of various kinds, while it is estimated by the maximum number of points, which increases the likelihood of making an erroneous decision. In addition, this method does not take into account the influence of factors such as menopausal hormone therapy and analysis of changes according to routine data (radiography, electrocardiography, Doppler echocardiography) and laboratory examination methods.

Known methods for the clinical determination of the likelihood of pulmonary embolism in patients with sinus node syndrome syndrome corrected by an pacemaker (Patent No. 2294150, published 02.22.07 ^[5] ) and the clinical determination of the likelihood of pulmonary embolism in patients with atriventricular blockade, Patient 64 , published December 10, 2006. These methods are also based on the use of scales that summarize scores for assessing the significance of risk factors and wedges These methods have been developed to improve the accuracy and informativeness of the clinical determination of the probability of pulmonary embolism in specific categories of patients: patients with sinus node syndrome, corrected by a pacemaker and patients with atriventricular block, corrected by a pacemaker. be applied to other categories of patients.

Closest to the proposed is a method for determining the likelihood of thromboembolism using the Geneva scale (2006), in which the following clinical data are evaluated in points: age> 65 years, history of deep vein thrombosis of the lower extremities or pulmonary embolism, history of surgery or fracture over the past month , suspicion of deep vein thrombosis of the lower extremities (pain in one limb), hemoptysis, tachycardia ≥95 beats / min, pain on palpation of the vein + edema of one limb. The total score is used to evaluate the clinical likelihood of pulmonary embolism.

However, this method has the following disadvantages: its scope is limited, since there are no specific criteria for the clinical determination of the likelihood of non-massive pulmonary embolism in patients taking menopausal hormone therapy (MHT) drugs. The criteria of the known method are not fully manifested in patients taking MHT, since age over 65 is already an irrelevant factor, deep vein thrombosis of the lower extremities is a contraindication for the appointment of MHT, hemoptysis is also not a significant factor, since non-massive PE is more often manifested shortness of breath and dissatisfaction with the breath, or a sudden cough or bronchial obstruction syndrome. In addition, the disadvantages of these methods are the lack of assessment of paraclinical indicators, concomitant, including iatrogenic, diseases (such as antiphospholipid syndrome), and a specific risk factor in women, such as prolonged uncontrolled intake of MHT drugs, which increases the risk of pulmonary embolism, is also not evaluated. 2-9 times [1, 2].

Thus, the identification of the clinical likelihood of pulmonary embolism in a known manner in patients taking MHT does not allow a reliable verification of the diagnosis during further examination, since the first stage of diagnosis — the assessment of the clinical likelihood of pulmonary embolism — is complicated by the lack of criteria, and therefore the information content and accuracy of diagnosis are reduced using a known method in patients taking MHT.

A new technical result is an increase in the accuracy and information content of the method

To achieve a new technical result in a method for clinically determining the likelihood of non-massive pulmonary thromboembolism in patients taking menopausal hormone therapy, the presence or absence of a number of symptoms is determined, then they are evaluated in points and a diagnostic indicator is calculated, and the following symptoms are determined: the presence of menopausal drugs hormonal therapy, the appearance on the ECG of signs of a pulmonary heart rate is 3 points, the presence of two or more respiratory respirators typical of pulmonary embolism x and / or cardiac and / or neurological symptoms, the appearance of shortness of breath or increased chronic shortness of breath, a feeling of shortness of breath, chest pain, coughing, hemoptysis, cyanosis of the face and neck, pallor of the skin, a feeling of palpitations, a feeling of heart rhythm disturbance, pressure pain behind the sternum, dizziness, general weakness, impaired coordination of movements, syncope, darkening in the eyes, fatigue, while in the column "points" write the value "4" if this condition is missing "0", also with doppler p-echocardiography of signs of dysfunction of the right ventricle is assessed at 3 points, detection of chest pulmonary heart symptoms during radiography is assessed at 4 points, the presence of hereditary or acquired hemostatic disorders is evaluated at 3 points, the presence of at least two or more risk factors in patients is evaluated 2 points, the appearance of signs of chronic venous insufficiency for the period of menopausal hormone therapy is assessed at 3 points, the presence of deviations from the norm of any two or more from laboratory indicators, such as homocysteine level, the presence of antiphospholipid syndrome markers in the blood, the product of dehydration of fibrin D-dimer above 500 ng / ml, changes in the coagulation system (coagulation and / or platelet hemostasis), the value “3” is entered in the “points” column ”, If the indicators are“ 0 ”, the patient’s metabolic syndrome is assessed at 1 point, the presence of two or more risk factors, such as age, chronic venous insufficiency, taking MHT, the possible presence of antiphospholipid syndrome and assessed at 2 points, in this case, the absence of any of the listed clinical signs is evaluated at 0 points, after which the total points are calculated, and with a total of more than 19 points, respectively, high is determined, with a total of points from 13 to 18 points - moderate and with a score of less than 12, a low clinical likelihood of pulmonary embolism.

The method is as follows: in patients taking menopausal hormone therapy, history and complaints are clarified, special attention is paid to the pharmacological history of the fact of using female sex steroid preparations; conduct a thorough examination, paying attention to the presence and severity of pallor of the skin, the presence and severity of acrocyanosis, cyanosis of the lips, nasolabial triangle, the frequency of respiratory excursions per minute; they inspect and palpate the veins of the lower extremities, measure their circumferences at the level of the legs, hips; conduct routine clinical studies (general and biochemical blood tests). In addition, the hemostasis system is examined (the presence of markers of antiphospholipid syndrome - lupus anticoagulant, the presence of fibrin degradation product D-dimer in the blood, homocysteine level is determined in the blood). Examine the ECG, comparing with previous studies. If there is a change in the cardiogram (signs of overload of the right ventricle, such as a deviation of the electrical axis of the heart to the right, inversion of the T wave in leads V1-V4, ventricular complex type QR in lead V1, classic symptom S1Q3T3 (McGinn-White syndrome [4]) and complete or incomplete blockade of the right leg of the bundle of His, high and pointed P wave (P-pulmonale, a sign of overload of the right atrium)) conduct a Doppler echocardiographic examination of the heart (paying attention to signs of impaired right ventricular function (its expansion and hypokinesis, swelling of the interventricular septum toward the left ventricle), signs of pulmonary hypertension, tricuspid regurgitation) and radiography (paying attention to such symptoms as Fleischner symptom (high standing of the dome of the diaphragm on the affected side, expansion of the right heart and lung roots), Pall sign (expansion of the right descending pulmonary artery), a symptom of Westermark (local depletion of the vascular pattern of the lung). According to the indications, ventilation-perfusion lung scintigraphy is prescribed, which reveals areas of hypo- or aperfusion of the lungs. The detected signs are entered in the table in which scoring is carried out. If there is a fact of using menopausal hormone therapy, the value “3” is written in the “points” column; if this condition is absent, the value “0” is written. In the presence of two or more respiratory and / or cardiac and / or neurological symptoms typical for pulmonary embolism (the appearance of shortness of breath or increased chronic shortness of breath, a feeling of shortness of breath, chest pain, coughing, hemoptysis, face and neck cyanosis, pallor of the skin, feeling of palpitations , a feeling of heart rhythm disturbance, pressing pains behind the sternum, dizziness, general weakness, impaired coordination of movements, syncope, darkening of the eyes, fatigue) in the “points” column write the value “4” if this no catch, record the value "0". When ECG shows signs of pulmonary heart (McGin-White syndrome (deep S wave in I standard lead, deep Q wave and negative T wave in III standard lead), signs of complete or incomplete blockade of the right bundle branch block) in the “points” box "Write" 3 ", if this condition is absent, write the value" 0 ". When Doppler echocardiography is detected for signs of dysfunction of the right ventricle (its expansion and hypokinesis, swelling of the interventricular septum towards the left ventricle), signs of pulmonary hypertension, tricuspid regurgitation, the value “3” is written in the “points” column, if this condition is absent, write “0 ". If the patient has a metabolic syndrome, the value "1" is entered in the "scores" column, in the absence - "0". Then, the total points are calculated, and with a total of more than 19 points, a high, from 13 to 18 points - moderate and less than 12 points low clinical probability of pulmonary embolism is determined.

Determining the clinical likelihood of non-massive pulmonary embolism serves as the basis for further instrumental diagnosis of pulmonary embolism with the aim of confirming or excluding it. With moderate and high probability of non-massive pulmonary embolism, instrumental diagnostics includes the study of perfusion and ventilation of the lung by perfusion and ventilation lung scintigraphy, angiopulmonography, spiral computed angiopulmonography, transesophageal and transthoracic echocardiography. The choice of further diagnostic measures and tests depends on both the specific clinical conditions and the diagnostic capabilities of the clinic. With a low clinical likelihood of pulmonary embolism, refusing further diagnostic tests and antithrombotic therapy is safe for the patient.

Example 1

Patient K., 60 years old, was hospitalized in February 2005 in the cardiology department of the Tomsk Regional Clinical Hospital. Upon receipt complained of severe shortness of breath during normal walking; constant dissatisfaction with the breath; cardialgia; blood pressure rise to 180-200 / 100 mm Hg with no effect on antihypertensive therapy; swelling of the legs and a sharp progression of varicose veins; presyncopal condition.

From the anamnesis: for ten years I took HRT drugs (first, clemen, then femoston).

Objectively: The condition is relatively satisfactory, nutrition is increased. Respiratory rate 20-22 per minute. Over the lungs against the background of weakened breathing, gentle crepitation is heard on the left. The border of relative dullness of the heart is increased to the left, the rhythm is correct, it is prone to tachycardia at rest to 95-100 beats per minute. Second tone accent above the aorta = second tone accent above the pulmonary artery. A slight systolic murmur is heard above the pulmonary artery. HELL 180/100 mm Hg From the side of the lower extremities there are signs of severe chronic venous insufficiency on the left and on the right.

Considering the fact that nonmassive pulmonary embolism was suspected, the patient underwent the following studies: electrocardiography, echocardiography, chest x-ray, coagulogram, ultrasound examination of the veins of the lower extremities, determination of lupus-type anticoagulants, qualitative determination of the level of D-dimer.

On the ECG - tachycardia (95 beats per minute) against the background of signs of overload of the right heart (p-pulmonale), shift of the transition zone to V ₅ -V ₆ . On the echocardiogram, the right ventricle is larger than the left (the size of the left ventricle is normal), the right atrium is slightly increased, the pressure in the right ventricle is moderately increased (25 mmHg), the tricuspid valve is not structurally changed, slight regurgitation. On the radiograph - relaxation of the dome of the diaphragm on the left, impoverishment of the pulmonary pattern, bulging of the second arc along the left contour of the heart shadow. Coagulogram - 7.5 orthophenanthroline test, positive ethanol test, D-dimer> 500 ng / ml. Lupus test: possibly there is a "lupus anticoagulant. It is recommended to repeat the analysis after 6 months. Ultrasound examination of veins of the lower extremities: signs of post-thrombophlebitic syndrome of deep veins of both legs, stage of recanalization.

The study was conducted according to the proposed method (table 1 - see Appendix). By the sum of the scores (26), a high clinical probability of pulmonary embolism was established, which served as the basis for perfusion lung scintigraphy with 99mTc-Makrotech with an activity of 185 MBK. On scintigrams made in four projections, both lungs were visualized. General hypoperfusion of the left lung, mainly of its basal sections, was noted. In addition, there was a hypoperfusion of the region 5, 8 of the bronchopulmonary segments of both lungs. This, in the absence of pneumofibrosis in the projections of these segments on the radiograph, served as the basis for establishing the diagnosis of thromboembolism of small and medium branches of both pulmonary arteries, more pronounced on the left.

The main diagnosis: Thromboembolism in the system of small and medium branches of the pulmonary artery. Subacute pulmonary heart. Thrombophlebitis of deep and superficial veins in a patient with varicose veins of the legs and chronic venous insufficiency against the background of prolonged and uncontrolled administration of MHT drugs.

Concomitant diagnosis: Stage II hypertension, grade 3, risk III.

Treatment was performed, including fraxiparin 0.6 mg / day for 10 days, then transferred to oral anticoagulants (warfarin 5 mg per day under the control of MHO), the drug menopausal hormone therapy femoston was canceled, antihypertensive therapy was prescribed. Against this background, shortness of breath and cardialgia disappeared in the patient, presyncopal conditions disappeared, blood pressure decreased to the target, the phenomena of chronic venous insufficiency decreased and thrombophlebitis was stopped.

Example 2

Patient V., 54 years old, was hospitalized in the pulmonology department of the Tomsk Regional Clinical Hospital with complaints of shortness of breath, dry cough, pain in the left half of the chest, general weakness. On admission: temperature 37 °, marked general pallor, cyanosis of the lips, number of breaths 28 per minute, breathing in the lower parts of the left half of the chest is weakened, dry rales on both sides, blood pressure 115/85 mm Hg, heart sounds are muffled pulse of 74 beats per minute. Signs of chronic venous insufficiency of the lower extremities.

In the hospital, chest x-rays, electrocardiography, doppler echocardiography were performed. X-ray revealed signs of inflammatory infiltration of the lower lobe on the left, pleurisy (?). Complete blood count: white blood cells 5.3 × 10 9 / l, ESR 36 mm / h. ECG: Sinus rhythm, heart rate 74 per minute, normal position of the electrical axis of the heart, moderate changes in the myocardium. Doppler echocardiography: increased systolic pressure in the right ventricle, tricuspid regurgitation I degree.

Based on the above complaints and research results, the diagnosis was made: Pneumonia of the lower lobe of the left lung. The patient was given antibacterial (oxacillin, cephalotin, perth), mucolytic (bromhexine), anti-inflammatory (indomethacin) and metabolic therapy (riboxin, aloe, ascorbic acid).

After the treatment, there was no improvement - shortness of breath, cough, chest pain persisted. In addition, it turned out that the patient over the past seven years has been uncontrollably taking menopausal hormone therapy (femoston). Since the results of the studies do not allow to exclude pulmonary embolism, the patient was tested according to the proposed method (table 2 - see Appendix). By the sum of the scores (15), a moderate clinical probability of pulmonary embolism was established, which served as the basis for perfusion lung scintigraphy with 99mTc-Makrotech with an activity of 185 MBK. On scintigrams made in four projections, both lungs were visualized. The pattern of pulmonary fields was changed due to hypo- and aperfusion of 5, 8, 9 and 10 segments of the left lung. This, in the absence of pneumofibrosis in the projections of these segments on the radiograph, served as the basis for establishing the diagnosis of thromboembolism of small and medium branches of the left pulmonary artery.

The diagnosis of the main: Varicose disease of both lower extremities. CVI of both lower extremities.

Complication: Recurrent thromboembolism in the system of small and medium branches of the pulmonary artery on the background of prolonged and uncontrolled administration of MHT drugs.

Treatment was carried out, including fraxiparin 0.6 mg / day for 10 days, then transferred to oral anticoagulants (warfarin 5 mg per day under the control of MHO), phenyline 30 mg per day, the drug menopausal hormone therapy femoston was canceled. Against this background, the patient's shortness of breath and chest pain disappeared, the phenomena of chronic venous insufficiency decreased and thrombophlebitis was stopped.

The proposed criteria for determining the clinical likelihood of pulmonary embolism in menopausal syndrome patients taking menopausal hormone therapy drugs were selected based on the interpretation of data from a retrospective analysis of case histories of patients with menopausal syndrome during hospitalization in multidisciplinary hospitals of medical institutions for “mask diseases” under which often hides pulmonary embolism, as well as on the basis of clinical observation of patients with cf dnyuyu and high clinical probability of pulmonary embolism, according to the proposed method.

We analyzed 7 clinical cases in middle-aged women 53.0 ± 4.24 years, the average term for taking drugs was from 3.78 ± 3.44. At the same time, we noted the time elapsed from the start of taking menopausal hormone therapy drugs and compared it with the time complaints first occurred during this period, assessed the diagnoses and the degree of their validity, possible risk factors for pulmonary embolism in each patient, data from clinical and paraclinical examination methods. The control group consisted of 10 women who did not take MHT and, accordingly, they did not have respiratory and cardiac complaints, laboratory indicators were normal. All indicators were entered into the database. To assess the contribution of each of the factors and their interaction, the non-parametric Chi-square criteria and Fisher's exact test were used, which made it possible to single out several working algorithms for determining the clinical probability of pulmonary embolism with various combinations of indicators and their scoring.

Clinical observation was carried out for 7 patients, 4 identified a high probability of pulmonary embolism, 3 - moderate probability of pulmonary embolism according to the proposed method. Six patients underwent electrocardiography, Doppler echocardiography, chest x-ray, and ventilation-perfusion scintigraphy. Moreover, the data of the radionuclide study were compared with the data of the x-ray picture. The results of the studies showed that with a high and medium probability for clinical symptoms, the diagnosis of pulmonary embolism was confirmed in 6 out of 7 people.

Thus, the proposed method allows you to most accurately diagnose the clinical likelihood of non-massive pulmonary thromboembolism in patients taking menopausal hormone therapy, which is important to improve the quality and life expectancy and conduct the most appropriate and timely diagnostic and treatment and preventive measures in this category of patients.

Sources of information taken into account when compiling the description

1. Anderson FA Jr, Spencer FA. Risk factors for venous thromboembolism. Circulation. 2003 Jun 17; 107 (23 Suppl 1): I9-16.

http://circ.ahajournals.org/cgi/content/full/107/23_suppl_1/I-9

2. Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J. 2008 Sep; 29 (18): 2276-315. http://www.ncbi.nlm.nih.gov/pubmed/18757870?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum http://www.escardio.org/guideslines /Pages/acute-pulmonary-embolism.aspx

3. McGinn S, White PD (1935). "Acute cor pulmonale resulting from pulmonary embolism." J Am Med Assoc 104: 1473-80.

4. Scott RC (July 1971). "The S1Q3 (McGinn-White) pattern in acute cor pulmonale: a form of transient left posterior hemiblock?". Am. Heart J. 82 (1): 135-7. PMID 5581712.

5. A method for the clinical determination of the likelihood of pulmonary embolism in patients with sinus node syndrome, corrected pacemaker: US Pat. 2294150 Ros. Federation: А61В 10 / Posokhov I.N., Tyukalova L.I., Popov S.V .; applicants and patent holders Posokhov I.N., Tyukalova L.I., Vidisheva O.N., Popov S.V. No. 2005117769/14; declared 06/08/2005; publ. 02/27/2007, Bull. No. 6.

6. A method for the clinical determination of the likelihood of pulmonary embolism in patients with atrioventricular blockade corrected by a pacemaker: US Pat. 2288641 Ros. Federation: А61В 10 / Tyukalova L.I., Dzhuraeva E.R., Popov S.V., Posokhov I.N .; Applicants and patent holders Tyukalova L.I., Juraeva E.R., Popov S.V., Posokhov I.N. No. 2005117770/14; declared 06/08/2005; publ. 12/10/2006, Bull. No. 6.

Claims (1)

A method for the clinical determination of the likelihood of non-massive pulmonary thromboembolism in patients taking menopausal hormone therapy, characterized by determining the presence or absence of a number of symptoms, then scoring and calculating a diagnostic indicator, and the following symptoms are determined: the presence of menopausal hormonal therapy, the appearance of An ECG of the signs of a pulmonary heart is assessed at 3 points, the presence of two or more respiratory and / or cardiac, and / or typical for pulmonary embolism neurological symptoms, the appearance of shortness of breath or increased chronic shortness of breath, a feeling of shortness of breath, chest pain, coughing, hemoptysis, cyanosis of the face and neck, pallor of the skin, a feeling of palpitations, a feeling of heart rhythm disturbance, pressing pains behind the sternum, dizziness, general weakness, impaired coordination of movements, syncope, darkening in the eyes, fatigue, while in the column "points" write the value "4", if this condition is absent, - "0", also the presence of Doppler echocardiography prize the incidence of right ventricular dysfunction is estimated at 3 points, the detection of signs of pulmonary heart during chest x-ray is assessed at 4 points, the presence of hereditary or acquired hemostasis disorders is estimated at 3 points, the presence of at least two or more risk factors in patients is rated at 2 points , the appearance of signs of chronic venous insufficiency during the period of application of menopausal hormone therapy is estimated at 3 points, the presence of deviations from any of two or more laboratory indicators factors, such as homocysteine levels, the presence in the blood of markers of antiphospholipid syndrome, the product of dehydration of fibrin D-dimer above 500 ng / ml, changes in the coagulation system (coagulation and / or platelet hemostasis), enter the value “3” in the “points” column, if the indicators are normal, “0”, the patient’s metabolic syndrome is assessed at 1 point, the presence of two or more risk factors, such as age, chronic venous insufficiency, MHT administration, the possible presence of antiphospholipid syndrome is estimated at 2 points, p In this case, the absence of any of the listed clinical signs is evaluated at 0 points, after which the total points are calculated, and with a total of more than 19 points, they are determined accordingly high, with a total of 13 to 18 points - moderate and low with a total of less than 12 - low clinical likelihood of pulmonary embolism.

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