The pulmonary embolism rule‐out criteria (PERC) rule does not safely exclude pulmonary embolism

Abstract

Summary. Background: The Pulmonary Embolism Rule-out Criteria (PERC) rule is a clinical diagnostic rule designed to exclude pulmonary embolism (PE) without further testing. We sought to externally validate the diagnostic performance of the PERC rule alone and combined with clinical probability assessment based on the revised Geneva score. Methods: The PERC rule was applied retrospectively to consecutive patients who presented with a clinical suspicion of PE to six emergency departments, and who were enrolled in a randomized trial of PE diagnosis. Patients who met all eight PERC criteria [PERC ()) ] were considered to be at a very low risk for PE. We calculated the prevalence of PE among PERC ()) patients according to their clinical pretest probability of PE. We estimated the negative likelihood ratio of the PERC rule to predict PE. Results: Among 1675 patients, the prevalence of PE was 21.3%. Overall, 13.2% of patients were PERC ()) . The prevalence of PE was 5.4% [95% confidence interval (CI): 3.1-9.3%] among PERC ()) patients overall and 6.4% (95% CI: 3.7-10.8%) among those PERC ()) patients with a low clinical pretest probability of PE. The PERC rule had a negative likelihood ratio of 0.70 (95% CI: 0.67-0.73) for predicting PE overall, and 0.63 (95% CI: 0.38-1.06) in low-risk patients. Conclusions: Our results suggest that the PERC rule alone or even when combined with the revised Geneva score cannot safely identify very low risk patients in whom PE can be ruled out without additional testing, at least in populations with a relatively high prevalence of PE.

Use of a three‐tiered clinical decision rule to quantify unnecessary radiological investigation of suspected pulmonary embolism

“…The PERC rule is valid only in subgroups with a low prevalence of PE (<15%), typically in patients presenting to ED. Its negative predictive value (NPV) is poor in patients with intermediate to high probability of PE, including inpatients . Our audit therefore excluded patients investigated for suspected PE during an inpatient admission or patients undergoing follow‐up scans for previous PE.…”

Ronda clínica y epidemiológica: club de revistas

“…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.…”

Decreased facial expression variability in patients with serious cardiopulmonary disease in the emergency care setting

“…In general, the addition of gestalt assessment appeared to improve performance of decision rules 10 11. Many of the so-called objective decision rules for both ACS and PE actually contain a subjective variable that requires the user to assess whether the patient has a presentation that is typical for ACS or PE 3 12 13.…”