Emergency Department, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Paris, France.
Emergency Department, Cliniques Universitaires St-Luc, Université Catholique de Louvain, Brussels, Belgium.
Acad Emerg Med. 2019 Jan;26(1):23-30. doi: 10.1111/acem.13508. Epub 2018 Aug 10.
This study aimed to determine the failure rate of a combination of the PERC and the YEARS rules for the diagnosis of pulmonary embolism (PE) in the emergency department (ED).
We performed a retrospective analysis of two European cohorts of emergency patients with low gestalt clinical probability of PE (PROPER and PERCEPIC). All patients we included were managed using a conventional strategy (D-dimer test, followed, if positive, by computed tomographic pulmonary angiogram (CTPA). We tested a diagnostic strategy that combined PERC and YEARS to rule out PE. The primary endpoint was a thromboembolic event diagnosed in the ED or at 3-months follow-up. Secondary endpoints included a thromboembolic event at baseline in the ED and a CTPA in the ED. Ninety-five percent confidence intervals (CIs) of proportions were calculated with the use of Wilson's continuity correction.
We analyzed 1,951 patients (mean ± SD age = 47 ± 18 years, 56% women) with an overall proportion of patients with PE of 3.5%. Both PERC and YEARS strategies were associated with 11 missed PE in the ED: failure rate 0.57 (95% CI = 0.32-1.02). At 3-month follow-up, the overall failure rate was 0.83% (95% CI = 0.51-1.35). Among the 503 patients who underwent a CTPA (26%), the use of the PERC-YEARS combination would have ruled out PE without CTPA in 249 patients (50% [95%CI = 45%-54%], absolute reduction 13% (95% CI = 11%-14%]).
The combination of PERC then YEARS was associated with a low risk of PE diagnostic failure and would have resulted in a relative reduction of almost half of CTPA.
本研究旨在确定 PERC 和 YEARS 规则联合用于诊断急诊科（ED）肺栓塞（PE）的失败率。
我们对两个具有低整体临床可能性的欧洲急诊患者队列（PROPER 和 PERCEPIC）进行了回顾性分析。所有纳入的患者均采用常规策略（D-二聚体检测，如果阳性，进行计算机断层肺动脉造影（CTPA））进行管理。我们测试了一种联合 PERC 和 YEARS 规则排除 PE 的诊断策略。主要终点是在 ED 或 3 个月随访时诊断出的血栓栓塞事件。次要终点包括 ED 基线时的血栓栓塞事件和 ED 中的 CTPA。使用 Wilson 连续性校正计算比例的 95%置信区间（CI）。
我们分析了 1951 名患者（平均年龄±标准差为 47±18 岁，56%为女性），总体 PE 患者比例为 3.5%。PERC 和 YEARS 两种策略在 ED 中均漏诊了 11 例 PE：失败率为 0.57（95%CI=0.32-1.02）。在 3 个月随访时，总体失败率为 0.83%（95%CI=0.51-1.35）。在接受 CTPA（26%）的 503 名患者中，使用 PERC-YEARS 联合策略可排除 249 例患者（50%[95%CI=45%-54%]，绝对减少 13%[95%CI=11%-14%]）而无需进行 CTPA。
PERC 后联合 YEARS 规则与 PE 诊断失败的低风险相关，并将导致 CTPA 的相对减少近一半。
