For healthcare professionals

4PEPS score calculator

The 4-Level Pulmonary Embolism Clinical Probability Score (4PEPS) adds and subtracts points for 13 clinical findings in an emergency department patient with suspected pulmonary embolism (PE). The total sets one of four probability levels, and each level comes with its own D-dimer step. This tool is written for clinicians and is not a diagnosis.

Last reviewed: 2026-11-03 By the uncovermyrisk.com editorial team Educational only, not medical advice.

Sudden shortness of breath, chest pain, coughing up blood or fainting: call 911 now.General safety advice (not part of the published score). These can be signs of a blood clot in the lungs; do not wait for a score.

Source

The 4PEPS by Roy PM and colleagues, JAMA Cardiology 2021 (open access, CC BY): every item, point, level and D-dimer step from Tables 1 and 3, cross-checked item by item against Table 2 of the review by Roy and colleagues, Diagnostics 2023 (CC BY 4.0). The tests check each item, the age, heart rate and saturation cutoffs, the lowest and highest possible score, the level edges at minus 1 and 0, 5 and 6, 12 and 13, and the D-dimer cutoff for each level.

Validated in

Consecutive outpatients with suspected PE in US and European emergency departments. The score was derived in 5,588 patients from 3 merged management studies (overall PE prevalence 11%), internally validated, and externally validated in 2 independent cohorts of 1,548 (PE prevalence 21.5%) and 1,669 patients (11.7%).

Limits

The area under the ROC curve was 0.79 and 0.78 in the two external cohorts. The strategy was applied retrospectively to existing study data: if used, false-negative rates were 0.71% and 0.89%, and imaging fell by 22% and 19%. The authors say it still needs a prospective outcome study. All cohorts were emergency department patients, so the authors note it may not suit inpatients. Patients with missing variables were left out. The D-dimer steps assume a high-sensitivity D-dimer assay in μg/mL, the unit printed in the study.

The point table

4PEPS, as printed in Table 3 of Roy and colleagues 2021 (Roy 2021) and in Table 2 of Roy and colleagues 2023 (Roy 2023):

Age under 50 years: minus 2; 50 to 64 years: minus 1; 65 or older: 0
Chronic respiratory disease: minus 1
Heart rate under 80 per minute: minus 1
Chest pain and acute dyspnea: plus 1
Male sex: plus 2
Hormonal estrogenic treatment: plus 2
Personal history of venous thromboembolism: plus 2
Syncope: plus 2
Immobility within the last 4 weeks (surgery, lower limb plaster cast, or bedridden more than 3 days for an acute medical condition): plus 2
Pulse oxygen saturation under 95%: plus 3
Calf pain and/or unilateral lower limb edema: plus 3
PE is the most likely diagnosis: plus 5

Worked example: a 72-year-old man (0 and plus 2) with heart rate 110 (0), oxygen saturation 92% (plus 3), calf pain (plus 3), in whom PE is the most likely diagnosis (plus 5), scores 13: high clinical probability, so imaging without a D-dimer first.

The four levels and the D-dimer step

Very low (under 0; clinical probability under 2%): PE can be ruled out without testing.
Low (0 to 5; 2% to 20%): PE can be ruled out if the D-dimer is under 1.0 μg/mL.
Moderate (6 to 12; 20% to 65%): PE can be ruled out if the D-dimer is under 0.5 μg/mL, or under age x 0.01 μg/mL from age 50.
High (13 or more; over 65%): PE cannot be ruled out without imaging (CT pulmonary angiography or V/Q scan).

Levels and steps as printed in Tables 1 and 3 of Roy and colleagues 2021 (Roy 2021). Any positive D-dimer at the low or moderate level leads to imaging. The authors defined the levels in advance so that, with the D-dimer step for each, the probability of PE after a negative result stays under 2% (Roy 2021). They list hemoptysis, cancer, chronic heart failure, pregnancy or the postpartum period, and heart rate 80 to 100 among the variables that were not independently linked to PE in the model, so they are not items (Roy 2021).

Related tools

Other pretest scores for suspected PE: the Wells score for PE, the revised Geneva score, the PERC rule and the YEARS algorithm. After a confirmed PE, see the PESI score and the Hestia criteria. Other bedside scores are listed under For healthcare professionals. The age-adjusted D-dimer calculator applies the age × 10 cutoff from age 50.

Sources

Roy PM, Friou E, Germeau B, Douillet D, Kline JA, Righini M, Le Gal G, Moumneh T, Penaloza A. 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. doi:10.1001/jamacardio.2021.0064. PMID 33656522. Open access (CC BY). Table 3 (4PEPS items, points and levels) and Table 1 (D-dimer step per level). pmc.ncbi.nlm.nih.gov/articles/PMC7931139/
Roy PM, Moumneh T, Bizouard T, Duval D, Douillet D. How to combat over-testing for patients suspected of pulmonary embolism: a narrative review. Diagnostics (Basel). 2023;13(7):1326. doi:10.3390/diagnostics13071326. PMID 37046544. Open access (CC BY 4.0). Table 2 (4PEPS items, points and levels). pmc.ncbi.nlm.nih.gov/articles/PMC10093278/

Written and maintained by the uncovermyrisk.com editorial team. We do not have a medical reviewer; every claim links to its primary source above. Last reviewed: 2026-11-03. Spotted an error? See About.