Prospective multicenter evaluation of the pulmonary embolism rule‐out criteria

Abstract

Summary. Backgound: Over-investigation of low-risk patients with suspected pulmonary embolism (PE) represents a growing problem. The combination of gestalt estimate of low suspicion for PE, together with the PE rule-out criteria [PERC()): age < 50 years, pulse < 100 beats min, SaO 2 ‡ 95%, no hemoptysis, no estrogen use, no surgery/trauma requiring hospitalization within 4 weeks, no prior venous thromboembolism (VTE), and no unilateral leg swelling], may reduce speculative testing for PE. We hypothesized that low suspicion and PERC()) would predict a post-test probability of VTE(+) or death below 2.0%. Methods: We enrolled outpatients with suspected PE in 13 emergency departments. Clinicians completed a 72-field, web-based data form at the time of test order. Low suspicion required a gestalt pretest probability estimate of <15%. The main outcome was the composite of image-proven VTE(+) or death from any cause within 45 days. Results: We enrolled 8138 patients, 85% of whom had a chief complaint of either dyspnea or chest pain. Clinicians reported a low suspicion for PE, together with PERC()), in 1666 patients (20%). At initial testing and within 45 days, 561 patients (6.9%, 95% confidence interval 6.5-7.6) were VTE(+), and 56 others died. Among the low suspicion and PERC()) patients, 15 were VTE(+) and one other patient died, yielding a false-negative rate of 16/1666 (1.0%, 0.6-1.6%). As a diagnostic test, low suspicion and PERC()) had a sensitivity of 97.4% (95.8-98.5%) and a specificity of 21.9% (21.0-22.9%). Conclusions:The combination of gestalt estimate of low suspicion for PE and PERC()) reduces the probability of VTE to below 2% in about 20% of outpatients with suspected PE.

Potential Impact of Adjusting the Threshold of the Quantitative D‐dimer Based on Pretest Probability of Acute Pulmonary Embolism

“…We followed patients for 45 days using a previously validated, published methodology that included chart review and telephone follow-up. 13,19 Data Analysis We used SAS v 9.l, (SAS Institute, Cary, NC) for all statistical calculations. Baseline characteristics are reported as simple proportions, means with standard deviations (±SD), and medians with interquartile ranges (IQR).…”

D-Dimer and Exhaled CO2/O2 to Detect Segmental Pulmonary Embolism in Moderate-Risk Patients

“…In addition to the requirement of an MDCTPA ordered as standard care, we restricted enrollment to those patients with explicitly documented signs or symptoms and at least one known risk factor for PE. This resulted in a significantly higher prevalence of any-size PE (18%; 95% CI, 15-22%) than the 8% prevalence we recently found in a large, multicenter sample of ED patients who enrolled on the basis of any test ordered for PE (27). Recognizing the potential confounding effect of a very low prevalence of PE was a major reason for restricting the inclusion criteria to yield at least a moderate-risk population.…”

Ronda clínica y epidemiológica: club de revistas

“…Aunque el criterio clínico puede tener igual validez que los puntajes mencionados, e incluso algunos estudios sugieren que presenta mejor rendimiento que los modelos predictivos (14,15), la poca reproducibilidad de una valoración subjetiva del riesgo sería un obstáculo para la aplicabilidad de los resultados.…”

“…Aunque estos criterios han sido validados en otros estudios (15,16), es importante resaltar que solo deben ser utilizados en los servicios de urgencias y en pacientes con baja prevalencia de PE (< 15 %), ya que en otros contextos y en poblaciones con alta prevalencia de PE (> 15 %), los PERC solos o en combinación con el puntaje de Geneva no excluyen con seguridad a los pacientes con PE (17). Lo anterior indica la importancia y la necesidad de hacer estudios similares en población latinoamericana, para evaluar de manera confiable la aplicabilidad y reproducibilidad de estos criterios en el medio local.…”