4-Level Pulmonary Embolism Clinical Probability Score (4PEPS)
Novel 4-level clinical probability score for pulmonary embolism that includes age and directly classifies patients into unlikely/low/intermediate/high PE probability. Developed by Roy et al. 2021 as an improvement over Wells and revised Geneva scores in the age of D-dimer adjustment. Designed to reduce unnecessary CTPA ordering. Validated in 1,746 patients.
Score interpretation
4PEPS below 0 -- PE unlikely (<2% probability)
→ Perform D-dimer (ELISA highly sensitive assay preferred); if D-dimer negative (below 500 mcg/L, or age-adjusted: age x 10 if age above 50): PE excluded -- no CTPA needed; treat underlying cause of symptoms; if D-dimer positive: proceed to CTPA; document clinical probability and D-dimer result in notes; if patient has high bleeding risk for anticoagulation and D-dimer mildly elevated: discuss with haematology before CTPA.
4PEPS 0-5 -- low PE probability (3-7%)
→ D-dimer (ELISA): if negative (below 500 mcg/L or age-adjusted): PE excluded; if positive: CTPA; if age-adjusted D-dimer negative: no CTPA required (saves significant radiation dose); consider proximal compression USS if DVT signs present; document probability.
4PEPS 6-12 -- intermediate PE probability (15-25%)
→ CTPA recommended (D-dimer unreliable at this probability -- likely positive even without PE); if CTPA positive: start anticoagulation (LMWH or DOAC per PESI/sPESI risk class); if CTPA negative but clinical suspicion remains: proximal compression USS lower limbs; ensure adequate anticoagulation bridge while awaiting imaging; document.
4PEPS above 12 -- high PE probability (above 50%)
→ Start anticoagulation immediately (LMWH or UFH) while awaiting CTPA unless active bleeding or contraindication; urgent CTPA; do not wait for D-dimer result; if CTPA not immediately available: ventilation-perfusion scan (V/Q) as alternative; if haemodynamically unstable: see PESI management; CTPA confirms diagnosis and allows PESI risk-stratification for treatment decisions; document urgency and anticoagulation initiated.
Interpretation bands for the 4PEPS Score. Apply clinical judgement and local guidance.
References
- Roy PM et al. 4PEPS: a new score for clinical probability assessment of pulmonary embolism. Eur Respir J. 2021;57(1):2003474.
- ESC Task Force. 2019 ESC Guidelines for diagnosis and management of acute pulmonary embolism. Eur Heart J. 2020;41(4):543-603.
Related
Curated clinical cross-links plus same-class fallbacks.
- Composite Pulmonary Embolism Shock (CPES) Score · Pulmonary Embolism
- Pulmonary Embolism Severity Index (PESI) · Pulmonary Embolism
- YEARS Algorithm for Pulmonary Embolism · Pulmonary Embolism
- Wells' Criteria for Pulmonary Embolism · Pulmonary Embolism
- Revised Geneva Score for Pulmonary Embolism · Pulmonary Embolism
- Bova Score for Pulmonary Embolism Complications · Pulmonary Embolism
- Nitric Oxide (Inhaled — iNO) · Selective Pulmonary Vasodilator
- Selexipag · Pulmonary Arterial Hypertension
- Macitentan · Pulmonary Arterial Hypertension
- Lissamine Green 1% Eye Drops · Vital Dye — Ocular Surface Staining (Dry Eye Diagnosis)
- Sildenafil (Paediatric — PPHN / PAH) · PDE5 Inhibitor (Paediatric Pulmonary Hypertension)
- Sildenafil · PDE5 Inhibitor — Pulmonary Arterial Hypertension
- Acute Asthma in Adults · BTS/SIGN British Guideline on Asthma 2019; NICE NG80
- Pulmonary Embolism Assessment · NICE NG158; ESC 2019 PE Guidelines
- Acute Exacerbation of COPD (AECOPD) · NICE NG115; GOLD 2024
- Spontaneous Pneumothorax (Adult) · BTS Pleural Disease 2023
- Atypical Pneumonia (Legionella / Mycoplasma / Chlamydophila) · BTS 2023; IDSA
- COPD Exacerbation Management · NICE NG115 / GOLD 2024
Decision support only — verify against a current formulary, NICE, or your local guideline before clinical use.