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Robert-Ebadi H, Roy PM, Sanchez O, Verschuren F, Le Gal G, Righini M. External validation of the PEGeD diagnostic algorithm for suspected pulmonary embolism in an independent cohort. Blood Adv 2023; 7:3946-3951. [PMID: 36521170 PMCID: PMC10410134 DOI: 10.1182/bloodadvances.2022007729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 10/18/2022] [Accepted: 10/18/2022] [Indexed: 12/23/2022] Open
Abstract
Sequential diagnostic algorithms are used in the case of suspected pulmonary embolism (PE). The PEGeD study proposed a new diagnostic strategy to reduce the use of computed tomography pulmonary angiography (CTPA). We aimed to externally validate this diagnostic strategy in an independent cohort. We analyzed data from 3 prospective studies of outpatients with suspected PE. As per the PEGeD algorithm, patients were classified as having a low, moderate, or high clinical pretest probability (C-PTP). PE was excluded with a D-dimer <1000 ng/mL in case of low C-PTP and <500 ng/mL in case of moderate C-PTP. We assessed the yield and safety of this approach and compared them with those of previously validated algorithms. Among the 3308 evaluated patients, 1615 (49%) patients could have had PE excluded according to the PEGeD algorithm, without the need for imaging. Of these patients, 38 (2.3%; 95% confidence interval [CI], 1.7-3.2) were diagnosed with a symptomatic PE at initial testing or during the 3-month follow-up. On further analysis, 36 patients out of these 38 patients had a positive age-adjusted D-dimer. The risk of venous thromboembolic events among the 414 patients with a D-dimer <1000 ng/mL but above the age-adjusted D-dimer cut-off was 36 of 414 (8.7%; 95% CI, 6.4-11.8). We provide external validation of the PEGeD algorithm in an independent cohort. Compared with standard algorithms, the PEGeD decreased the number of CTPA examinations. However, caution is required in patients with a low C-PTP and a D-dimer <1000 ng/mL but above their age-adjusted D-dimer cut-off.
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Affiliation(s)
- Helia Robert-Ebadi
- Division of Angiology and Hemostasis and Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Pierre-Marie Roy
- Department of Emergency Medicine, University Hospital of Angers, Angers, France
| | - Olivier Sanchez
- Department of Respiratory Disease, Hôpital Européen Georges Pompidou, APHP, and Université Paris Descartes, Paris, France
| | - Frank Verschuren
- Emergency Department, Saint-Luc University Hospital, Brussels, Belgium
| | - Grégoire Le Gal
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Marc Righini
- Division of Angiology and Hemostasis and Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
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Bannelier H, Gorlicki J, Penaloza A, Douillet D, Roy PM, Freund Y, Roussel M. Evaluation of the "hemoptysis" item in clinical decision rules for the diagnosis of pulmonary embolism in the emergency department. Acad Emerg Med 2022; 29:1205-1212. [PMID: 35975482 DOI: 10.1111/acem.14574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 05/31/2022] [Accepted: 07/12/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Hemoptysis is not common in pulmonary embolism (PE) and lacks specificity for its diagnosis. However, this item is present in different validated scores that estimate the clinical probability of PE. The relevance of this item in clinical decision rules (CDRs) is not clearly established. OBJECTIVE The aim of this study was to evaluate the impact of removing the "hemoptysis" item from the PERC, YEARS, and PEGeD CDR in patients with low clinical probability of PE. DESIGN This was a post hoc analysis of two European prospective cohorts, which included 2968 patients presenting to the ED with a low clinical probability of PE (PROPER and PERCEPIC) and a 3-month follow-up. The primary endpoint was the false-negative rate of a CDR score without the hemoptysis item. Secondary endpoints included the potential reduction of chest imaging if the item hemoptysis was to be removed and risk stratification of the Geneva and Wells scores without the hemoptysis item. RESULTS Of 2968 patients included (mean ± SD age 46 ± 18 years, 53% female), 87 patients (3%) had a PE diagnosed at 3 months. A total of 2908 were followed-up at 3 months and analyzed. Using the PERC rule with and without the hemoptysis item, there were 13 and 14 missed cases of PE, respectively (failure rate 0.45% [95% CI 0.25%-0.78%] and 0.48% [95% CI 0.27%-0.82%]). Using the YEARS strategy, there were 11 missed PE cases with or without the hemoptysis item (false-negative rate 0.57% [95% CI 0.30%-1.05%]). With the PERC and YEARS rule, removing the hemoptysis item would have led to a 1% reduction in chest imaging. The PEGeD strategy was not modified by the removal of the hemoptysis item. CONCLUSIONS The hemoptysis item could be safely removed from the PERC, YEARS, and PEGeD CDRs. However, there was no subsequent clinically relevant reduction of chest imaging.
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Affiliation(s)
- Héloïse Bannelier
- Emergency Department, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Judith Gorlicki
- Emergency Department, Hôpital Avicenne, Assistance Publique-Hôpitaux de Paris, INSERM U942-MASCOT, Bobigny, France
| | - Andrea Penaloza
- Emergency Department, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Bruxelles, Belgium
| | - Delphine Douillet
- Emergency Department, Angers University Hospital, Angers, France.,FCRIN, INNOVTE, Saint Etienne, France
| | - Pierre-Marie Roy
- Emergency Department, Angers University Hospital, Angers, France.,FCRIN, INNOVTE, Saint Etienne, France
| | - Yonathan Freund
- Emergency Department, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.,Sorbonne Université, Improving Emergency Care FHU, Paris, France
| | - Melanie Roussel
- Emergency Department, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.,Sorbonne Université, Improving Emergency Care FHU, Paris, France
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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. Eur J Emerg Med 2022; 29:341-347. [PMID: 36062433 DOI: 10.1097/mej.0000000000000967] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND The optimal strategy for the diagnosis of pulmonary embolism (PE) in the emergency department (ED) remains debated. To reduce the need of imaging testing, several rules have been recently validated using an elevated D-dimer threshold. OBJECTIVE To validate the safety of different diagnostic strategies and compare the efficacy in terms of chest imaging testing. DESIGN AND PATIENTS Post-hoc analysis of individual data of 3330 adult patients without a high clinical probability of PE in the ED followed-up at 3 months in France and Spain (1916 from the PROPER cohort, 1414 from the MODIGLIANI cohort). EXPOSURE Four diagnostic strategies with an elevated D-dimer threshold if PE is unlikely. The YEARS combined with Pulmonary Embolism Rule-out Criteria (PERC) the pulmonary embolism graduated D-dimer (PEGeD) combined with PERC and the 4-level pulmonary embolism probability score (4PEPS) rules were assessed. A modified simplified (MODS) rule with a simplified YEARS reduced to the sole item of "Is PE the most likely diagnosis" combined with PERC was also tested. OUTCOME MEASURE AND ANALYSIS The primary outcome was the proportion of diagnosed PE or deep venous thrombosis at 3 months in patients in whom PE could have been excluded without chest imaging according to the tested strategy. The safety of a strategy was confirmed if the failure rate was less than 1.85%. The secondary outcome was the use of imaging testing according to each rule. RESULTS Among 3330 analyzed patients, 150 (4.5%) had a PE. The number of missed PEs were 25, 29, 30 and 26 for the PERC+YEARS, PERC+PEGeD, 4PEPS and MODS rules respectively, with a failure rate of 0.75% (95% CI 0.51% to 1.10%), 0.87% (0.61% to 1.25%), 0.90% (0.63% to 1.28%) and 0.78% (0.53% to 1.14%) respectively. There was no significant difference in the failure rate between rules. Except for a significant lower use of chest imaging for 4PEPS compared to YEARS (14.9% vs 16.3%, difference -1.4% [95%CI -2.1% to -0.8%]), there was no difference in the proportion of imaging testing. CONCLUSION In this post-hoc analysis of patients with suspicion of PE, YEARS and PEGeD combined with PERC, and 4PEPS were safe to exclude PE. The safety of the modified simplified MODS strategy was also confirmed. There was no significant difference of the failure rate between strategies.
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Freund Y, Chauvin A, Jimenez S, Philippon AL, Curac S, Fémy F, Gorlicki J, Chouihed T, Goulet H, Montassier E, Dumont M, Lozano Polo L, Le Borgne P, Khellaf M, Bouzid D, Raynal PA, Abdessaied N, Laribi S, Guenezan J, Ganansia O, Bloom B, Miró O, Cachanado M, Simon T. Effect of a Diagnostic Strategy Using an Elevated and Age-Adjusted D-Dimer Threshold on Thromboembolic Events in Emergency Department Patients With Suspected Pulmonary Embolism: A Randomized Clinical Trial. JAMA 2021; 326:2141-2149. [PMID: 34874418 PMCID: PMC8652602 DOI: 10.1001/jama.2021.20750] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
IMPORTANCE Uncontrolled studies suggest that pulmonary embolism (PE) can be safely ruled out using the YEARS rule, a diagnostic strategy that uses varying D-dimer thresholds. OBJECTIVE To prospectively validate the safety of a strategy that combines the YEARS rule with the pulmonary embolism rule-out criteria (PERC) rule and an age-adjusted D-dimer threshold. DESIGN, SETTINGS, AND PARTICIPANTS A cluster-randomized, crossover, noninferiority trial in 18 emergency departments (EDs) in France and Spain. Patients (N = 1414) who had a low clinical risk of PE not excluded by the PERC rule or a subjective clinical intermediate risk of PE were included from October 2019 to June 2020, and followed up until October 2020. INTERVENTIONS Each center was randomized for the sequence of intervention periods. In the intervention period (726 patients), PE was excluded without chest imaging in patients with no YEARS criteria and a D-dimer level less than 1000 ng/mL and in patients with 1 or more YEARS criteria and a D-dimer level less than the age-adjusted threshold (500 ng/mL if age <50 years or age in years × 10 in patients ≥50 years). In the control period (688 patients), PE was excluded without chest imaging if the D-dimer level was less than the age-adjusted threshold. MAIN OUTCOMES AND MEASURES The primary end point was venous thromboembolism (VTE) at 3 months. The noninferiority margin was set at 1.35%. There were 8 secondary end points, including chest imaging, ED length of stay, hospital admission, nonindicated anticoagulation treatment, all-cause death, and all-cause readmission at 3 months. RESULTS Of the 1414 included patients (mean age, 55 years; 58% female), 1217 (86%) were analyzed in the per-protocol analysis. PE was diagnosed in the ED in 100 patients (7.1%). At 3 months, VTE was diagnosed in 1 patient in the intervention group (0.15% [95% CI, 0.0% to 0.86%]) vs 5 patients in the control group (0.80% [95% CI, 0.26% to 1.86%]) (adjusted difference, -0.64% [1-sided 97.5% CI, -∞ to 0.21%], within the noninferiority margin). Of the 6 analyzed secondary end points, only 2 showed a statistically significant difference in the intervention group compared with the control group: chest imaging (30.4% vs 40.0%; adjusted difference, -8.7% [95% CI, -13.8% to -3.5%]) and ED median length of stay (6 hours [IQR, 4 to 8 hours] vs 6 hours [IQR, 5 to 9 hours]; adjusted difference, -1.6 hours [95% CI, -2.3 to -0.9]). CONCLUSIONS AND RELEVANCE Among ED patients with suspected PE, the use of the YEARS rule combined with the age-adjusted D-dimer threshold in PERC-positive patients, compared with a conventional diagnostic strategy, did not result in an inferior rate of thromboembolic events. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04032769.
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Affiliation(s)
- Yonathan Freund
- Sorbonne Université, Improving Emergency Care FHU, Paris, France
- Emergency Department, Hôpital Pitié–Salpêtrière, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Anthony Chauvin
- Emergency Department, Hôpital Lariboisière, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Sonia Jimenez
- Emergency Department, Hospital Clínic, IDIBAPS, Barcelona, University of Barcelona, Catalonia, Spain
| | - Anne-Laure Philippon
- Sorbonne Université, Improving Emergency Care FHU, Paris, France
- Emergency Department, Hôpital Pitié–Salpêtrière, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Sonja Curac
- Emergency Department, Hôpital Beaujon, Assistance Publique–Hôpitaux de Paris, Clichy, France
| | - Florent Fémy
- Emergency Department, Hôpital Européen Georges Pompidou, Assistance Publique–Hôpitaux de Paris, Paris University, Paris, France
- Toxicology and Chemical Risks Department, French Armed Forces Biomedical Institute, Bretigny-Sur-Orges, France
| | - Judith Gorlicki
- Emergency Department, Hôpital Avicenne, Assistance Publique–Hôpitaux de Paris, INSERM U942-MASCOT, Bobigny, France
| | - Tahar Chouihed
- Emergency Department, University Hospital of Nancy, Université de Lorraine, UMR_S 1116, Nancy, France
| | - Hélène Goulet
- Emergency Department, Hôpital Tenon, Assistance Publique–Hôpitaux de Paris, Paris, France
| | | | - Margaux Dumont
- Emergency Department, Hôpital Pitié–Salpêtrière, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Laura Lozano Polo
- Emergency Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Universitat Autònoma de Barcelona, Catalonia, Spain
| | - Pierrick Le Borgne
- Emergency Department, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Mehdi Khellaf
- Emergency Department, CHU Henri Mondor, INSERM U955, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Donia Bouzid
- Université de Paris, INSERM, IAME, F-75006 Paris, France
- Emergency Department, Bichat-Claude Bernard University Hospital, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Pierre-Alexis Raynal
- Emergency Department, Hôpital St-Antoine, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Nizar Abdessaied
- Emergency Department, Centre Hospitalier de St Denis, St Denis, France
| | - Saïd Laribi
- Tours University, Emergency Medicine Department, Tours University Hospital, Tours, France
| | - Jeremy Guenezan
- Emergency Department, University Hospital of Poitiers, Poitiers, France
| | - Olivier Ganansia
- Emergency Department, Groupe Hospitalier Paris–St Joseph, Paris, France
| | - Ben Bloom
- Emergency Department, Barts Health NHS Trust, London, United Kingdom
| | - Oscar Miró
- Emergency Department, Hôpital Lariboisière, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Marine Cachanado
- Department of Clinical Pharmacology and Clinical Research Platform Paris-East (URCEST-CRC-CRB), Assistance Publique–Hôpitaux de Paris, Sorbonne University, St Antoine Hospital, Paris, France
| | - Tabassome Simon
- Sorbonne Université, Improving Emergency Care FHU, Paris, France
- Department of Clinical Pharmacology and Clinical Research Platform Paris-East (URCEST-CRC-CRB), Assistance Publique–Hôpitaux de Paris, Sorbonne University, St Antoine Hospital, Paris, France
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