Roussel Mélanie, Gorlicki Judith, Douillet Delphine, Moumneh Thomas, Bérard Laurence, Cachanado Marine, Chauvin Anthony, Roy Pierre-Marie, Freund Yonathan
Sorbonne Université, FHU IMPEC Improving Emergency Care, UMR 1166, IHU ICAN.
Emergency Department, Hôpital Pitié-Salpêtrière, Assistance Publique - Hôpitaux de Paris, Paris.
Eur J Emerg Med. 2022 Oct 1;29(5):341-347. doi: 10.1097/MEJ.0000000000000967. Epub 2022 Aug 4.
The optimal strategy for the diagnosis of pulmonary embolism (PE) in the emergency department (ED) remains debated. To reduce the need of imaging testing, several rules have been recently validated using an elevated D-dimer threshold.
To validate the safety of different diagnostic strategies and compare the efficacy in terms of chest imaging testing.
Post-hoc analysis of individual data of 3330 adult patients without a high clinical probability of PE in the ED followed-up at 3 months in France and Spain (1916 from the PROPER cohort, 1414 from the MODIGLIANI cohort).
Four diagnostic strategies with an elevated D-dimer threshold if PE is unlikely. The YEARS combined with Pulmonary Embolism Rule-out Criteria (PERC) the pulmonary embolism graduated D-dimer (PEGeD) combined with PERC and the 4-level pulmonary embolism probability score (4PEPS) rules were assessed. A modified simplified (MODS) rule with a simplified YEARS reduced to the sole item of "Is PE the most likely diagnosis" combined with PERC was also tested.
The primary outcome was the proportion of diagnosed PE or deep venous thrombosis at 3 months in patients in whom PE could have been excluded without chest imaging according to the tested strategy. The safety of a strategy was confirmed if the failure rate was less than 1.85%. The secondary outcome was the use of imaging testing according to each rule.
Among 3330 analyzed patients, 150 (4.5%) had a PE. The number of missed PEs were 25, 29, 30 and 26 for the PERC+YEARS, PERC+PEGeD, 4PEPS and MODS rules respectively, with a failure rate of 0.75% (95% CI 0.51% to 1.10%), 0.87% (0.61% to 1.25%), 0.90% (0.63% to 1.28%) and 0.78% (0.53% to 1.14%) respectively. There was no significant difference in the failure rate between rules. Except for a significant lower use of chest imaging for 4PEPS compared to YEARS (14.9% vs 16.3%, difference -1.4% [95%CI -2.1% to -0.8%]), there was no difference in the proportion of imaging testing.
In this post-hoc analysis of patients with suspicion of PE, YEARS and PEGeD combined with PERC, and 4PEPS were safe to exclude PE. The safety of the modified simplified MODS strategy was also confirmed. There was no significant difference of the failure rate between strategies.
急诊科（ED）中肺栓塞（PE）的最佳诊断策略仍存在争议。为减少影像学检查的需求，最近通过提高D-二聚体阈值验证了几条诊断规则。
验证不同诊断策略的安全性，并比较胸部影像学检查方面的有效性。
对法国和西班牙3330例在急诊科无PE高临床概率的成年患者的个体数据进行事后分析，随访3个月（1916例来自PROPER队列，1414例来自MODIGLIANI队列）。
如果PE可能性不大，则采用四种提高D-二聚体阈值的诊断策略。评估了YEARS联合肺栓塞排除标准（PERC）、肺栓塞分级D-二聚体（PEGeD）联合PERC以及四级肺栓塞概率评分（4PEPS）规则。还测试了一种简化的YEARS规则（简化为“PE是否为最可能诊断”这一唯一项目）联合PERC的改良简化（MODS）规则。
主要结局是根据所测试策略在无需胸部影像学检查即可排除PE的患者中，3个月时诊断为PE或深静脉血栓形成的比例。如果失败率低于1.85%，则确认一种策略的安全性。次要结局是根据每条规则进行影像学检查的情况。
在3330例分析患者中，150例（4.5%）患有PE。PERC+YEARS、PERC+PEGeD、4PEPS和MODS规则漏诊PE的例数分别为25例、29例、30例和26例，失败率分别为0.75%（95%CI 0.51%至1.10%）、0.87%（0.61%至1.25%）、0.90%（0.63%至1.28%）和0.78%（0.53%至1.14%）。各规则之间的失败率无显著差异。除4PEPS与YEARS相比胸部影像学检查的使用显著减少（14.9%对16.3%，差异-1.4%[9�%CI -2.1%至-0.8%]）外，影像学检查比例无差异。
在这项对疑似PE患者的事后分析中，YEARS、PEGeD联合PERC以及4PEPS用于排除PE是安全的。改良简化的MODS策略的安全性也得到了证实。各策略之间的失败率无显著差异。
