4-Level Pulmonary Embolism Clinical Probability Score (4PEPS)
4-level clinical pretest probability score for suspected PE in emergency department outpatients (Roy 2021), paired with a probability-adjusted D-dimer cut-off to reduce imaging. Derived and validated retrospectively (false-negative rate < 1%); the authors call for a prospective outcome study.
Score interpretation
Clinical pretest probability < 2% (PE in 1.1% in the derivation set).
→ PE can be ruled out on clinical grounds without D-dimer or imaging (Roy 2021).
Clinical pretest probability 2–20%.
→ D-dimer: PE ruled out if < 1.0 µg/mL (1000 ng/mL FEU); otherwise CTPA.
Clinical pretest probability 20–65%.
→ D-dimer: PE ruled out if below the age-adjusted cut-off (0.5 µg/mL, or age × 0.01 µg/mL over 50); otherwise CTPA.
Clinical pretest probability > 65%.
→ Imaging (CTPA, or V/Q scan) without a preceding D-dimer; start anticoagulation while awaiting imaging if there is no contraindication (ESC 2019).
Interpretation bands for the 4PEPS Score. Apply clinical judgement and local guidance.
References
- Roy PM, Friou E, Germeau B, et al. Derivation and Validation of a 4-Level Clinical Pretest Probability Score for Suspected Pulmonary Embolism to Safely Decrease Imaging Testing. JAMA Cardiol. 2021;6(6):669–677.
- Konstantinides SV, Meyer G, et al. 2019 ESC Guidelines for the 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.