Effect of the Pulmonary Embolism Rule-Out Criteria on Subsequent Thromboembolic Events Among Low-Risk Emergency Department Patients

Freund, Yonathan; Cachanado, Marine; Aubry, Alix; Orsini, C.; Raynal, Pierre-Alexis; Féral‐Pierssens, Anne‐Laure; Charpentier, Sandrine; Dumas, Florence; Baarir, N.; Truchot, Jennifer; Desmettre, T.; Tazarourte, Karim; Beaune, Sébastien; Leleu, Agathe; Khellaf, Mehdi; Wargon, Mathias; Bloom, Ben; Rousseau, Alexandra; Simon, Tabassome; Riou, Bruno

doi:10.1001/jama.2017.21904

Cited by 122 publications

(118 citation statements)

References 32 publications

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“…The pulmonary embolism rule‐out criteria (PERC) is a scoring system for excluding PE . It is only applicable to patients younger than 50 years of age and when the estimated rate of PE is low (< 15%) . This rate is seen in most Australian and New Zealand emergency departments and, therefore, PERC can be applied.…”

Section: Diagnosis and Treatment Of Pulmonary Embolism And Deep Vein mentioning

confidence: 99%

See 1 more Smart Citation

New guidelines from the Thrombosis and Haemostasis Society of Australia and New Zealand for the diagnosis and management of venous thromboembolism

Tran

Gibbs

Merriman

et al. 2019

Medical Journal of Australia

113

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Introduction Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is the third most common cardiovascular disease and, globally, more than an estimated 10 million people have it yearly. It is a chronic and recurrent disease. The symptoms of VTE are non‐specific and the diagnosis should actively be sought once considered. The mainstay of VTE treatment is anticoagulation, with few patients requiring additional intervention. A working group of experts in the area recently completed an evidence‐based guideline for the diagnosis and management of DVT and PE on behalf of the Thrombosis and Haemostasis Society of Australia and New Zealand (http://www.thanz.org.au/resources/thanz-guidelines). Main recommendations The diagnosis of VTE should be established with imaging; it may be excluded by the use of clinical prediction rules combined with D‐dimer testing. Proximal DVT or PE caused by a major surgery or trauma that is no longer present should be treated with anticoagulant therapy for 3 months. Proximal DVT or PE that is unprovoked or associated with a transient risk factor (non‐surgical) should be treated with anticoagulant therapy for 3–6 months. Proximal DVT or PE that is recurrent (two or more) and provoked by active cancer or antiphospholipid syndrome should receive extended anticoagulation. Distal DVT caused by a major provoking factor that is no longer present should be treated with anticoagulant therapy for 6 weeks. For patients continuing with extended anticoagulant therapy, either therapeutic or low dose direct oral anticoagulants can be prescribed and is preferred over warfarin in the absence of contraindications. Routine thrombophilia testing is not indicated. Thrombolysis or a suitable alternative is indicated for massive (haemodynamically unstable) PE. Changes in management as a result of the guideline Most patients with acute VTE should be treated with a factor Xa inhibitor and be assessed for extended anticoagulation.

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Section: Diagnosis and Treatment Of Pulmonary Embolism And Deep Vein mentioning

confidence: 99%

“…14 It is only applicable to patients younger than 50 years of age and when the estimated rate of PE is low (< 15%). 16 This rate is seen in most Australian and New Zealand emergency departments and, therefore, PERC can be applied. If used in this way, additional investigations can be avoided in some patients.…”

Section: Clinical Prediction Rulesmentioning

confidence: 99%

New guidelines from the Thrombosis and Haemostasis Society of Australia and New Zealand for the diagnosis and management of venous thromboembolism

Tran

Gibbs

Merriman

et al. 2019

Medical Journal of Australia

113

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“…Comentario: es evidente la problemática actual de sobrediagnóstico de PE y el sobreuso de recursos para descartar este tipo de diagnósticos (9,10). Por esto es relevante el trabajo de Freund Y., et al, quienes evidencian la seguridad de los criterios PERC para descartar el diagnóstico en pacientes con bajo riesgo de PE.…”

Section: ¿Cómo Y En Quiénes Se Puede Excluirunclassified

Ronda clínica y epidemiológica: club de revistas

Mendoza-Mendoza

Restrepo-Álvarez

Caraballo

et al. 2018

iatreia

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RESUMENEn esta nueva edición de la Ronda Clínica y Epidemiológica, el lector podrá encontrar cuatro artículos que consideramos de especial interés para la práctica clínica actual. Abuzaid A. et al, realizan una revisión sistemática y meta-análisis que compara los desenlaces de la terapia con oxígeno vs. sin oxígeno en escenarios post-infarto agudo de miocardio. Freund Y., et al, presentan un ensayo clínico cluster de no inferioridad en el que buscan validar prospectivamente la seguridad de una estrategia basada en criterios clínicos para descartar embolismo pulmonar. Por otro lado, por medio de un diseño de cohorte retrospectiva con emparejamiento por índice de propensión, Pasternak, et al, se proponen investigar si el uso de fluoroquinolonas orales se asocia con un incremento en el riesgo de aneurisma o disección aórtica. Por último, el grupo de investigadores SMART evalúa, a través de un ensayo clínico pragmático en pacientes críticamente enfermos, el impacto de soluciones balanceadas en comparación al uso de solución salina normal en el riesgo de desarrollar eventos renales mayores.

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“…Yet, fewer than 10% of these scans show PE . Multiple validated risk stratification tools exist to promote appropriate workup for PE and are recommended by professional society guidelines, including the Pulmonary Embolism Rule Out Criteria (PERC), Wells score, and D‐dimer laboratory test (Figure ) . Provider uptake of the tools has been slow, with recent ED studies finding 25% of patients who warranted no laboratory or imaging studies still received testing .…”

Section: Introductionmentioning

confidence: 99%

Provider Perspectives on the Use of Evidence‐based Risk Stratification Tools in the Evaluation of Pulmonary Embolism: A Qualitative Study

Westafer

Kunz

Bugajska

et al. 2020

Academic Emergency Medicine

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Objectives Providers often pursue imaging in patients at low risk of pulmonary embolism (PE), resulting in imaging yields <10% and false‐positive imaging rates of 10% to 25%. Attempts to curb overtesting have had only modest success and no interventions have used implementation science frameworks. The objective of this study was to identify barriers and facilitators to the adoption of evidence‐based diagnostic testing for PE. Methods We conducted semistructured interviews with a purposeful sample of providers. An interview guide was developed using the implementation science frameworks, consolidated framework for implementation research, and theoretical domains framework. Interviews were recorded, transcribed, and analyzed in an iterative process. Emergent themes were identified, discussed, and organized. Results We interviewed 23 providers from four hospital systems, and participants were diverse with regard to years in practice and practice setting. Barriers were predominately at the provider level and included lack of knowledge of the tools, particularly misunderstanding of the validated scoring systems in Wells, as well as risk avoidance and need for certainty. Barriers to prior implementation strategies included the perception of a clinical decision support (CDS) tool for PE as adding steps with little value; most participants reported that they overrode CDS interventions because they had already made the decision. All providers identified institution‐level strategies as facilitators to use, including endorsed guidelines, audit feedback with peer comparison about imaging yield, and peer pressure. Conclusions This exploration of the use of risk stratification tools in the evaluation of PE found that barriers to use primarily exist at the provider level, whereas facilitators to the use of these tools are largely perceived at the level of the institution. Future efforts to promote the evidence‐based diagnosis of PE should be informed by these determinants.

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Effect of the Pulmonary Embolism Rule-Out Criteria on Subsequent Thromboembolic Events Among Low-Risk Emergency Department Patients

Abstract: clinicaltrials.gov Identifier: NCT02375919.

Cited by 122 publications

References 32 publications

New guidelines from the Thrombosis and Haemostasis Society of Australia and New Zealand for the diagnosis and management of venous thromboembolism

New guidelines from the Thrombosis and Haemostasis Society of Australia and New Zealand for the diagnosis and management of venous thromboembolism

Ronda clínica y epidemiológica: club de revistas

Provider Perspectives on the Use of Evidence‐based Risk Stratification Tools in the Evaluation of Pulmonary Embolism: A Qualitative Study

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