Diagnostic Accuracy of Pulmonary Embolism Rule-Out Criteria: A Systematic Review and Meta-analysis

Singh, Balwinder; Parsaik, Ajay K.; Agarwal, Deepmala; Surana, Alok; Mascarenhas, Soniya S.; Chandra, Subhash

doi:10.1016/j.annemergmed.2011.10.022

Cited by 40 publications

(25 citation statements)

References 19 publications

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“…The pooled (95% CI) sensitivity, specificity, positive likelihood ratio and negative likelihood ratio were 0.97 (0.96 to 0.98), 0.22 (0.22 to 0.23), 1.22 (1.16 to 1.29) and 0.17 (0.13 to 0.23), respectively, for PERC alone. Even though minimal decrease was seen in pooled specificity, positive likelihood ratio and negative likelihood ratio after combining the PERC rule with the clinical gestalt, it was clinically insignificant 12. The pooled (95% CI) diagnostic OR was 7.4 (5.5 to 9.8).…”

Section: Resultsmentioning

confidence: 86%

“…Data points were study characteristics (author, country, publication year, number of patients, study settings, study design, description of study participants and duration of follow-up), subject selection (inclusion and exclusion criteria), PERC classification, outcome definition and measurement, outcomes in PERC positives and negatives, and follow-up. In a study reporting multiple cohorts, each cohort was included separately 12. The primary outcome of our study was the diagnosis of PE or venous thromboembolism or death caused by venous thromboembolism within 90 days of initial ED evaluation.…”

Section: Methodsmentioning

confidence: 99%

“…The primary outcome of our study was the diagnosis of PE or venous thromboembolism or death caused by venous thromboembolism within 90 days of initial ED evaluation. For the quality assessment of the study methodology, we used the modified Quality Assessment of Diagnostic Accuracy Studies tool; further details about quality assessment are given elsewhere 12. The quality assessment of study methodology was done independently by two reviewers and the inter-reviewer agreement was assessed with Cohen's weighted κ and any disagreement was resolved by mutual consensus.…”

Section: Methodsmentioning

confidence: 99%

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Pulmonary embolism rule-out criteria (PERC) in pulmonary embolism—revisited: A systematic review and meta-analysis

et al. 2012

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ObjectivesTo perform a systematic review and meta-analysis including all the current studies to assess the accuracy of pulmonary embolism rule-out criteria (PERC) in ruling out pulmonary embolism (PE).MethodsWe conducted a comprehensive search of the major databases (Ovid Medline In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid PsycInfo, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews and Scopus) and references of potentially eligible articles and conference proceedings of major emergency medicine organisations through May 2012. We included all original research studies conducted in emergency departments on diagnostic performance of PERC. Two reviewers independently identified the eligible studies and extracted data. Sensitivity, specificity and likelihood ratios were calculated using contingency tables.Results12 studies including 13 cohorts (three retrospective, 10 prospective) were included, comprising of 14 844 patients from six countries. 12 cohorts were urban and one was rural. Pooled (95% CI) sensitivity, specificity, positive and negative likelihood ratio were 0.97 (0.96 to 0.98), 0.22 (0.22 to 0.23), 1.22 (1.16 to 1.29) and 0.17 (0.13 to 0.23), respectively. The pooled (95% CI) diagnostic OR was 7.4 (5.5–9.8). On meta-regression analysis, there was no significant difference between PE prevalence and PERC diagnostic performance (coefficient (SE) of −0.032 (0.022), p=0.173) or on relative diagnostic OR (0.97, 95% CI 0.92 to 1.02). Significant heterogeneity was observed in specificity (I2=97.4%) and positive likelihood ratio (I2=89.1%).ConclusionsBecause of the high sensitivity and low negative likelihood ratio, PERC rule can be used confidently in clinically low probability population settings.

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Section: Resultsmentioning

confidence: 86%

Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

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Pulmonary embolism rule-out criteria (PERC) in pulmonary embolism—revisited: A systematic review and meta-analysis

et al. 2012

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“…However, just the fact that the Wells/Geneva score was calculated was not associated with positive CTPA. But, patients with a high pretest probability for PE were more likely to have a positive CTPA, regardless of whether the pretest probability was estimated by using the Wells/Geneva score, or if it was estimated by considering other criteria (e.g., the Pulmonary Embolism Rule Out Criteria (PERC), including the risk factor oral contraceptive [17]), or the clinical experience of the physician. Thus, the Wells/Geneva score should be seen as one possible tool for estimating the pretest probability of PE, among a variety of other factors that influence the estimation of pretest probability, such as all clinical experience and diagnostic skills of the physician.…”

Section: Discussionmentioning

confidence: 99%

Ordering CT pulmonary angiography to exclude pulmonary embolism: defense versus evidence in the emergency room

et al. 2012

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Purpose: To identify reasons for ordering computed tomography pulmonary angiography (CTPA), to identify the frequency of reasons for CTPA reflecting defensive behavior and evidence-based behavior, and to identify the impact of defensive medicine and of training about diagnosing pulmonary embolism (PE) on positive results of CTPA. Methods: Physicians in the emergency department of a tertiary care hospital completed a questionnaire before CTPA after being trained about diagnosing PE and completing questionnaires. Results: Nine hundred patients received a CTPA during 3 years. For 328 CTPAs performed during the 1-year study period, 140 (43 %) questionnaires were completed. The most frequent reasons for ordering a CTPA were to confirm/rule out PE (93 %), elevated D-dimers (66 %), fear of missing PE (55 %), and Wells/simplified revised Geneva score (53 %). A positive answer for ''fear of missing PE'' was inversely associated with positive CTPA (OR 0.36, 95 % CI 0.14-0.92, p = 0.033), and ''Wells/simplified revised Geneva score'' was associated with positive CTPA (OR 3.28, 95 % CI 1.24-8.68, p = 0.017). The proportion of positive CTPA was higher if a questionnaire was completed, compared to the 2-year comparison period (26.4 vs. 14.5 %, OR 2.12, 95 % CI 1.36-3.29, p \ 0.001). The proportion of positive CTPA was nonsignificantly higher during the study period than during the comparison period (19.2 vs. 14.5 %, OR 1.40, 95 % CI 0.98-2.0, p = 0.067). Conclusion: Reasons for CTPA reflecting defensive behavior-such as ''fear of missing PE''-were frequent, and were associated with a decreased odds of positive CTPA. Defensive behavior might be modifiable by training in using guidelines.

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“…The pulmonary embolism rule-out criteria (PERC) is an alternative method for pretest probability assessment in low-risk patients, as determined either by Wells criteria or by physician gestalt [39]. When all components of the rule are satisfied (low risk of PE, age less than 50 years, oxygen saturation 95 % or greater, pulse rate below 100 beats per minute, no hemoptysis, no estrogen use, no hospitalization within 4 weeks for surgery/trauma, no prior VTE, and no unilateral leg swelling) the probability of VTE is less than 2 % [38].…”

Section: Clinical Scoring Systemsmentioning

confidence: 99%

Expedited Management of Deep Vein Thrombosis and Acute Pulmonary Embolism

Johnson

Yarbrough

2013

Curr Emerg Hosp Med Rep

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Deep vein thrombosis and pulmonary embolism are common diseases with significant morbidity and mortality. Clinical probability assessment reliably identifies low-risk patients, and when paired with a negative D-dimer test, safely excludes venous thromboembolism. Compression ultrasonography confirms the diagnosis of deep vein thrombosis, whereas computed tomography pulmonary angiography is typically used to confirm pulmonary embolism. Risk assessment of acute pulmonary embolism stratifies low-risk patients for outpatient treatment, and high-risk patients for consideration of thrombolytic therapy. The recent approval of rivaroxaban, a novel oral anticoagulant, can simplify and expedite treatment in select patients. Ongoing clinical trials may uncover methods to prevent postthrombotic syndrome and chronic thromboembolic pulmonary hypertension. In this report, we review current diagnostic and management methods for deep vein thrombosis and pulmonary embolism.

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Diagnostic Accuracy of Pulmonary Embolism Rule-Out Criteria: A Systematic Review and Meta-analysis

Cited by 40 publications

References 19 publications

Pulmonary embolism rule-out criteria (PERC) in pulmonary embolism—revisited: A systematic review and meta-analysis

Pulmonary embolism rule-out criteria (PERC) in pulmonary embolism—revisited: A systematic review and meta-analysis

Ordering CT pulmonary angiography to exclude pulmonary embolism: defense versus evidence in the emergency room

Expedited Management of Deep Vein Thrombosis and Acute Pulmonary Embolism

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