Retrospective validation of the pulmonary embolism rule-out criteria rule in ‘PE unlikely’ patients with suspected pulmonary embolism

Crane, Steven; Jaconelli, Tom; Eragat, Mazin

doi:10.1097/mej.0000000000000442

Cited by 17 publications

(11 citation statements)

References 20 publications

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“…These data suggests that PERC should be utilized in the emergency department. Prior to this aforementioned randomised controlled trial for the PERC rule, a 2016 study demonstrated that although PERC had a high negative predictive value for excluding PE, it may miss around 8% of confirmed PE and caution was advised to its utilization [18]. We hope the subsequent multi-centre randomised controlled trial helps to alleviate these concerns.…”

Section: Discussionmentioning

confidence: 99%

Retrospective Analysis of the Computed Tomography Pulmonary Angiogram Utilization Patterns in the Emergency Department

2019

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Objectives Guidelines and high-quality studies recommend using clinical decision-making (CDM) tools over clinical gestalt when evaluating a patient for pulmonary embolism. The purpose of this study is to investigate our computed tomography pulmonary angiogram (CTPA) utilization patterns and identify causal factors. Methods A retrospective cohort study of CTPA studies ordered by emergency physicians in January, April, July, and October 2017 was undertaken. All necessary information to categorize patients by Wells' score, revised Geneva score, and pulmonary embolism rule-out criteria (PERC) was collected. In addition, various bloodwork, chest radiograph, and computed tomography results were collected. This data was analysed by the Pearson chi-square test or Fisher's exact test for categorical data and independent-samples t test for continuous variables. Results A total of 510 CTPA studies were performed, with a mean age was 61.6 and a 50.6% female population. 136 studies (26.7%) failed to appropriately follow any CDM tool. CDM tool failure rate was dependent on whether the study was ordered from a community (14.9%) or tertiary hospital (University of Alberta Hospital, 27.9% and Royal Alexandra Hospital, 24.6%) ( P = .038). Of these 136 studies, 31 were low/moderate risk and the d-dimer was negative. The remainder were either PERC-negative or low/moderate risk without d-dimer performed. The cumulative positive pulmonary embolism rate was 12.5%. With utilization of a CDM tool, the positive pulmonary embolism rate was 15.0%, compared to 5.9% when using gestalt ( P = .026). Conclusions This study confirms a high rate of CDM tool use failure, and a higher positive CTPA rate for CDM tools compared to clinical gestalt.

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Section: Discussionmentioning

confidence: 99%

Retrospective Analysis of the Computed Tomography Pulmonary Angiogram Utilization Patterns in the Emergency Department

2019

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“…In a recent randomised clinical trial including 1916 patients with suspected PE, considered by clinical judgement (holistically) to be at very low risk for PE, the use of the pulmonary embolism rule-out criteria (PERC) safely excluded PE [48]. The PERC strategy may reduce the number of d -dimer tests in patients with very low clinical probability of PE [48], although caution is advised in using the PERC rule [49].…”

Section: Pulmonary Embolismmentioning

confidence: 99%

EANM guideline for ventilation/perfusion single-photon emission computed tomography (SPECT) for diagnosis of pulmonary embolism and beyond

Bajc

Schümichen

Grüning

et al. 2019

Eur J Nucl Med Mol Imaging

157

159

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These guidelines update the previous EANM 2009 guidelines on the diagnosis of pulmonary embolism (PE). Relevant new aspects are related to (a) quantification of PE and other ventilation/perfusion defects; (b) follow-up of patients with PE; (c) chronic PE; and (d) description of additional pulmonary physiological changes leading to diagnoses of left ventricular heart failure (HF), chronic obstructive pulmonary disease (COPD) and pneumonia. The diagnosis of PE should be reported when a mismatch of one segment or two subsegments is found. For ventilation, Technegas or krypton gas is preferred over diethylene triamine pentaacetic acid (DTPA) in patients with COPD. Tomographic imaging with V/PSPECT has higher sensitivity and specificity for PE compared with planar imaging. Absence of contraindications makes V/PSPECT an essential method for the diagnosis of PE. When V/PSPECT is combined with a low-dose CT, the specificity of the test can be further improved, especially in patients with other lung diseases. Pitfalls in V/PSPECT interpretation are discussed. In conclusion, V/PSPECT is strongly recommended as it accurately establishes the diagnosis of PE even in the presence of diseases like COPD, HF and pneumonia and has no contraindications.

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“…However, despite high negative predictive value, approximately 8% of confirmed PEs are missed in patients with a low Wells score [15].…”

Section: Resultsmentioning

confidence: 99%

Untitled

2017

IJRRT

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Introduction : In-patient requests for CTPA should be performed and reported within one working day of receipt and acceptance of the request form, with a target of 90%.Methods: 400 CTPA scans over a three-month period were retrospectively recorded. We noted: Date and time of the request, vetting, scan and report as well as the presence of a PE, Wells score and d-dimer result.Results and discussion: Scans were reported within 24 hours the request in 51.7% of cases. The target is only reached within 96 hours of the request. The average time from request to report, request to vetting, vetting to scan and scan to report, was 35.3, 11.7, 19.39, and 1.66 hours respectively. There was no significant difference for scans requested out of hours between 17.00 and 09.00. A PE was diagnosed in 11.3% of cases. The average time from vetting to scan is the largest portion of the time from request to report. The British Thoracic Society (BTS) guidelines suggest a Wells score ≥ 4 does not require a d-dimer for which we were non-compliant in 56% of cases. It also states a CTPA should not be requested without a positive d-dimer if the Well's score is <4 for which we were non-compliant in 6.3% of instances. Conclusion:a. Scrutinise the organisation of the CTPA service.

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Retrospective validation of the pulmonary embolism rule-out criteria rule in ‘PE unlikely’ patients with suspected pulmonary embolism

Cited by 17 publications

References 20 publications

Retrospective Analysis of the Computed Tomography Pulmonary Angiogram Utilization Patterns in the Emergency Department

Retrospective Analysis of the Computed Tomography Pulmonary Angiogram Utilization Patterns in the Emergency Department

EANM guideline for ventilation/perfusion single-photon emission computed tomography (SPECT) for diagnosis of pulmonary embolism and beyond

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