Comparison of the safety and efficacy of YEARS, PEGeD, 4PEPS or the sole item "PE is the most likely diagnosis" strategies for the diagnosis of pulmonary embolism in the emergency department: post-hoc analysis of two European cohort studies

Safety of the pulmonary embolism rule-out criteria rule: Findings from the Registro Informatizado de la Enfermedad TromboEmbolica venosa (RIETE) registry

BACKGROUND

The diagnostic strategy for pulmonary embolism (PE) includes a D-dimer test when PE probability is low or intermediate, but false-positive D-dimer results are frequent and can result in an unnecessary computed tomography pulmonary angiogram. The PE rule-out criteria (PERC) rule excludes PE without D-dimer testing when pretest probability is <15%. The aim of this study was to assess the safety of the PERC rule strategy in patients included in the Registro Informatizado de la Enfermedad TromboEmbolica venosa (RIETE) registry.

METHODS

This retrospective cohort study used data from the RIETE registry, an ongoing, international prospective registry of patients with objectively confirmed venous thromboembolism. The primary outcome was the failure rate of the PERC strategy, represented by the proportion of PERC-negative (PERC-N) patients with a PE included in the registry. Secondary outcomes were a comparison of the clinical characteristics, treatment strategy, and outcome of PERC-N versus PERC-positive (PERC-P) patients at 3 months.

RESULTS

From 2001 to 2021, a total of 49,793 patients with acute PE were enrolled in the RIETE registry. We included 48,903 in the final analysis after exclusion of 890 patients with an undetermined PERC status. Only 346 patients were PERC-N with a failure rate of 0.7% (95% confidence interval 0.6%-0.8%). PERC-N patients presented more frequently with chest pain but less often with dyspnea, syncope, or hypotension. They also had subsegmental or segmental PE more frequently, were more often treated with direct oral anticoagulants, and received mechanical or pharmacological thrombolysis less often. In addition, PERC-N patients had a lower incidence of recurrent deep vein thrombosis, major bleeding, and death attributed to PE during the 3-month follow-up.

CONCLUSIONS

A low failure rate of the PERC rule was observed in the RIETE registry, thus supporting its use to safely identify patients with an unlikely probability of PE.

Temporal Trends in the Use of Computed Tomographic Pulmonary Angiography for Suspected Pulmonary Embolism in the Emergency Department : A Retrospective Analysis

BACKGROUND

Recently, validated clinical decision rules have been developed that avoid unnecessary use of computed tomographic pulmonary angiography (CTPA) in patients with suspected pulmonary embolism (PE) in the emergency department (ED).

OBJECTIVE

To measure any resulting change in CTPA use for suspected PE.

DESIGN

Retrospective analysis.

SETTING

26 European EDs in 6 countries.

PATIENTS

Patients with CTPA performed for suspected PE in the ED during the first 7 days of each odd month between January 2015 and December 2019.

MEASUREMENTS

The primary end points were the CTPAs done for suspected PE in the ED and the number of PEs diagnosed in the ED each year adjusted to an annual census of 100 000 ED visits. Temporal trends were estimated using generalized linear mixed regression models.

RESULTS

8970 CTPAs were included (median age, 63 years; 56% female). Statistically significant temporal trends for more frequent use of CTPA (836 per 100 000 ED visits in 2015 vs. 1112 in 2019; P < 0.001), more diagnosed PEs (138 per 100 000 in 2015 vs. 164 in 2019; P = 0.028), a higher proportion of low-risk PEs (annual percent change [APC], 13.8% [95% CI, 2.6% to 30.1%]) with more ambulatory management (APC, 19.3% [CI, 4.1% to 45.1%]), and a lower proportion of intensive care unit admissions (APC, -8.9% [CI, -17.1% to -0.3%]) were observed.

LIMITATION

Data were limited to 7 days every 2 months.

CONCLUSION

Despite the recent validation of clinical decision rules to limit the use of CTPA, an increase in the CTPA rate along with more diagnosed PEs and especially low-risk PEs were instead observed.

PRIMARY FUNDING SOURCE

None specific for this study.

How to Combat Over-Testing for Patients Suspected of Pulmonary Embolism: A Narrative Review

The diagnosis of PE remains difficult in 2023 because the signs and symptoms are not sensible nor specific. The consequences of potential diagnostic errors can be dramatic, whether by default or by excess. Furthermore, the achievement of a simple diagnostic strategy, based on clinical probability assessment, D-dimer measurement and computed tomography pulmonary angiography (CTPA) leads to a new challenge for PE diagnosis: over-testing. Indeed, since the 2000s, the wide availability of CTPA resulted in a major increase in investigations with a mod I confirm erate increase in PE diagnosis, without any notable improvement in patient outcomes. Quite the contrary, the complications of anticoagulation for PE increased significantly, and the long-term consequences of imaging diagnostic radiation is an important concern, especially the risk of breast cancer for young women. As a result, several strategies have been proposed to fight over-testing. They are mostly based on defining a subgroup of patients for whom no specific exam should be required to rule-out PE and adjusting the D-dimer cutoff to allow the exclusion of PE without performing CTPA. This narrative review presents the advantages and limitations of these different strategies as well as the perspective in PE diagnosis.

Diagnostic Strategy for Suspected Pulmonary Embolism in Emergency Departments Based on the 4-Level Pulmonary Embolism Clinical Probability Score: Study Protocol of SPEED&PEPS Trial

Introduction: Several strategies have been devised to safely limit the use of thoracic imaging in patients suspected of pulmonary embolism (PE). However, they are based on different rules for clinical probability (CP) assessment, rendering their combination difficult. The four-level pulmonary embolism probability score (4PEPS) allows the combination of all other strategies using a single CP assessment. Methods and analysis: Pragmatic cluster-randomized trial in 20 EDs. Patients with suspected PE will be included and followed for 90 days (number of patients to be included: 2560, 1280 in each arm). Ten centers will be allocated to the control group where physicians will be free to do as they see fit but they will be given the recommendation to apply a validated strategy. Ten centers will be allocated to the interventional group where the physicians will be given the recommendation to apply the 4PEPS strategy. The primary objective will be to demonstrate that the application of the 4PEPS strategy by the emergency physicians, in comparison to current practices, (i) does not increase the risk of serious events related to diagnostic strategies and (ii) significantly reduces the use of thoracic imaging. Ethics and dissemination: The study will be submitted for approval to an institutional ethics review board for all participating centers. If successful, the SPEED&PEPS trial will have an important impact for patients suspected of PE limiting their irradiation and for public health in substantial savings in terms of the direct cost of diagnostic investigations and the indirect cost of hospitalizations due to waiting times or delayed harmful effects. Funding: This work is funded by a French Public Health grant (PREPS-N 2019). The funding source plays no role in the study design, data collection, analysis, interpretation or the writing of the manuscript. Trial registration: ongoing. Trial status: not started.