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Truong P, Mazzolai L, Font C, Ciammaichella M, González-Martínez J, Tufano A, Gavín-Sebastián O, Le Mao R, Monreal M, Hugli O. Safety of the pulmonary embolism rule-out criteria rule: Findings from the Registro Informatizado de la Enfermedad TromboEmbolica venosa (RIETE) registry. Acad Emerg Med 2023; 30:935-945. [PMID: 37092646 DOI: 10.1111/acem.14744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/29/2023] [Accepted: 04/20/2023] [Indexed: 04/25/2023]
Abstract
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.
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Affiliation(s)
- Perrine Truong
- Department of Emergency Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Lucia Mazzolai
- Department of Angiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Carme Font
- Department of Medical Oncology, Hospital Clínic, Barcelona, Spain
| | | | - José González-Martínez
- Department of Internal Medicine, Hospital Universitari Sant Joan de Déu, Fundació Althaia, Manresa, Barcelona, Spain
| | - Antonella Tufano
- Regional Reference Centre, Federico II University Hospital, Naples, Italy
| | - Olga Gavín-Sebastián
- Department of Haematology, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Raphael Le Mao
- Department of Internal Medicine, CHRU Brest, Brest, France
| | - Manuel Monreal
- Faculty of Health Sciences, UCAM-Universidad Católica San Antonio de Murcia, Murcia, Spain
- CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Olivier Hugli
- Department of Emergency Medicine, Lausanne University Hospital, Lausanne, Switzerland
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Westafer LM, Long B, Gottlieb M. Managing Pulmonary Embolism. Ann Emerg Med 2023; 82:394-402. [PMID: 36805291 PMCID: PMC10432572 DOI: 10.1016/j.annemergmed.2023.01.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/18/2023] [Accepted: 01/19/2023] [Indexed: 02/19/2023]
Affiliation(s)
- Lauren M Westafer
- Department for Healthcare Delivery and Population Science and Department of Emergency Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield, MA.
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, TX
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL
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Ling LLL, Zhang VJW, Lim HY, Lim MJ, Ho P. Clinical predictors of pulmonary embolism for inpatients: are computed tomography pulmonary angiograms being requested appropriately? Intern Med J 2023; 53:1224-1230. [PMID: 35049098 DOI: 10.1111/imj.15696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 12/14/2021] [Accepted: 01/10/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND The heterogeneity of inpatient pulmonary embolism (PE) presentations may lead to computed tomography pulmonary angiograms (CTPA) being over-requested. Current clinical predictors for PE, including Wells criteria and Pulmonary Embolism Rule-out Criteria (PERC), have predominantly focussed on outpatient and emergency department populations. AIM To determine the clinical indicators for ordering inpatient CTPA and the predictors of positive scans for PE. METHODS Consecutive inpatient CTPA (performed >24 h after admission) from January 2017 to December 2017 were retrospectively reviewed. Variables including baseline characteristics, vital signs and risk factors for PE were extracted. RESULTS A total of 312 CTPA was reviewed (average patient age 67 years; 46% male) and 36 CTPA were positive for PE (11.5%). The average time to inpatient CTPA request was 7 days. Clinical indicators associated with positive scans were hypoxia (odds ratio (OR) 2.4; 95% confidence interval (CI) 1.1-5.6), tachypnoea (OR 2.5; 95% CI 1.2-6.0), recent surgery or immobilisation (OR 2.7; 95% CI 1.2-6.4), S1Q3T3 pattern on electrocardiogram (ECG; OR 7.2; 95% CI 1.4-35.7) and right bundle branch block pattern on ECG (OR 4.7; 95% CI 1.6-13.1). Hypotension, fever and malignancy were not significant. Both PERC and Wells criteria had poor positive predictive value (12% and 27% respectively), but the negative predictive value for PERC and Wells was 100% and 95.8% respectively. CONCLUSION Inpatient CTPA appear to be over-requested and can potentially be rationalised based on a combination of clinical predictors and Wells criteria and/or PERC rule. Further prospective studies are needed to develop accurate clinical decision tools targeted towards inpatients.
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Affiliation(s)
- Lisa Luo-Lan Ling
- Department of Haematology, Northern Health, Melbourne, Victoria, Australia
| | | | - Hui Yin Lim
- Department of Haematology, Northern Health, Melbourne, Victoria, Australia
| | - Ming Joe Lim
- Department of Radiology, Northern Health, Melbourne, Victoria, Australia
| | - Prahlad Ho
- Department of Haematology, Northern Health, Melbourne, Victoria, Australia
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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:diagnostics13071326. [PMID: 37046544 PMCID: PMC10093278 DOI: 10.3390/diagnostics13071326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/26/2023] [Accepted: 03/30/2023] [Indexed: 04/05/2023] Open
Abstract
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.
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Affiliation(s)
- Pierre-Marie Roy
- Department of Emergency Medicine, University Hospital of Angers, Avenue of the Hotel Dieu, 49100 Angers, France
- UMR MitoVasc CNRS 6215 INSERM 1083, University Angers, 49100 Angers, France
- FCRIN, INNOVTE, 42023 Saint-Étienne, France
| | - Thomas Moumneh
- Department of Emergency Medicine, University Hospital of Tours, Avenue of the Republic, 37044 Tours, France
| | - Thomas Bizouard
- Department of Emergency Medicine, University Hospital of Angers, Avenue of the Hotel Dieu, 49100 Angers, France
| | - Damien Duval
- Department of Emergency Medicine, University Hospital of Angers, Avenue of the Hotel Dieu, 49100 Angers, France
| | - Delphine Douillet
- Department of Emergency Medicine, University Hospital of Angers, Avenue of the Hotel Dieu, 49100 Angers, France
- UMR MitoVasc CNRS 6215 INSERM 1083, University Angers, 49100 Angers, France
- FCRIN, INNOVTE, 42023 Saint-Étienne, France
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Sprockel Diaz JJ, Veronesi Zuluaga LA, Coral Coral DC, Fierro Rodriguez DM. Application of the pulmonary embolism rule-out criteria (PERC rule) and age-adjusted D-Dimer in patients undergoing computed tomography pulmonary angiography for diagnosis of pulmonary embolism. J Vasc Bras 2023; 22:e20220022. [PMID: 37143505 PMCID: PMC10153795 DOI: 10.1590/1677-5449.202200222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 01/27/2023] [Indexed: 05/06/2023] Open
Abstract
Background Diagnosis of pulmonary embolism (PE) constitutes a challenge for practitioners. Current practice involves use of pre-test probability prediction rules. Several strategies to optimize this process have been explored. Objectives To explore whether application of the pulmonary embolism rule-out criteria (PERC rule) and age-adjusted D-dimer (DD) would have reduced the number of computed tomography pulmonary angiography (CTPA) examinations performed in patients with suspected PE. Methods A retrospective cross-sectional study of adult patients taken for CTPA under suspicion of PE in 2018 and 2020. The PERC rule and age-adjusted DD were applied. The number of cases without indications for imaging studies was estimated and the operational characteristics for diagnosis of PE were calculated. Results 302 patients were included. PE was diagnosed in 29.8%. Only 27.2% of 'not probable' cases according to the Wells criteria had D-dimer assays. Age adjustment would have reduced tomography use by 11.1%, with an AUC of 0.5. The PERC rule would have reduced use by 7%, with an AUC of 0.72. Conclusions Application of age-adjusted D-dimer and the PERC rule to patients taken for CTPA because of suspected PE seems to reduce the number of indications for the procedure.
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Affiliation(s)
- John Jaime Sprockel Diaz
- Fundación Universitaria de Ciencias de la Salud - FUCS, Bogotá, Colombia
- Hospital de San José - HSJ, Bogotá, Colombia
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Park HS, Hyun SY, Choi WS, Cho JS, Jang JH, Choi JY. Epidemiology and clinical characteristics of posttraumatic hospitalized patients with symptoms related to venous thromboembolism: a single-center retrospective study. JOURNAL OF TRAUMA AND INJURY 2022. [DOI: 10.20408/jti.2021.0052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Purpose: The aim of this study was to investigate the epidemiology of trauma inpatients with venous thromboembolism (VTE) symptoms diagnosed using computed tomographic angiography (CTA) in KoreaMethods: In total, 7,634 patients admitted to the emergency department of Gachon University Gil Medical Center, a tertiary hospital, and hospitalized between July 1, 2018 and December 31, 2020 were registered for this study. Of these patients, 278 patients who underwent CTA were enrolled in our study. Results: VTE was found in 120 of the 7,634 patients (1.57%), and the positive diagnosis rate of the 278 patients who underwent CTA was 43.2% (120 of 278). The incidence of VTE was statistically significantly higher among those with severe head and neck injuries (Abbreviated Injury Scale, 3–5) than among those with nonsevere head and neck injuries (Abbreviated Injury Scale, 0–2; P=0.038). In a subgroup analysis, the severe and nonsevere head and neck injury groups showed statistically significant differences in known independent risk factors for VTE. In logistic regression analysis, the adjusted odds ratio of severe head and neck injury (Abbreviated Injury Scale, 3–5) for VTE was 1.891 (95% confidence interval, 1.043–3.430). Conclusions: Trauma patients with severe head and neck injuries are more susceptible to VTE than those with nonsevere head and neck injuries. Thus, physicians must consider CTA as a priority for the diagnosis of VTE in trauma patients with severe head and neck injuries who show VTE-associated symptoms.
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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; 6:669-677. [PMID: 33656522 PMCID: PMC7931139 DOI: 10.1001/jamacardio.2021.0064] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance In patients with suspected pulmonary embolism (PE), overuse of diagnostic imaging is an important point of concern. Objective To derive and validate a 4-level pretest probability rule (4-Level Pulmonary Embolism Clinical Probability Score [4PEPS]) that makes it possible to rule out PE solely on clinical criteria and optimized D-dimer measurement to safely decrease imaging testing for suspected PE. Design, Setting, and Participants This study included consecutive outpatients suspected of having PE from US and European emergency departments. Individual data from 3 merged management studies (n = 11 114; overall prevalence of PE, 11%) were used for the derivation cohort and internal validation cohort. The external validation cohorts were taken from 2 independent studies, the first with a high PE prevalence (n = 1548; prevalence, 21.5%) and the second with a moderate PE prevalence (n = 1669; prevalence, 11.7%). A prior definition of pretest probability target values to achieve a posttest probability less than 2% was used on the basis of the negative likelihood ratios of D-dimer. Data were collected from January 2003 to April 2016, and data were analyzed from June 2018 to August 2019. Main Outcomes and Measures The rate of PE diagnosed during the initial workup or during follow-up and the rate of imaging testing. Results Of the 5588 patients in the derivation cohort, 3441 (61.8%) were female, and the mean (SD) age was 52 (18.5) years. The 4PEPS comprises 13 clinical variables scored from -2 to 5. It results in the following strategy: (1) very low probability of PE if 4PEPS is less than 0: PE ruled out without testing; (2) low probability of PE if 4PEPS is 0 to 5: PE ruled out if D-dimer level is less than 1.0 μg/mL; (3) moderate probability of PE if 4PEPS is 6 to 12: PE ruled out if D-dimer level is less than the age-adjusted cutoff value; (4) high probability of PE if 4PEPS is greater than 12: PE ruled out by imaging without preceding D-dimer test. In the first and the second external validation cohorts, the area under the receiver operator characteristic curves were 0.79 (95% CI, 0.76 to 0.82) and 0.78 (95% CI, 0.74 to 0.81), respectively. The false-negative testing rates if the 4PEPS strategy had been applied were 0.71% (95% CI, 0.37 to 1.23) and 0.89% (95% CI, 0.53 to 1.49), respectively. The absolute reductions in imaging testing were -22% (95% CI, -26 to -19) and -19% (95% CI, -22 to -16) in the first and second external validation cohorts, respectively. The 4PEPS strategy compared favorably with all recent strategies in terms of imaging testing. Conclusions and Relevance The 4PEPS strategy may lead to a substantial and safe reduction in imaging testing for patients with suspected PE. It should now be tested in a formal outcome study.
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Affiliation(s)
- Pierre-Marie Roy
- Emergency Department, CHU Angers, Institut Mitovasc UMR (CNRS 6015-INSERM 1083), UNIV Angers, F-CRIN INNOVTE, Angers, France
| | - Emilie Friou
- Emergency Department, CHU Angers, Angers, France
| | - Boris Germeau
- Emergency Department, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Delphine Douillet
- Emergency Department, CHU Angers, Institut Mitovasc UMR (CNRS 6015-INSERM 1083), UNIV Angers, F-CRIN INNOVTE, Angers, France
| | - Jeffrey Allen Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
| | - Marc Righini
- Division of Angiology and Hemostasis, Department of Internal Medicine, Faculty of Medicine, Geneva University Hospital, Geneva, Switzerland
| | - Grégoire Le Gal
- Ottawa Hospital Research Institute, The Ottawa Hospital, Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Thomas Moumneh
- Emergency Department, CHU Angers, Institut Mitovasc UMR (CNRS 6015-INSERM 1083), UNIV Angers, F-CRIN INNOVTE, Angers, France
| | - Andrea Penaloza
- Emergency Department, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, F-CRIN INNOVTE, Brussels, Belgium
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Xantus G, Burke D, Kanizsai P. Previously undiagnosed scoliosis presenting as pleuritic chest pain in the emergency department - a case series and a validating retrospective audit. BMC Emerg Med 2021; 21:62. [PMID: 34001003 PMCID: PMC8130124 DOI: 10.1186/s12873-021-00455-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 05/05/2021] [Indexed: 12/02/2022] Open
Abstract
Background Chest pain is one of the commonest presenting complaints in urgent/emergency care, with a lifelong prevalence of up to 25% in the adult population. Pleuritic chest pain is a subset of high investigation burden because of a diverse range of possible causes varying from simple musculoskeletal conditions to pulmonary embolism. Case series Among otherwise fit and healthy adult patients presenting in our emergency department with sudden onset of unilateral pleuritic chest pain, within 1 month we identified a cohort of five patients with pin-point tenderness in one specific costo-sternal joint often with referred pain to the back. All cases had apparent and, previously undiagnosed mild/moderate scoliosis. Methods To confirm and validate the observed association between scoliosis and pleuritic chest pain, a retrospective audit was designed and performed using the hospital’s electronic medical record system to reassess all consecutive adult chest pain patients. Results The Odds Ratio for having chest pain with scoliosis was 30.8 [95%CI 1.71–553.37], twenty times higher than suggested by prevalence data. Discussion In scoliosis the pathologic lateral curvature of the spine adversely affects the functional anatomy of both the spine and ribcage. In our hypothesis the chest wall asymmetry enables minor slip/subluxation of a rib either in the costo-sternal and/or costovertebral junction exerting direct pressure on the intercostal nerve causing pleuritic pain. Conclusion Thorough physical examination of the anterior and posterior chest wall is key to identify underlying scoliosis in otherwise fit patients presenting with sudden onset of pleuritic pain. Incorporating assessment for scoliosis in the low-risk chest pain protocols/tools may help reducing the length of stay in the emergency department and, facilitate speedy but safe discharge with increased patient satisfaction.
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Affiliation(s)
- Gabor Xantus
- Clinical Centre, University of Pécs, Pecs, Hungary.
| | - Derek Burke
- Gibraltar University, Gibraltar, GX11 1AA, Gibraltar
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Douillet D, Roy PM, Penaloza A. Suspected Acute Pulmonary Embolism: Gestalt, Scoring Systems, and Artificial Intelligence. Semin Respir Crit Care Med 2021; 42:176-182. [PMID: 33592653 DOI: 10.1055/s-0041-1723936] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Pulmonary embolism (PE) remains a diagnostic challenge in 2021. As the pathology is potentially fatal and signs and symptoms are nonspecific, further investigations are classically required. Based on the Bayesian approach, clinical probability became the keystone of the diagnostic strategy to rule out PE in the case of a negative testing. Several clinical probability assessment methods are validated: gestalt, the Wells score, or the revised Geneva score. While the debate persists as to the best way to assess clinical probability, its assessment allows for the good interpretation of the investigation results and therefore directs the correct diagnostic strategy. The wide availability of computed tomography pulmonary angiography (CTPA) resulted in a major increase in investigations with a moderate increase in diagnosis, without any notable improvement in patient outcomes. This leads to a new challenge for PE diagnosis which is the limitation of the number of testing for suspected PE. We review different strategies recently developed to achieve this goal. The last challenge concerns the implementation in clinical practice. Two approaches are developed: simplification of the strategies versus the use of digital support tools allowing more sophisticated strategies. Artificial intelligence with machine-learning algorithms will probably be a future tool to guide the physician in this complex approach concerning acute PE suspicion.
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Affiliation(s)
- Delphine Douillet
- Emergency Department, Angers University Hospital, INSERM 1083, Health Faculty, UNIV Angers, F-CRIN INNOVTE, Angers, France
| | - Pierre-Marie Roy
- Emergency Department, Angers University Hospital, INSERM 1083, Health Faculty, UNIV Angers, F-CRIN INNOVTE, Angers, France
| | - Andrea Penaloza
- Emergency Department, Cliniques Universitaires Saint Luc, UCLouvain, F-CRIN INNOVTE, Brussels, Belgium
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Al Dandan O, Hassan A, Alnasr A, Al Gadeeb M, AbuAlola H, Alshahwan S, Al Shammari M, Alzaki A. The use of clinical decision rules for pulmonary embolism in the emergency department: a retrospective study. Int J Emerg Med 2020; 13:23. [PMID: 32393324 PMCID: PMC7216540 DOI: 10.1186/s12245-020-00281-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 04/23/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Pulmonary embolism (PE) is a common and life-threatening medical condition with non-specific clinical presentation. Computed tomography pulmonary angiography (CT-PA) has been the diagnostic modality of choice, but its use is not without risks. Clinical decision rules have been established for the use of diagnostic modalities for patients with suspected PE. This study aims to assess the adherence of physicians to the diagnostic algorithms and rules. METHODS A retrospective observational study examining the utilization of CT-PA in the Emergency Department of King Fahd Hospital of Imam Abdulrahman Bin Faisal University for patients with suspected PE from May 2016 to December 2019. The electronic health records were used to collect the data, including background demographic data, clinical presentation, triage vital signs, D-dimer level (if ordered), risk factors for PE, and the CT-PA findings. The Wells score and pulmonary embolism rule-out (PERC) criteria were calculated retrospectively without knowledge of the results of D-dimer and the CT-PA. RESULTS The study involved a total of 353 patients (125 men and 228 women) with a mean age of 46.7 ± 18.4 years. Overall, 200 patients (56.7%) were classified into the "PE unlikely" group and 153 patients (43.3%) in the "PE likely" group as per Wells criteria. Out of all the CT-PA, 119 CT-PA (33.7%) were requested without D-dimer assay (n = 114) or with normal D-dimer level (n = 5) despite being in the "PE unlikely" group. Only 49 patients had negative PERC criteria, of which three patients had PE. CONCLUSIONS The study revealed that approximately one-third of all CT-PA requests were not adhering to the clinical decision rules with a significant underutilization of D-dimer assay in such patients. To reduce overutilization of imaging, planned interventions to promote the adherence to the current guidelines seem imperative.
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Affiliation(s)
- Omran Al Dandan
- Department of Radiology, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Al-Khobar, Saudi Arabia
| | - Ali Hassan
- Department of Radiology, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Al-Khobar, Saudi Arabia
| | - Afnan Alnasr
- Department of Radiology, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Al-Khobar, Saudi Arabia
| | - Mohammed Al Gadeeb
- Department of Radiology, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Al-Khobar, Saudi Arabia
| | - Hossain AbuAlola
- Department of Radiology, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Al-Khobar, Saudi Arabia
| | - Sarah Alshahwan
- Department of Radiology, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Al-Khobar, Saudi Arabia
| | - Malak Al Shammari
- Department of Family and Community Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Alaa Alzaki
- Department of Internal Medicine, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Al-Khobar, Saudi Arabia
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Bautz B, Schneider JI. High-Risk Chief Complaints I: Chest Pain-The Big Three (an Update). Emerg Med Clin North Am 2020; 38:453-498. [PMID: 32336336 DOI: 10.1016/j.emc.2020.01.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Nontraumatic chest pain is a frequent concern of emergency department patients, with causes that range from benign to immediately life threatening. Identifying those patients who require immediate/urgent intervention remains challenging and is a high-risk area for emergency medicine physicians where incorrect or delayed diagnosis may lead to significant morbidity and mortality. This article focuses on the 3 most prevalent diagnoses associated with adverse outcomes in patients presenting with nontraumatic chest pain, acute coronary syndrome, thoracic aortic dissection, and pulmonary embolism. Important aspects of clinical evaluation, diagnostic testing, treatment, and disposition and other less common causes of lethal chest pain are also discussed.
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Affiliation(s)
- Benjamin Bautz
- Department of Emergency Medicine, Boston Medical Center, 1 Boston Medical Center Place, Boston, MA 02118, USA
| | - Jeffrey I Schneider
- Department of Emergency Medicine, Boston Medical Center, 1 Boston Medical Center Place, Boston, MA 02118, USA; Department of Emergency Medicine, Boston University School of Medicine, Boston, MA, USA.
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12
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Roy PM, Revel MP, Salaün PY, Sanchez O. [How to make the diagnosis of pulmonary embolism?]. Rev Mal Respir 2019; 38 Suppl 1:e7-e23. [PMID: 31734045 DOI: 10.1016/j.rmr.2019.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- P-M Roy
- F-CRIN INNOVTE, 42055 St-Étienne cedex 2, France; Département de médecine d'urgence et service de médecine vasculaire, CHU Angers, 49000 Angers, France; UMR 1083, UFR santé, Institut Mitovasc, université d'Angers, 49000 Angers, France
| | - M-P Revel
- Service de radiologie A, hôpital Cochin, Université de Paris, Assistance publique des Hôpitaux de Paris, 75014 Paris, France
| | - P-Y Salaün
- Inserm EA3878 (GETBO), service de médecine nucléaire, université de Bretagne occidentale, CHRU de Brest, 29200 Brest, France
| | - O Sanchez
- F-CRIN INNOVTE, 42055 St-Étienne cedex 2, France; Université de Paris, service de pneumologie et soins intensifs, AH-HP, hôpital Européen Georges-Pompidou, 75015 Paris, France; Innovations Thérapeutiques en Hémostase, INSERM UMRS 1140, 75006 Paris, France.
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Stüssi-Helbling M, Arrigo M, Huber LC. Pearls and Myths in the Evaluation of Patients with Suspected Acute Pulmonary Embolism. Am J Med 2019; 132:685-691. [PMID: 30710540 DOI: 10.1016/j.amjmed.2019.01.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 01/15/2019] [Accepted: 01/17/2019] [Indexed: 11/25/2022]
Abstract
Significant improvement has been achieved in diagnostic accuracy, validation of probability scores, and standardized treatment algorithms for patients with suspected acute pulmonary embolism. These developments have provided the tools for a safe and cost-effective management for most of these patients. In our experience, however, the presence of medical myths and ongoing controversies seem to hinder the implementation of these tools in everyday clinical practice. This review provides a selection of such dilemmas and controversies and discusses the published evidence beyond them. By doing so, we try to overcome these dilemmas and suggest pragmatic approaches guided by the available evidence and current guidelines.
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Affiliation(s)
- Melina Stüssi-Helbling
- Department of Internal Medicine, Clinic for Internal Medicine, City Hospital Triemli Zurich, Switzerland.
| | - Mattia Arrigo
- Division of Cardiology, University Hospital Zurich, Switzerland
| | - Lars C Huber
- Department of Internal Medicine, Clinic for Internal Medicine, City Hospital Triemli Zurich, Switzerland
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Harder EM, Desai O, Marshall PS. Clinical Probability Tools for Deep Venous Thrombosis, Pulmonary Embolism, and Bleeding. Clin Chest Med 2019; 39:473-482. [PMID: 30122172 DOI: 10.1016/j.ccm.2018.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Overdiagnosis of venous thromboembolism is associated with increasing numbers of patient complications and health care burden. Multiple clinical tools exist to estimate the probability of pulmonary embolism and deep venous thrombosis. When used with d-dimer testing, these can further stratify venous thromboembolism risk to help inform the use of additional diagnostic testing. Although there are similar tools to estimate bleeding risk, these are not as well-validated and lack reliability.
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Affiliation(s)
- Eileen M Harder
- Department of Internal Medicine, Yale University School of Medicine, 15 York Street, LCI 101, New Haven, CT 06520, USA
| | - Omkar Desai
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Yale University School of Medicine, 15 York Street, LCI 101, New Haven, CT 06520, USA
| | - Peter S Marshall
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Yale University School of Medicine, 15 York Street, LCI 101, New Haven, CT 06520, USA.
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Madsen T, Jedick R, Teeples T, Carlson M, Steenblik J. Impact of altitude-adjusted hypoxia on the Pulmonary Embolism Rule-out Criteria. Am J Emerg Med 2019; 37:281-285. [DOI: 10.1016/j.ajem.2018.05.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 05/23/2018] [Accepted: 05/24/2018] [Indexed: 10/16/2022] Open
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Lim LH, Hayes AG, Toh DJ. Use of a three-tiered clinical decision rule to quantify unnecessary radiological investigation of suspected pulmonary embolism. Intern Med J 2019; 49:1371-1377. [PMID: 30697929 DOI: 10.1111/imj.14234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 01/24/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Clinical decision rules for suspected pulmonary embolism are proposed to identify patients suitable for discharge without radiological investigation. Their use varies between institutions. AIMS To quantify unnecessary radiological investigations for suspected pulmonary embolism (PE) as defined by a newly proposed three-tiered clinical decision rule incorporating the revised Geneva score, Pulmonary Embolism Rule-Out Criteria and D-dimer. To quantify missed diagnosis of PE if the proposed clinical decision rule were followed. METHODS A retrospective audit was conducted; applying the proposed clinical decision rule to 584 emergency department (ED)-based encounters at the Royal Adelaide Hospital from May to November 2015. Encounters were confined to emergency presentations where suspected acute PE was investigated with computed tomography pulmonary angiography or ventilation-perfusion scanning; inpatient and follow-up studies were excluded. Sensitivity, specificity, positive predictive value and negative predictive value of the proposed clinical decision rule within the studied population were calculated. RESULTS Data were obtained for 584 patient encounters where suspected PE was investigated radiologically. Applied retrospectively, the proposed clinical decision rule had a negative predictive value of 97.7% and a sensitivity of 98.5% for radiologically proven PE; 9.2% of scans could have been avoided. One case of PE would have been missed; a false-negative rate of 1.5%. CONCLUSION Retrospective application of the proposed clinical decision rule to the studied cohort indicates at least 9% of radiological investigations were unnecessary. A prospective study is needed to assess the safety and cost-effectiveness of applying such a pathway to all patients presenting to ED with suspected PE.
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Affiliation(s)
- Lauren H Lim
- Royal Adelaide Hospital, University of Adelaide, Adelaide, South Australia, Australia.,Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | | | - Dylan J Toh
- Royal Adelaide Hospital, University of Adelaide, Adelaide, South Australia, Australia
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Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Suspected Acute Venous Thromboembolic Disease. Ann Emerg Med 2018; 71:e59-e109. [PMID: 29681319 DOI: 10.1016/j.annemergmed.2018.03.006] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Abstract
IMPORTANCE Venous thromboembolism (VTE), comprising deep vein thrombosis (DVT) and pulmonary embolism (PE), is a common and potentially fatal disease. OBJECTIVE To summarize the advances in diagnosis and treatment of VTE of the past 5 years. EVIDENCE REVIEW A systematic search was conducted in EMBASE Classic, EMBASE, Ovid MEDLINE, and other nonindexed citations using broad terms for diagnosis and treatment of VTE to find systematic reviews and meta-analyses, randomized trials, and prospective cohort studies published between January 1, 2013, and July 31, 2018. The 10th edition of the American College of Chest Physicians Antithrombotic Therapy Guidelines was screened to identify additional studies. Screening of titles, abstracts, and, subsequently, full-text articles was performed in duplicate, as well as data extraction and risk-of-bias assessment of the included articles. FINDINGS Thirty-two articles were included in this review. The application of an age-adjusted D-dimer threshold in patients with suspected PE has increased the number of patients in whom imaging can be withheld. The Pulmonary Embolism Rule-Out Criteria safely exclude PE when the pretest probability is low. The introduction of direct oral anticoagulants has allowed for a simplified treatment of VTE with a lower risk of bleeding regardless of etiology or extent of the VTE (except for massive PE) and has made extended secondary prevention more acceptable. Thrombolysis is best reserved for patients with massive PE or those with DVT and threatened limb loss. Insertion of inferior vena cava filters should be avoided unless anticoagulation is absolutely contraindicated in patients with recent acute VTE. Graduated compression stockings are no longer recommended to treat DVT but may be used when acute or chronic symptoms are present. Anticoagulation may no longer be indicated for patients with isolated distal DVT at low risk of recurrence. CONCLUSIONS AND RELEVANCE Over the past 5 years, substantial progress has been made in VTE management, allowing for diagnostic and therapeutic strategies tailored to individual patient characteristics, preferences, and values.
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Affiliation(s)
- Tobias Tritschler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Noémie Kraaijpoel
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - Grégoire Le Gal
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Philip S Wells
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Retrospective validation of the pulmonary embolism rule-out criteria rule in 'PE unlikely' patients with suspected pulmonary embolism. Eur J Emerg Med 2018; 25:185-190. [PMID: 28002070 DOI: 10.1097/mej.0000000000000442] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Patients presenting to emergency departments (EDs) with suspected pulmonary embolism (PE) can be risk stratified and those who are deemed to be at low risk for PE usually undergo D-dimer testing. A negative D-dimer in this low-risk group rules out PE with a high degree of certainty because of its high sensitivity. The D-dimer is, however, a poorly specific test and positive results often lead to unnecessary radiological imaging (notably computed tomography pulmonary angiography). The Pulmonary Embolism Rule-Out Criteria (PERC) rule has been suggested as an alternative to D-dimer testing in these patients. This study looked at whether the PERC rule could safely replace the use of D-dimer in patients suspected of PE, but deemed 'PE unlikely' by the dichotomized Wells score in a UK ED setting. PATIENTS AND METHODS This was a retrospective review of 986 patients with suspected PE who had a blood sample for D-dimer level taken. In patients deemed 'PE unlikely' (using the dichotomized Wells score), the diagnostic performance of the PERC rule was compared with a standard D-dimer level in the detection of PE at index presentation and up to 3 months afterwards. RESULTS Of the 986 patients, 940 patients were deemed 'PE unlikely' using the dichotomized Wells score. Three patients with confirmed PE would have been missed by the PERC rule compared with only one missed by the D-dimer test. In these patients, the sensitivity of the PERC rule for detecting PE was 91.4% [95% confidence interval (CI): 76.9-98.2%], with a negative likelihood ratio of 0.25 (95% CI: 0.08-0.73). However, the negative predictive value of the PERC rule was 99.1% (95% CI: 97.3-99.8%). In comparison, the sensitivity for the standard D-dimer test was 97.1% (95% CI: 85.1-99.9%), with a negative likelihood ratio of 0.04 (95% CI: 0.01-0.27). The negative predictive value for the standard D-dimer test was 99.8% (95% CI: 99.2-100%). CONCLUSION The PERC rule has a high negative predictive value for excluding PE in patients presenting with suspected PE to the ED. However, the PERC rule may still miss around 8% of confirmed PE in patients who are deemed 'PE unlikely' by a dichotomized Wells score. Caution is advised in using the PERC rule as a substitute for the standard D-dimer test in all these patients.
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Glober N, Tainter CR, Brennan J, Darocki M, Klingfus M, Choi M, Derksen B, Rudolf F, Wardi G, Castillo E, Chan T. The DAGMAR Score: D-dimer assay-guided moderation of adjusted risk. Improving specificity of the D-dimer for pulmonary embolism. Am J Emerg Med 2018; 37:895-901. [PMID: 30104092 DOI: 10.1016/j.ajem.2018.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 08/03/2018] [Accepted: 08/07/2018] [Indexed: 10/28/2022] Open
Abstract
We generated a novel scoring system to improve the test characteristics of D-dimer in patients with suspected PE (pulmonary emboli). Electronic Medical Record data were retrospectively reviewed on Emergency Department (ED) patients 18 years or older for whom a D-dimer and imaging were ordered between June 4, 2012 and March 30, 2016. Symptoms (dyspnea, unilateral leg swelling, hemoptysis), age, vital signs, medical history (cancer, recent surgery, medications, history of deep vein thrombosis or PE, COPD, smoking), laboratory values (quantitative D-dimer, platelets, and mean platelet volume (MPV)), and imaging results (CT, VQ) were collected. Points were designated to factors that were significant in two multiple regression analyses, for PE or positive D-dimer. Points predictive of PE were designated positive values and points predictive of positive D-dimer, irrespective of presence of PE, were designated negative values. The DAGMAR (D-dimer Assay-Guided Moderation of Adjusted Risk) score was developed using age and platelet adjustment and points for factors associated with PE and elevated D-dimer. Of 8486 visits reviewed, 3523 were unique visits with imaging, yielding 2253 (26.5%) positive D-dimers. 3501 CT scans and 156 VQ scans were completed, detecting 198 PE. In our cohort, a DAGMAR Score < 2 equated to overall PE risk < 1.2%. Specificity improved (38% to 59%) without compromising sensitivity (94% to 96%). Use of the DAGMAR Score would have reduced CT scans from 2253 to 1556 and lead to fewer false negative results. By considering factors that affect D-dimer and also PE, we improved specificity without compromising sensitivity.
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Affiliation(s)
- Nancy Glober
- University of California at San Diego, Department of Emergency Medicine, 200 W Arbor Drive, San Diego, CA 92102, United States of America.
| | - Christopher R Tainter
- University of California at San Diego, Department of Emergency Medicine, 200 W Arbor Drive, San Diego, CA 92102, United States of America
| | - Jesse Brennan
- University of California at San Diego, Department of Emergency Medicine, 200 W Arbor Drive, San Diego, CA 92102, United States of America.
| | - Mark Darocki
- University of California at San Diego, Department of Emergency Medicine, 200 W Arbor Drive, San Diego, CA 92102, United States of America.
| | - Morgan Klingfus
- University of California at San Diego, Department of Emergency Medicine, 200 W Arbor Drive, San Diego, CA 92102, United States of America
| | - Michelle Choi
- University of California at San Diego, Department of Emergency Medicine, 200 W Arbor Drive, San Diego, CA 92102, United States of America.
| | - Brenna Derksen
- University of California at San Diego, Department of Emergency Medicine, 200 W Arbor Drive, San Diego, CA 92102, United States of America.
| | - Frances Rudolf
- University of California at San Diego, Department of Emergency Medicine, 200 W Arbor Drive, San Diego, CA 92102, United States of America.
| | - Gabriel Wardi
- University of California at San Diego, Department of Emergency Medicine, 200 W Arbor Drive, San Diego, CA 92102, United States of America.
| | - Edward Castillo
- University of California at San Diego, Department of Emergency Medicine, 200 W Arbor Drive, San Diego, CA 92102, United States of America.
| | - Theodore Chan
- University of California at San Diego, Department of Emergency Medicine, 200 W Arbor Drive, San Diego, CA 92102, United States of America.
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Glober N, Tainter CR, Brennan J, Darocki M, Klingfus M, Choi M, Derksen B, Rudolf F, Wardi G, Castillo E, Chan T. Use of the d-dimer for Detecting Pulmonary Embolism in the Emergency Department. J Emerg Med 2018; 54:585-592. [PMID: 29502865 DOI: 10.1016/j.jemermed.2018.01.032] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 01/07/2018] [Accepted: 01/21/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Assessment for pulmonary embolism (PE) in the emergency department (ED) remains complex, involving clinical decision tools, blood tests, and imaging. OBJECTIVE Our objective was to examine the test characteristics of the high-sensitivity d-dimer for the diagnosis of PE at our institution and evaluate use of the d-dimer and factors associated with a falsely elevated d-dimer. METHODS We retrospectively collected data on adult patients evaluated with a d-dimer and computed tomography (CT) pulmonary angiogram or ventilation perfusion scan at two EDs between June 4, 2012 and March 30, 2016. We collected symptoms (dyspnea, unilateral leg swelling, hemoptysis), vital signs, and medical and social history (cancer, recent surgery, medications, history of deep vein thrombosis or PE, chronic obstructive pulmonary disease, smoking). We calculated test characteristics, including sensitivity, specificity, and likelihood ratios for the assay using conventional threshold and with age adjustment, and performed a univariate analysis. RESULTS We found 3523 unique visits with d-dimer and imaging, detecting 198 PE. Imaging was pursued on 1270 patients with negative d-dimers, revealing 9 false negatives, and d-dimer was sent on 596 patients for whom negative Pulmonary Embolism Rule-Out Criteria (PERC) were documented with 2% subsequent radiographic detection of PE. The d-dimer showed a sensitivity of 95.7% (95% confidence interval [CI] 91-98%), specificity of 40.0% (95% CI 38-42%), negative likelihood ratio of 0.11 (95% CI 0.06-0.21), and positive likelihood ratio of 1.59 (95% CI 1.53-1.66) for the radiographic detection of PE. With age adjustment, 347 of the 2253 CT scans that were pursued in patients older than 50 years with an elevated d-dimer could have been avoided without missing any additional PE. Many risk factors, such as age, history of PE, recent surgery, shortness of breath, tachycardia and hypoxia, elevated the d-dimer, regardless of the presence of PE. CONCLUSIONS Many patients with negative d-dimer and PERC still received imaging. Our data support the use of age adjustment, and perhaps adjustment for other factors seen in patients evaluated for PE.
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Affiliation(s)
- Nancy Glober
- Department of Emergency Medicine, University of California at San Diego, San Diego, California
| | - Christopher R Tainter
- Department of Emergency Medicine, University of California at San Diego, San Diego, California
| | - Jesse Brennan
- Department of Emergency Medicine, University of California at San Diego, San Diego, California
| | - Mark Darocki
- Department of Emergency Medicine, University of California at San Diego, San Diego, California
| | - Morgan Klingfus
- Department of Emergency Medicine, University of California at San Diego, San Diego, California
| | - Michelle Choi
- Department of Emergency Medicine, University of California at San Diego, San Diego, California
| | - Brenna Derksen
- Department of Emergency Medicine, University of California at San Diego, San Diego, California
| | - Frances Rudolf
- Department of Emergency Medicine, University of California at San Diego, San Diego, California
| | - Gabriel Wardi
- Department of Emergency Medicine, University of California at San Diego, San Diego, California
| | - Edward Castillo
- Department of Emergency Medicine, University of California at San Diego, San Diego, California
| | - Theodore Chan
- Department of Emergency Medicine, University of California at San Diego, San Diego, California
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Freund Y, Cachanado M, Aubry A, Orsini C, Raynal PA, Féral-Pierssens AL, Charpentier S, Dumas F, Baarir N, Truchot J, Desmettre T, Tazarourte K, Beaune S, Leleu A, Khellaf M, Wargon M, Bloom B, Rousseau A, Simon T, Riou B. Effect of the Pulmonary Embolism Rule-Out Criteria on Subsequent Thromboembolic Events Among Low-Risk Emergency Department Patients: The PROPER Randomized Clinical Trial. JAMA 2018; 319:559-566. [PMID: 29450523 PMCID: PMC5838786 DOI: 10.1001/jama.2017.21904] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
IMPORTANCE The safety of the pulmonary embolism rule-out criteria (PERC), an 8-item block of clinical criteria aimed at ruling out pulmonary embolism (PE), has not been assessed in a randomized clinical trial. OBJECTIVE To prospectively validate the safety of a PERC-based strategy to rule out PE. DESIGN, SETTING, AND PATIENTS A crossover cluster-randomized clinical noninferiority trial in 14 emergency departments in France. Patients with a low gestalt clinical probability of PE were included from August 2015 to September 2016, and followed up until December 2016. INTERVENTIONS Each center was randomized for the sequence of intervention periods. In the PERC period, the diagnosis of PE was excluded with no further testing if all 8 items of the PERC rule were negative. MAIN OUTCOMES AND MEASURES The primary end point was the occurrence of a thromboembolic event during the 3-month follow-up period that was not initially diagnosed. The noninferiority margin was set at 1.5%. Secondary end points included the rate of computed tomographic pulmonary angiography (CTPA), median length of stay in the emergency department, and rate of hospital admission. RESULTS Among 1916 patients who were cluster-randomized (mean age 44 years, 980 [51%] women), 962 were assigned to the PERC group and 954 were assigned to the control group. A total of 1749 patients completed the trial. A PE was diagnosed at initial presentation in 26 patients in the control group (2.7%) vs 14 (1.5%) in the PERC group (difference, 1.3% [95% CI, -0.1% to 2.7%]; P = .052). One PE (0.1%) was diagnosed during follow-up in the PERC group vs none in the control group (difference, 0.1% [95% CI, -∞ to 0.8%]). The proportion of patients undergoing CTPA in the PERC group vs control group was 13% vs 23% (difference, -10% [95% CI, -13% to -6%]; P < .001). In the PERC group, rates were significantly reduced for the median length of emergency department stay (mean reduction, 36 minutes [95% CI, 4 to 68]) and hospital admission (difference, 3.3% [95% CI, 0.1% to 6.6%]). CONCLUSIONS AND RELEVANCE Among very low-risk patients with suspected PE, randomization to a PERC strategy vs conventional strategy did not result in an inferior rate of thromboembolic events over 3 months. These findings support the safety of PERC for very low-risk patients presenting to the emergency department. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02375919.
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Affiliation(s)
- Yonathan Freund
- Sorbonne Université, INSERM UMRS 1166, IHU ICAN, Paris, France
- Emergency Department, Hôpital Universitaire Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Marine Cachanado
- Clinical Research Platform (URC-CRC-CRB), AP-HP Hôpital Saint-Antoine, Paris, France
| | - Adeline Aubry
- Emergency Department, Hôpital Universitaire Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | | | | | | | - Sandrine Charpentier
- Université Toulouse III Paul Sabatier, INSERM UMR 1027, CHU Toulouse, Toulouse, Emergency Department, Toulouse, France
| | - Florence Dumas
- Université Paris Descartes, INSERM UMR970, APHP, Emergency Department, Hôpital Cochin, Paris, France
| | - Nacera Baarir
- Emergency Department, Hôpital Tenon, APHP, Paris, France
| | | | - Thibaut Desmettre
- Université Bourgogne Franche-Comté, Emergency Department, CHRU Minjoz, Besançon, France
| | - Karim Tazarourte
- Université Claude Bernard Lyon1, HESPER EA 7425, Hospices Civils de Lyon, Emergency Department, Hôpital Edouard Herriot, Lyon, France
| | - Sebastien Beaune
- Emergency Department, Hôpital Ambroise-Paré, APHP, Boulogne, France
| | - Agathe Leleu
- Emergency Department, Hôpital Bichat, APHP, Paris, France
| | - Mehdi Khellaf
- Université Paris Est, INSERM U955, APHP, Emergency Department, Hôpital Henri Mondor, Créteil, France
| | - Mathias Wargon
- Emergency Department, Hôpital Saint Camille, Bry sur Marne, France
| | - Ben Bloom
- Emergency Department, Barts Health NHS Trust, London, United Kingdom
| | - Alexandra Rousseau
- Clinical Research Platform (URC-CRC-CRB), AP-HP Hôpital Saint-Antoine, Paris, France
| | - Tabassome Simon
- Sorbonne Université, INSERM UMRS 1166, IHU ICAN, Paris, France
- Clinical Research Platform (URC-CRC-CRB), AP-HP Hôpital Saint-Antoine, Paris, France
| | - Bruno Riou
- Sorbonne Université, INSERM UMRS 1166, IHU ICAN, Paris, France
- Emergency Department, Hôpital Universitaire Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
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23
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Kabrhel C. Diagnosing pulmonary embolism: we are not so different after all…. Lancet Haematol 2017; 4:e571-e572. [PMID: 29150391 DOI: 10.1016/s2352-3026(17)30212-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 11/07/2017] [Indexed: 06/07/2023]
Affiliation(s)
- Christopher Kabrhel
- Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Emergency Medicine, Harvard Medical School, Boston, MA 02114, USA.
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24
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Penaloza A, Soulié C, Moumneh T, Delmez Q, Ghuysen A, El Kouri D, Brice C, Marjanovic NS, Bouget J, Moustafa F, Trinh-Duc A, Le Gall C, Imsaad L, Chrétien JM, Gable B, Girard P, Sanchez O, Schmidt J, Le Gal G, Meyer G, Delvau N, Roy PM. Pulmonary embolism rule-out criteria (PERC) rule in European patients with low implicit clinical probability (PERCEPIC): a multicentre, prospective, observational study. LANCET HAEMATOLOGY 2017; 4:e615-e621. [PMID: 29150390 DOI: 10.1016/s2352-3026(17)30210-7] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 10/21/2017] [Accepted: 10/23/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND The ability of the pulmonary embolism rule-out criteria (PERC) to exclude pulmonary embolism without further testing remains debated outside the USA, especially in the population with suspected pulmonary embolism who have a high prevalence of the condition. Our main objective was to prospectively assess the predictive value of negative PERC to rule out pulmonary embolism among European patients with low implicit clinical probability. METHODS We did a multicentre, prospective, observational study in 12 emergency departments in France and Belgium. We included consecutive patients aged 18 years or older with suspected pulmonary embolism. Patients were excluded if they had already been hospitalised for more than 2 days, had curative anticoagulant therapy in progress for more than 48 h, or had a diagnosis of thromboembolic disease documented before admission to emergency department. Physicians completed a standardised case report form comprising implicit clinical probability assessment (low, moderate, or high) and a list of risk factors including criteria of the PERC rule. They were asked to follow international recommendations for diagnostic strategy, masked to PERC assessment. The primary endpoint was the proportion of patients with low implicit clinical probability and negative PERC who had venous thromboembolic events, diagnosed during initial diagnostic work-up or during 3-month follow-up, as externally adjudicated by an independent committee masked to the PERC and clinical probability assessment. The upper limit of the 95% CI around the 3-month thromboembolic risk was set at 3%. We did all analyses by intention to treat, including all patients with complete follow-up. This trial is registered with ClinicalTrials.gov, number NCT02360540. FINDINGS Between May 1, 2015, and April 30, 2016, 1773 consecutive patients with suspected pulmonary embolism were prospectively assessed for inclusion, of whom 1757 were included. 1052 (60%) patients were classed as having low clinical probability, 49 (4·7%, 95% CI 3·5-6·1) of whom had a venous thromboembolic event. In patients with a low implicit clinical probability, 337 (32%) patients had negative PERC, of whom four (1·2%; 95% CI 0·4-2·9) went on to have a pulmonary embolism. INTERPRETATION In European patients with low implicit clinical probability, PERC can exclude pulmonary embolism with a low percentage of false-negative results. The results of our prospective, observational study allow and justify an implementation study of the PERC rule in Europe. FUNDING French Ministry of Health.
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Affiliation(s)
- Andrea Penaloza
- Emergency Department, Cliniques Universitaires St-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Caroline Soulié
- Emergency Department, Centre Hospitalier Universitaire Angers, Institut Mitovasc, Université d'Angers, Angers, France
| | - Thomas Moumneh
- Emergency Department, Centre Hospitalier Universitaire Angers, Institut Mitovasc, Université d'Angers, Angers, France
| | - Quentin Delmez
- Emergency Department, Cliniques Universitaires St-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Alexandre Ghuysen
- Emergency Department, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - Dominique El Kouri
- Emergency Department, Médecine Polyvalente, Centre Hospitalier Universitaire Hôtel Dieu, Nantes, France
| | - Christian Brice
- Emergency Department, Centre Hospitalier de Saint-Brieuc, Saint-Brieuc, France
| | - Nicolas S Marjanovic
- Emergency Department, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | - Jacques Bouget
- Emergency Department, Centre Hospitalier Universitaire de Rennes, Rennes, France
| | - Fares Moustafa
- Emergency Department, Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, France
| | | | - Catherine Le Gall
- Emergency Department, Centre Hospitalier d'Argenteuil, Argenteuil, France
| | - Lionel Imsaad
- Emergency Department, Centre Hospitalier de Le Mans, Le Mans, France
| | - Jean-Marie Chrétien
- Research Unit, Centre Hospitalier Universitaire Angers, Institut Mitovasc, Université d'Angers, Angers, France
| | - Béatrice Gable
- Emergency Department, Centre Hospitalier Universitaire Angers, Institut Mitovasc, Université d'Angers, Angers, France
| | - Philippe Girard
- Thorax Department, Institut Mutualiste Montsouris, Paris, France
| | - Olivier Sanchez
- Pneumology Department, Hôpital Européen Georges Pompidou, APHP, Université Paris Descartes, Paris, France
| | - Jeannot Schmidt
- Emergency Department, Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, France
| | - Grégoire Le Gal
- Division of Haematology-Thrombosis Program, Ottawa Hospital Research Institute and University of Ottawa, Ottawa, ON, Canada
| | - Guy Meyer
- Pneumology Department, Hôpital Européen Georges Pompidou, APHP, Université Paris Descartes, Paris, France
| | - Nicolas Delvau
- Emergency Department, Cliniques Universitaires St-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Pierre-Marie Roy
- Emergency Department, Centre Hospitalier Universitaire Angers, Institut Mitovasc, Université d'Angers, Angers, France.
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Role of Clinical Decision Tools in the Diagnosis of Pulmonary Embolism. AJR Am J Roentgenol 2017; 208:W60-W70. [DOI: 10.2214/ajr.16.17206] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Abstract
Deep vein thrombosis and pulmonary embolism, collectively referred to as venous thromboembolism, constitute a major global burden of disease. The diagnostic work-up of suspected deep vein thrombosis or pulmonary embolism includes the sequential application of a clinical decision rule and D-dimer testing. Imaging and anticoagulation can be safely withheld in patients who are unlikely to have venous thromboembolism and have a normal D-dimer. All other patients should undergo ultrasonography in case of suspected deep vein thrombosis and CT in case of suspected pulmonary embolism. Direct oral anticoagulants are first-line treatment options for venous thromboembolism because they are associated with a lower risk of bleeding than vitamin K antagonists and are easier to use. Use of thrombolysis should be limited to pulmonary embolism associated with haemodynamic instability. Anticoagulant treatment should be continued for at least 3 months to prevent early recurrences. When venous thromboembolism is unprovoked or secondary to persistent risk factors, extended treatment beyond this period should be considered when the risk of recurrence outweighs the risk of major bleeding.
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Affiliation(s)
- Marcello Di Nisio
- Department of Medical, Oral and Biotechnological Sciences, Gabriele D'Annunzio University, Chieti, Italy; Department of Vascular Medicine, Academic Medical Centre, Amsterdam, Netherlands.
| | - Nick van Es
- Department of Vascular Medicine, Academic Medical Centre, Amsterdam, Netherlands
| | - Harry R Büller
- Department of Vascular Medicine, Academic Medical Centre, Amsterdam, Netherlands
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Kearon C. Diagnosis of suspected venous thromboembolism. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:397-403. [PMID: 27913507 PMCID: PMC6142443 DOI: 10.1182/asheducation-2016.1.397] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The primary goal of diagnostic testing for venous thromboembolism (VTE) is to identify all patients who could benefit from anticoagulant therapy. Test results that identify patients as having a ≤2% risk of VTE in the next 3 months are judged to exclude deep vein thrombosis (DVT) or pulmonary embolism (PE). Clinical evaluation, with assessment of: (1) clinical pretest probability (CPTP) for VTE; (2) likelihood of important alternative diagnoses; and (3) the probable yield of D-dimer and various imaging tests, guide which tests should be performed. The combination of nonhigh CPTP and negative D-dimer testing excludes DVT or PE in one-third to a half of outpatients. Venous ultrasound of the proximal veins, with or without examination of the distal veins, is the primary imaging test for leg and upper-extremity DVT. If a previous test is not available for comparison, the positive predictive value of ultrasound is low in patients with previous DVT. Computed tomography pulmonary angiography (CTPA) is the primary imaging test for PE and often yields an alternative diagnosis when there is no PE. Ventilation-perfusion scanning is associated with less radiation exposure than CTPA and is preferred in younger patients, particularly during pregnancy. If DVT or PE cannot be "ruled-in" or "ruled-out" by initial diagnostic testing, patients can usually be managed safely by: (1) withholding anticoagulant therapy; and (2) doing serial ultrasound examinations to detect new or extending DVT.
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Affiliation(s)
- Clive Kearon
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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Stojanovska J, Carlos RC, Kocher KE, Nagaraju A, Guy K, Kelly AM, Chughtai AR, Kazerooni EA. CT Pulmonary Angiography: Using Decision Rules in the Emergency Department. J Am Coll Radiol 2016; 12:1023-9. [PMID: 26435116 DOI: 10.1016/j.jacr.2015.06.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 06/01/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE The aim of this study was to assess the appropriateness of utilization and diagnostic yields of CT pulmonary angiography (CTPA), comparing two commonly applied decision rules, the pulmonary embolism (PE) rule-out criteria (PERC) and the modified Wells criteria (mWells), in the emergency department (ED) setting. METHODS Institutional review board approval was obtained for this HIPAA-compliant, prospective-cohort, academic single-center study. Six hundred two consecutive adult ED patients undergoing CTPA for suspected PE formed the study population. The outcome was positive or negative for PE by CTPA and at 6-month follow-up. PERC and mWells scores were calculated. A positive PERC score was defined as meeting one or more criteria and a positive mWells score as >4. The percentage of CT pulmonary angiographic examinations that could have been avoided and the diagnostic yield of CTPA using PERC, mWells, and PERC applied to a negative mWells score were calculated. RESULTS The diagnostic yield of CTPA was 10% (61 of 602). By applying PERC, mWells, and PERC to negative mWells score, 17.6% (106 of 602), 45% (273 of 602), and 17.1% (103 of 602) of CT pulmonary angiographic examinations, respectively, could have been avoided. The diagnostic yield in PERC-positive patients was higher than in mWells-positive patients (10% [59 of 602] vs 8% [49 of 602], P < .0001). Among PERC-negative and mWells-negative patients, the diagnostic yields for PE were 1.9% (2 of 106) and 4% (12 of 273), respectively (P = .004). The diagnostic yield of a negative PERC score applied to a negative mWells score was 1.9% (2 of 103). CONCLUSIONS The use of PERC in the ED has the potential to significantly reduce the utilization of CTPA and misses fewer cases of PE compared with mWells, and it is therefore a more efficient decision tool.
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Affiliation(s)
- Jadranka Stojanovska
- Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan.
| | - Ruth C Carlos
- Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan
| | - Keith E Kocher
- Emergency Medicine, University of Michigan Health System, Ann Arbor, Michigan
| | - Arun Nagaraju
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Karen Guy
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Aine M Kelly
- Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan
| | - Aamer R Chughtai
- Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan
| | - Ella A Kazerooni
- Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan
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The Impact of Clinical Decision Rules on Computed Tomography Use and Yield for Pulmonary Embolism: A Systematic Review and Meta-analysis. Ann Emerg Med 2016; 67:693-701.e3. [DOI: 10.1016/j.annemergmed.2015.11.005] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Revised: 10/27/2015] [Accepted: 11/02/2015] [Indexed: 11/22/2022]
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Freund Y, Rousseau A, Guyot-Rousseau F, Claessens YE, Hugli O, Sanchez O, Simon T, Riou B. PERC rule to exclude the diagnosis of pulmonary embolism in emergency low-risk patients: study protocol for the PROPER randomized controlled study. Trials 2015; 16:537. [PMID: 26607669 PMCID: PMC4660778 DOI: 10.1186/s13063-015-1049-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 11/06/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The diagnosis of Pulmonary Embolism (PE) in the emergency department (ED) is crucial. As emergency physicians fear missing this potential life-threatening condition, PE tends to be over-investigated, exposing patients to unnecessary risks and uncertain benefit in terms of outcome. The Pulmonary Embolism Rule-out Criteria (PERC) is an eight-item block of clinical criteria that can identify patients who can safely be discharged from the ED without further investigation for PE. The endorsement of this rule could markedly reduce the number of irradiative imaging studies, ED length of stay, and rate of adverse events resulting from both diagnostic and therapeutic interventions. Several retrospective and prospective studies have shown the safety and benefits of the PERC rule for PE diagnosis in low-risk patients, but the validity of this rule is still controversial. We hypothesize that in European patients with a low gestalt clinical probability and who are PERC-negative, PE can be safely ruled out and the patient discharged without further testing. METHODS/DESIGN This is a controlled, cluster randomized trial, in 15 centers in France. Each center will be randomized for the sequence of intervention periods: a 6-month intervention period (PERC-based strategy) followed by a 6-month control period (usual care), or in reverse order, with 2 months of "wash-out" between the 2 periods. Adult patients presenting to the ED with a suspicion of PE and a low pre test probability estimated by clinical gestalt will be eligible. The primary outcome is the percentage of failure resulting from the diagnostic strategy, defined as diagnosed venous thromboembolic events at 3-month follow-up, among patients for whom PE has been initially ruled out. DISCUSSION The PERC rule has the potential to decrease the number of irradiative imaging studies in the ED, and is reported to be safe. However, no randomized study has ever validated the safety of PERC. Furthermore, some studies have challenged the safety of a PERC-based strategy to rule-out PE, especially in Europe where the prevalence of PE diagnosed in the ED is high. The PROPER study should provide high-quality evidence to settle this issue. If it confirms the safety of the PERC rule, physicians will be able to reduce the number of investigations, associated subsequent adverse events, costs, and ED length of stay for patients with a low clinical probability of PE. TRIAL REGISTRATION NCT02375919 .
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Affiliation(s)
- Yonathan Freund
- Paris Sorbonne Université, UPMC univ-Paris 6, UMRS INSERM 1166, IHU ICAN, Paris, France. .,Emergency Department, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France.
| | - Alexandra Rousseau
- Plateforme de recherche clinique de l'est parisien (URCEST-CRCEST), Hôpital St Antoine, APHP, Paris, France.
| | - France Guyot-Rousseau
- Plateforme de recherche clinique de l'est parisien (URCEST-CRCEST), Hôpital St Antoine, APHP, Paris, France.
| | | | - Olivier Hugli
- Emergency Department, Lausanne University Hospital, Lausanne, Switzerland.
| | - Olivier Sanchez
- Pneumology and Intensive Care Unit, Hôpital Européen Georges Pompidou, APHP, Université Paris Descartes, Sorbonne Paris Cite, Paris, France.
| | - Tabassome Simon
- Paris Sorbonne Université, UPMC univ-Paris 6, UMRS INSERM 1166, IHU ICAN, Paris, France. .,Plateforme de recherche clinique de l'est parisien (URCEST-CRCEST), Hôpital St Antoine, APHP, Paris, France.
| | - Bruno Riou
- Paris Sorbonne Université, UPMC univ-Paris 6, UMRS INSERM 1166, IHU ICAN, Paris, France. .,Emergency Department, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France.
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Emergency Evaluation for Pulmonary Embolism, Part 2: Diagnostic Approach. J Emerg Med 2015; 49:104-17. [DOI: 10.1016/j.jemermed.2014.12.041] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 12/17/2014] [Accepted: 12/21/2014] [Indexed: 12/14/2022]
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32
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Evaluation of the pulmonary embolism rule-out criteria in a retrospective cohort at an urban academic hospital. Am J Emerg Med 2015; 33:483-7. [DOI: 10.1016/j.ajem.2013.10.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 10/01/2013] [Accepted: 10/03/2013] [Indexed: 11/19/2022] Open
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Kline JA, Neumann D, Haug MA, Kammer DJ, Krabill VA. Decreased facial expression variability in patients with serious cardiopulmonary disease in the emergency care setting. Emerg Med J 2014; 32:3-8. [DOI: 10.1136/emermed-2014-203602] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Pulmonary Embolism Rule-out Criteria vs D-dimer testing in low-risk patients for pulmonary embolism: a retrospective study. Am J Emerg Med 2014; 32:609-13. [DOI: 10.1016/j.ajem.2014.03.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Revised: 03/09/2014] [Accepted: 03/10/2014] [Indexed: 11/19/2022] Open
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35
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Diagnostic de l’embolie pulmonaire au service des urgences. MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-013-0730-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Precautions With PERC. Ann Emerg Med 2013; 62:197. [DOI: 10.1016/j.annemergmed.2013.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Revised: 02/17/2013] [Accepted: 02/20/2013] [Indexed: 11/24/2022]
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In reply. Ann Emerg Med 2013; 62:197-8. [DOI: 10.1016/j.annemergmed.2013.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Revised: 03/05/2013] [Accepted: 03/06/2013] [Indexed: 11/19/2022]
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Is “PERC Negative” Adequate to Rule Out Pulmonary Embolism in the Emergency Department? Evaluating Meta-analysis for Studies of Clinical Prediction Models. Ann Emerg Med 2012. [DOI: 10.1016/j.annemergmed.2012.07.121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Singh B, Mommer SK, Erwin PJ, Mascarenhas SS, Parsaik AK. Pulmonary embolism rule-out criteria (PERC) in pulmonary embolism—revisited: A systematic review and meta-analysis. Emerg Med J 2012; 30:701-6. [DOI: 10.1136/emermed-2012-201730] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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40
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Kline J. Failed validation of a decision rule for chest radiography. Acad Emerg Med 2012; 19:E1086-7. [PMID: 22897483 DOI: 10.1111/j.1553-2712.2012.01427.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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41
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Self WH, Barrett TW. Is “PERC Negative” Adequate to Rule Out Pulmonary Embolism in the Emergency Department? Evaluating Meta-analysis for Studies of Clinical Prediction Models. Ann Emerg Med 2012; 60:129-31. [DOI: 10.1016/j.annemergmed.2012.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Validity of Clinical and Ultrasound Variables to Predict the Risk of Cesarean Delivery After Induction of Labor. Obstet Gynecol 2012; 120:53-9. [DOI: 10.1097/aog.0b013e31825b9adb] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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43
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A Patient With a Large Pulmonary Saddle Embolus Eluding Both Clinical Gestalt and Validated Decision Rules. Ann Emerg Med 2012; 59:521-3. [DOI: 10.1016/j.annemergmed.2011.11.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2011] [Revised: 11/08/2011] [Accepted: 11/11/2011] [Indexed: 11/17/2022]
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Abstract
Pulmonary embolism (PE) remains one of the most challenging medical diseases in the emergency department. PE is a potentially life threatening diagnosis that is seen in patients with chest pain and/or dyspnea but can span the clinical spectrum of medical presentations. In addition, it does not have any particular clinical feature, laboratory test, or diagnostic modality that can independently and confidently exclude its possibility. This article offers a review of PE in the emergency department. It emphasizes the appropriate determination of pretest probability, the approach to diagnosis and management, and special considerations related to pregnancy and radiation exposure.
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Affiliation(s)
- David W Ouellette
- Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada.
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45
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Corrigendum. J Thromb Haemost 2012. [DOI: 10.1111/j.1538-7836.2012.04687.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Penaloza A, Verschuren F, Dambrine S, Zech F, Thys F, Roy PM. Performance of the Pulmonary Embolism Rule-out Criteria (the PERC rule) combined with low clinical probability in high prevalence population. Thromb Res 2012; 129:e189-93. [PMID: 22424852 DOI: 10.1016/j.thromres.2012.02.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Revised: 02/15/2012] [Accepted: 02/21/2012] [Indexed: 10/28/2022]
Abstract
INTRODUCTION PERC rule was created to rule out pulmonary embolism (PE) without further exams, with residual PE risk<2%. Its safety is currently not confirmed in high PE prevalence populations even when combined with low clinical probability assessed by revised Geneva score (RGS). As PERC rule and RGS are 2 similar explicit rules with many redundant criteria, we hypothesized that the combination of PERC rule with gestalt clinical probability could resolve this limitation. METHODS We collected prospectively documented clinical gestalt assessments and retrospectively calculated PERC rules and RGS from a prospective study of PE suspected patients. We analyzed performance of combinations of negative PERC with low clinical probability assessed by both methods in high overall PE prevalence population. RESULTS Among the final study population (n = 959), the overall PE prevalence was 29.8%. Seventy-four patients (7.7%) were classified as PERC negative and among them, 4 patients (5.4%) had final diagnosis of PE. When negative PERC was combined with low pretest probability assessed by RGS or gestalt assessment, PE prevalence was respectively 6.2% and 0%. This last combination reaches threshold target of 2% and unnecessary exams could easily have been avoided in this subgroup (6%). However, it confidence interval was still wide (0%; CI 0-5). CONCLUSIONS PERC rule combined with low gestalt probability seems to identify a group of patients for whom PE could easily be ruled out without additional test. A larger study is needed to confirm this result and to ensure safety.
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Affiliation(s)
- Andrea Penaloza
- Emergency Department, Cliniques Universitaires St-Luc, Université Catholique de Louvain, Brussels, Belgium.
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Diagnostic accuracy of pulmonary embolism rule-out criteria: a systematic review and meta-analysis. Ann Emerg Med 2011; 59:517-20.e1-4. [PMID: 22177109 DOI: 10.1016/j.annemergmed.2011.10.022] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2011] [Revised: 10/10/2011] [Accepted: 10/25/2011] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE To perform a systematic review and meta-analysis to define the diagnostic performance of pulmonary embolism rule-out criteria (PERC) in deferring the need for D-dimer testing to rule out pulmonary embolism in the emergency department (ED). METHODS We searched EMBASE, MEDLINE, Scopus, Web of Knowledge, and all the evidence-based medicine reviews that included the Cochrane Database of Systematic Reviews through August 14, 2011, and hand searched references in potentially eligible articles and conference proceedings of major emergency medicine organizations for the previous 2 years. We selected studies that reported diagnostic performance of PERC, reported original research, and were conducted in the ED, with no language restrictions. Two investigators independently identified eligible studies and extracted data. We used contingency tables to calculate sensitivity, specificity, and likelihood ratios. RESULTS We found 12 qualifying cohorts (studying 13,885 patients with 1,391 pulmonary embolism diagnoses), 10 prospective and 2 retrospective, from 6 countries. Pooled sensitivity, specificity, positive likelihood ratios, and negative likelihood ratios for 10 included studies were 0.97 (95% confidence interval [CI] 0.96 to 0.98), 0.23 (95% CI 0.22 to 0.24), 1.24 (95% CI 1.18 to 1.30), and 0.17 (95% CI 0.13 to 0.23), respectively. Significant heterogeneity was observed in specificity (I(2)=97.2%) and positive likelihood ratio (I(2)=84.2%). CONCLUSION The existing literature suggests consistently high sensitivity and low but acceptable specificity of the PERC to rule out pulmonary embolism in patients with low pretest probability.
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