Buchanan Ian, Teeples Troy, Carlson Margaret, Steenblik Jacob, Bledsoe Joseph, Madsen Troy
Division of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT.
Emergency Department, Intermountain Medical Center, Murray, UT.
Acad Emerg Med. 2017 Nov;24(11):1369-1376. doi: 10.1111/acem.13270. Epub 2017 Sep 19.
Previous studies have demonstrated that rates of pulmonary embolism (PE) testing have increased without a concomitant decrease in PE-related mortality. The Pulmonary Embolism Rule-out Criteria (PERC) intend to reduce testing for PE in the emergency department (ED) by identifying low-risk patients ("PERC-negative") who do not require D-dimer, computed tomography pulmonary angiogram (CTPA), or ventilation/perfusion (VQ) scan for PE. This study assesses PE testing rates among PERC-negative patients presenting to an urban academic ED.
We prospectively enrolled a convenience sample of ED patients with chest pain and/or shortness of breath presenting between June 2010 and December 2015. We recorded baseline variables at the time of ED presentation, information on testing performed in the ED, and the diagnosis of acute PE during the ED visit. We classified patients as PERC-positive or PERC-negative utilizing baseline variables and clinical characteristics.
Of the 3,024 study patients, 54.8% (95% confidence interval = 53%-56.5%) were female and the mean age was 51.7 (51.1-52.3) years. A total of 17.5% (16.2%-18.9%) of study patients were PERC-negative and 33.7% (32%-35.4%) of all patients underwent testing for PE. A total of 25.5% (22%-29.4%) of PERC-negative patients had PE testing compared to 35.4% (33.6%-37.3%) of PERC-positive patients (p < 0.001). A total of 7.2% (5.3%-9.7%) of PERC-negative patients had advanced imaging without a D-dimer compared to 19.2% (17.8%-20.8%) of PERC-positive patients (p < 0.001). In multivariate analysis, factors associated with PE testing in PERC-negative patients included age, white non-Hispanic race/ethnicity, pleuritic chest pain, and a complaint of both chest pain and shortness of breath. Two PERC-negative patients (0.4%) were diagnosed with an acute PE in the ED compared to 2.2% of PERC-positive patients (p = 0.008). The overall testing yield for PE was 1.6% (0.4%-9.2%) among PERC-negative patients versus 6.3% (4.9%-8.1%) among PERC-positive patients (p = 0.017).
In an academic ED, a significant proportion of PERC-negative patients underwent testing for PE, including CT or VQ scan without D-dimer risk stratification. Future areas of research may include evaluating factors that lead clinicians to pursue PE testing in PERC-negative patients and implementing clinical pathways to minimize practice variability among these patients.
既往研究表明，肺栓塞（PE）检测率有所上升，但与PE相关的死亡率并未随之下降。肺栓塞排除标准（PERC）旨在通过识别不需要进行D - 二聚体检测、计算机断层扫描肺动脉造影（CTPA）或通气/灌注（VQ）扫描以排除PE的低风险患者（“PERC阴性”），来减少急诊科（ED）对PE的检测。本研究评估了就诊于城市学术性急诊科的PERC阴性患者中的PE检测率。
我们前瞻性纳入了2010年6月至2015年12月期间因胸痛和/或呼吸急促就诊于急诊科的便利样本患者。我们记录了患者在急诊科就诊时的基线变量、在急诊科进行的检测信息以及急诊就诊期间急性PE的诊断情况。我们利用基线变量和临床特征将患者分类为PERC阳性或PERC阴性。
在3024例研究患者中，54.8%（95%置信区间 = 53% - 56.5%）为女性，平均年龄为51.7（51.1 - 52.3）岁。共有17.5%（16.2% - 18.9%）的研究患者为PERC阴性，所有患者中有33.7%（32% - 35.4%）接受了PE检测。在PERC阴性患者中，共有25.5%（22% - 29.4%）进行了PE检测，而PERC阳性患者中这一比例为35.4%（33.6% - 37.3%）（p < 0.001）。在PERC阴性患者中，共有7.2%（5.3% - 9.7%）未进行D - 二聚体检测就接受了高级影像学检查，而PERC阳性患者中这一比例为19.2%（17.8% - 20.8%）（p < 0.001）。在多因素分析中，与PERC阴性患者进行PE检测相关的因素包括年龄、非西班牙裔白人种族/族裔、胸膜炎性胸痛以及胸痛和呼吸急促同时存在的主诉。在急诊科，2例（0.4%）PERC阴性患者被诊断为急性PE，而PERC阳性患者中这一比例为2.2%（p = 0.008）。PERC阴性患者中PE的总体检测阳性率为1.6%（0.4% - 9.2%），而PERC阳性患者中为6.3%（4.9% - 8.1%）（p = 0.017）。
在学术性急诊科中，相当一部分PERC阴性患者接受了PE检测，包括未进行D - 二聚体风险分层的CT或VQ扫描。未来的研究领域可能包括评估导致临床医生对PERC阴性患者进行PE检测的因素，以及实施临床路径以尽量减少这些患者之间的实践差异。
