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Clinical prediction rule for PE noninferior to usual care

The use of a pulmonary embolism rule-out criteria-based strategy identified similar rates of PE compared with a conventional strategy, according to findings published in JAMA.

“The safety of the pulmonary embolism rule-out criteria (PERC), an 8-item block of clinical criteria aimed at ruling out [PE] has not been assessed in a randomized clinical trial,” Yonathan Freund, MD, PhD, from Service d’accueil des Urgences, Paris, and colleagues wrote.

Freund and colleagues performed a crossover cluster-randomized clinical noninferiority trial to determine if use of a PERC-based strategy safely rules out PE in patients presenting to the ED with suspicion of PE. The researchers enrolled 1,916 patients (mean age, 44 years; 51% women) with low gestalt clinical probability of PE from 14 EDs in France.

Each center was randomly assigned to start with a 6-month control period, followed by a 6-month intervention period or the reverse. The PERC group consisted of 962 patients and the control group consisted of 954. The control group received usual care, while the intervention group received care based on PERC. In the PERC group, when all eight items of the rule were negative, a PE diagnosis was ruled out and further testing was not performed.

Results showed that more patients in the control group were diagnosed with PE at initial presentation to the ED than those in the PERC group (2.7% vs. 1.5%; difference = 1.3%; 95% CI, 0.1 to 2.7). During follow-up, one patient was diagnosed with PE in the PERC group, compared with no patients in the control group (difference = 0.1%; 95% CI, to 0.8).

A total of 13% of patients in the PERC group underwent CT pulmonary angiography, as did 23% of the control group (difference = 10%; 95% CI, 13 to 6). The rates for the median length of ED stay (mean reduction = 36 minutes; 95% CI, 4-68) and hospital admission (difference = 3.3%; 95% CI, 0.1-6.6) were significantly reduced among patients in the PERC group.

“Among very low-risk patients with suspected PE, randomization to a PERC strategy vs. conventional strategy did not result in an inferior rate of thromboembolic events over 3 months,” Freund and colleagues concluded. “These findings support the safety of PERC for very low-risk patients presenting to the [ED].” – by Alaina Tedesco

Disclosure: Freund reports receiving nonfinancial support from Sanofi and lecture fees from Bristol-Myers Squibb and AstraZeneca. Please see study for all other authors’ relevant financial disclosures.