POEMs

Patient-Oriented Evidence That Matters

Pulmonary Embolism Rule-Out Criteria Reduces the Need for CT Pulmonary Angiography in Low-Risk Patients

 

Am Fam Physician. 2018 Aug 15;98(4):250.

Clinical Question

Can the pulmonary embolism rule-out criteria (PERC) clinical decision rule reduce the need for computed tomographic (CT) pulmonary angiography in low-risk patients with suspected pulmonary embolism (PE)?

Bottom Line

Use of the PERC clinical decision rule significantly reduces the need for CT pulmonary angiography in adults with an initial low-risk clinical estimate of suspected PE. (Level of Evidence = 1b)

Synopsis

The PERC decision rule is an eight-item set of clinical criteria, including arterial oxygen saturation of 94% or less, pulse rate of at least 100 beats per minute, patient age at least 50 years, unilateral leg swelling, hemoptysis, recent trauma or surgery, prior PE or deep venous thrombosis, and exogenous estrogen use. These investigators identified all consenting adults who presented to an emergency department with new-onset presence or worsening of shortness of breath or chest pain and a low clinical probability of PE (estimated by the treating physician as less than 15% probability). The patients (N = 962) were cluster-randomized (concealed allocation assignment) based on emergency department location to a control group or to an intervention group with a diagnostic workup that included an initial calculation of the PERC score. Patients who scored zero had no additional workup for PE. Patients with a PERC score above zero had a standard diagnostic workup that included d-dimer testing, followed by CT pulmonary angiography if the d-dimer result was positive (based on age-adjusted thresholds). The control group received only the standard workup without a preceding PERC calculation. The intervention strategy continued for six months, followed by a two-month washout period, and then the two groups crossed over to the other diagnostic strategy protocol. Individuals who assessed outcomes remained masked to group assignments. Follow-up occurred for 97% of patients at three months.

Using both intention-to-treat and per-protocol analyses, there was no significant

POEMs (patient-oriented evidence that matters) are provided by EssentialEvidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, please see http://www.essentialevidenceplus.com. Copyright Wiley-Blackwell. Used with permission.

For definitions of levels of evidence used in POEMs, see https://www.essentialevidenceplus.com/product/ebm_loe.cfm?show=oxford.

To subscribe to a free podcast of these and other POEMs that appear in AFP, search in iTunes for “POEM of the Week” or go to http://goo.gl/3niWXb.

This series is coordinated by Sumi Sexton, MD, Editor-in-Chief.

A collection of POEMs published in AFP is available at https://www.aafp.org/afp/poems.

 

 

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