Bokobza J, Aubry A, Nakle N, Vincent-Cassy C, Pateron D, Devilliers C, Riou B, Ray P, Freund Y
Emergency Department, Hôpital Pitié-Salpêtrière, Assistance Publique - Hôpitaux de Paris (APHP), Paris, France.
Emergency Department, Hôpital Bicêtre, Assistance Publique - Hôpitaux de Paris (APHP), Le Kremlin-Bicêtre, France.
Am J Emerg Med. 2014 Jun;32(6):609-13. doi: 10.1016/j.ajem.2014.03.008. Epub 2014 Mar 17.
The Pulmonary Embolism Rule-out Criteria (PERC) score has shown excellent negative predictive value; however, its use in the European population with high prevalence of PE is controversial. In Europe, PERC is not part of routine practice. For low-risk patients, guidelines recommend D-dimer testing, followed if positive by imaging study. We aimed to study the rate of diagnosis of PE after D-dimer testing in PERC-negative patients that could have been discharged if PERC was applied.
This was a multicenter retrospective study in Paris, France. We included all patients with a suspicion of PE who had D-dimer testing in the emergency department, low pre-test probability, and a negative PERC score (that was retrospectively calculated). Patients with insufficient record to calculate PERC score were excluded. The primary end point was the rate of PE diagnosis before discharge in this population. Secondary end points included rate of invasive imaging studies and subsequent adverse events.
We screened 4301 patients who had D-dimer testing, 1070 of whom were PERC negative and could be analyzed. The mean age was 35 years and 46% were men. D-dimer was positive (>500 ng/L) in 167 (16%) of them; CTPA or V/Q scan was performed in 153 (14%) cases. PE was confirmed in 5 cases (total rate 0.5%, 95% confidence interval 0.1%-1.1%). Fifteen patients (1%) experienced non-severe adverse events.
D-dimer testing in PERC-negative patients led to a diagnosis of PE in 0.5% of them, with 15% of patients undergoing unnecessary irradiative imaging studies.
肺栓塞排除标准（PERC）评分已显示出出色的阴性预测价值；然而，其在肺栓塞患病率高的欧洲人群中的应用存在争议。在欧洲，PERC并非常规诊疗的一部分。对于低风险患者，指南建议进行D-二聚体检测，若结果为阳性则进一步进行影像学检查。我们旨在研究在PERC阴性患者中进行D-二聚体检测后肺栓塞的诊断率，若应用PERC这些患者本可出院。
这是一项在法国巴黎进行的多中心回顾性研究。我们纳入了所有在急诊科进行D-二聚体检测、预检概率低且PERC评分阴性（回顾性计算）的疑似肺栓塞患者。记录不充分无法计算PERC评分的患者被排除。主要终点是该人群出院前肺栓塞的诊断率。次要终点包括有创影像学检查率及随后的不良事件。
我们筛选了4301例进行D-二聚体检测的患者，其中1070例PERC阴性并可进行分析。平均年龄为35岁，46%为男性。其中167例（16%）D-二聚体呈阳性（>500 ng/L）；153例（14%）进行了CTPA或V/Q扫描。确诊肺栓塞5例（总发生率0.5%，95%置信区间0.1%-1.1%）。15例患者（1%）发生了非严重不良事件。
PERC阴性患者进行D-二聚体检测后，0.5%的患者被诊断为肺栓塞，15%的患者接受了不必要的放射性影像学检查。
