Jossein Thibaut, Mazzolai Lucia, Lorenzo Hernández Alicia, Otálora Valderrama Sonia, Zdraveska Marija, Rivas Guerrero Agustina, López Ruiz Antonio, Di Micco Pierpaolo, Monreal Manuel, Hugli Olivier
Department of Emergency Medicine, Lausanne University Hospital, Lausanne, Switzerland.
Department of Angiology, Lausanne University Hospital, Lausanne, Switzerland.
Acad Emerg Med. 2025 Apr;32(4):414-425. doi: 10.1111/acem.15046. Epub 2024 Nov 24.
The use of a computed tomography pulmonary angiogram to diagnose pulmonary embolism (PE) has increased, leading not only to higher PE diagnoses but also to overdiagnosis and unnecessary radiation exposure, even in young patients despite a lower PE incidence. The aim of this study was to assess the failure rate of the pulmonary embolism rule-out criteria 35 (PERC-35) rule developed to reduce unnecessary testing in individuals aged ≤35 years among patients included in the Registro Informatizado de la Enfermedad TromboEmbolica Venosa (RIETE) Registry.
This retrospective cohort study used data from the RIETE Registry, an ongoing, international prospective registry of patients with objectively confirmed venous thromboembolism. The primary outcome was the missed PE rate using PERC-35 criteria. Secondary outcomes included the comparison of demographic and clinical characteristics, PE localization, treatment strategies, and outcomes between PERC-negative (PERC-35N) versus PERC-positive (PERC-35P) patients.
Of 58,918 adult patients with acute PE, the PERC-35 rule demonstrated a low missed PE rate of 0.35% (n = 204), with an upper 95% confidence interval [CI] of 0.40%. The missed rate was 7.0% (95% CI 6.0%-7.9%) in the 18- to 35-year subgroup. Compared to PERC-35P patients, PERC-35N patients were younger (mean age 28.4 years), with a lower body mass index, and included a higher proportion of pregnant/postpartum women. PERC-35N patients had a significantly lower rate of chronic diseases and presented less frequently with dyspnea or syncope but more often with chest pain. They showed lower rates of positive D-dimer and troponin levels. PERC-35N patients experienced fewer major bleeding episodes, similar recurrence rates of PE/deep vein thrombosis, and no deaths during anticoagulation.
The PERC-35 rule demonstrated a low failure rate to exclude PE in patients aged 18-35 years and could reduce imaging and radiation exposure in young patients with a low PE pretest probability if confirmed prospectively.
计算机断层扫描肺动脉造影用于诊断肺栓塞（PE）的情况有所增加，这不仅导致PE诊断率提高，还导致过度诊断和不必要的辐射暴露，即使在PE发病率较低的年轻患者中也是如此。本研究的目的是评估为减少年龄≤35岁个体的不必要检查而制定的肺栓塞排除标准35（PERC-35）规则在静脉血栓栓塞疾病信息登记处（RIETE）登记的患者中的失败率。
这项回顾性队列研究使用了RIETE登记处的数据，该登记处是一个正在进行的、对客观确诊的静脉血栓栓塞患者的国际前瞻性登记处。主要结局是使用PERC-35标准的漏诊PE率。次要结局包括比较PERC阴性（PERC-35N）与PERC阳性（PERC-35P）患者的人口统计学和临床特征、PE定位、治疗策略及结局。
在58918例急性PE成年患者中，PERC-35规则显示漏诊PE率较低，为0.35%（n = 204），95%置信区间上限为0.40%。在18至35岁亚组中，漏诊率为7.0%（95%置信区间6.0%-7.9%）。与PERC-35P患者相比，PERC-35N患者更年轻（平均年龄28.4岁）且体重指数更低，其中孕妇/产后妇女比例更高。PERC-35N患者的慢性病发生率显著更低，出现呼吸困难或晕厥的频率更低，但胸痛更为常见。他们的D-二聚体和肌钙蛋白水平阳性率更低。PERC-35N患者发生大出血事件的次数更少，PE/深静脉血栓形成的复发率相似，且抗凝期间无死亡病例。
PERC-35规则在18至35岁患者中排除PE的失败率较低，如果前瞻性得到证实，可减少PE预检概率较低的年轻患者的影像学检查和辐射暴露。
