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

Singh, Balwinder; Mommer, Shannon K.; Erwin, Patricia J.; Mascarenhas, Soniya S.; Parsaik, Ajay K.

doi:10.1136/emermed-2012-201730

Cited by 88 publications

(48 citation statements)

References 20 publications

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“…A 2010 meta‐analysis found a pre‐test probability for aPE of 5.7% for low risk, 23.2% for intermediate risk and 49.3% for high risk. However, a definitive diagnosis still requires imaging (CTPA or V/Q scan) and most patients will require a D‐dimer or the PERC to ‘rule‐out’ a PE, given the 5.7% pre‐test probability in the low‐risk group (Fig. ).…”

Section: Diagnosis Of Suspected Pementioning

confidence: 99%

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Acute pulmonary embolism: a concise review of diagnosis and management

Hepburn-Brown

Darvall

Hammerschlag

2019

Internal Medicine Journal

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An acute pulmonary embolism (aPE) is characterised by occlusion of one or more pulmonary arteries. Physiological disturbance may be minimal, but often cardiac output decreases as the right ventricle attempts to overcome increased afterload. Additionally, ventilation‐perfusion mismatches can develop in affected vascular beds, reducing systemic oxygenation. Incidence is reported at 50–75 per 100 000 in Australia and New Zealand, with 30‐day mortality rates ranging from 0.5% to over 20%. Incidence is likely to increase with the ageing population, increased survival of patients with comorbidities that are considered risk factors and improving sensitivity of imaging techniques. Use of clinical prediction scores, such as the Wells score, has assisted in clinical decision‐making and decreased unnecessary radiological investigations. However, imaging (i.e. computed tomography pulmonary angiography or ventilation‐perfusion scans) is still necessary for objective diagnosis. Anti‐coagulation remains the foundation of PE management. Haemodynamically unstable patients require thrombolysis unless absolutely contraindicated, while stable patients with right ventricular dysfunction or ischaemia should be aggressively anti‐coagulated. Stable patients with no right ventricular dysfunction can be discharged home early with anti‐coagulation and review. However, treatment should be case dependent with full consideration of the patient’s clinical state. Direct oral anti‐coagulants have become an alternative to vitamin K antagonists and are facilitating shorter hospital admissions. Additionally, duration of anti‐coagulation must be decided by considering any provoking factors, bleeding risk and comorbid state. Patients with truly unprovoked or idiopathic PE often require indefinite treatment, while in provoked cases it is typically 3 months with some patients requiring longer periods of 6–12 months.

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Section: Diagnosis Of Suspected Pementioning

confidence: 99%

“…If the PERC score is 0, the 45‐day VTE incidence is reported at <1% . A 2013 meta‐analysis further supported that PERC can confidently rule‐out PE in low probability patients …”

Section: Diagnosis Of Suspected Pementioning

confidence: 99%

Acute pulmonary embolism: a concise review of diagnosis and management

Hepburn-Brown

Darvall

Hammerschlag

2019

Internal Medicine Journal

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“…Sensitivity of the tested alternative algorithm (PERC=0) to rule-out PE was 89% (64%–98%) and LR− was 0.52 (0.14–1.96), whereas a recent meta-analysis of 12 studies19 reported a pooled sensitivity of 97% (96%–98%) and an LR− of 0.17 (0.13–0.23). One explanation for the lower diagnostic accuracy of PERC in our study could be the smaller sample size of our study population compared with this meta-analysis where >14 000 patients were included.…”

Section: Discussionmentioning

confidence: 92%

A retrospective analysis of the combined use of PERC rule and Wells score to exclude pulmonary embolism in the Emergency Department

et al. 2016

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“…Diagnostic algorithms utilizing clinical features such as the Wells criteria, PERC tool and sensitive D-dimer testing can be used to safely rule out PE in many low risk patients without the need for imaging [17]. A large meta-analysis of 12 studies showed that the overall proportion of missed PE's using the PERC tool was only 0.3% [18]. More recently, a randomized controlled trial also suggested that utilizing pretest probability to avoid imaging in low risk patients is both safe and cost-saving [19].…”

Section: Discussionmentioning

confidence: 99%

Identifying existing Choosing Wisely recommendations of high relevance and importance to hematology

et al. 2016

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Choosing Wisely (CW) is a medical stewardship initiative led by the American Board of Internal Medicine Foundation in collaboration with professional medical societies in the United States. In an effort to learn from and leverage the work of others, the American Society of Hematology CW Task Force developed a method to identify and prioritize CW recommendations from other medical societies of high relevance and importance to patients with blood disorders and their physicians. All 380 CW recommendations were reviewed and assessed for relevance and importance. Relevance was assessed using the MORE TM relevance scale. Importance was assessed with regard to six guiding principles: harm avoidance, evidence, aggregate cost, relevance, frequency and impact. Harm avoidance was considered the most important principle. Ten highly relevant and important recommendations were identified from a variety of professional societies. Recommendations focused on decreasing unnecessary imaging, blood work, treatments and transfusions, as well as on increasing collaboration across disciplines and considering value when recommending treatments. Many CW recommendations have relevance beyond the society of origin. The methods developed by the ASH CW Task Force could be easily adapted by other Societies to identify additional CW recommendations of relevance and importance to their fields.

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

Cited by 88 publications

References 20 publications

Acute pulmonary embolism: a concise review of diagnosis and management

Acute pulmonary embolism: a concise review of diagnosis and management

A retrospective analysis of the combined use of PERC rule and Wells score to exclude pulmonary embolism in the Emergency Department

Identifying existing Choosing Wisely recommendations of high relevance and importance to hematology

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