Performance of clinical decision rules and clinical predictors to exclude pulmonary embolism in emergency department patients aged 35 and younger: a post-hoc analysis of three prospective cohorts.

Dorian TEISSANDIER, Anne-Laure Philippon, Héloise Bannelier, Pierre-Marie Roy, Andrea Penaloza, Sonia Jimenez, Yonathan Freund, Melanie Roussel, Pierre CATOIRE


Background: The pulmonary embolism (PE) rule-out criteria (PERC) score can safely rule out PE in emergency department (ED) patients if 8 clinical criteria are absent. An age-adapted modified PERC rule, the PERC-35 has been previously derived to safely increase the proportion of patients aged ≤ 35 years in whom PE can be safely excluded.

Objectives: To assess the performances of the original (PERC) and the PERC-35 rules for the exclusion of PE in the ED in patients aged ≤ 35 years. Secondary objectives included assessment of clinical predictors and other clinical decision rules.

Method: Post-hoc analysis of data from 3 European studies (PROPER, PERCEPIC, and MODIGLIANI), from which patients aged ≤ 35 years with suspicion of PE in the ED were included and followed-up for 3 months. Safety and efficiency of the PERC and PERC-35 were assessed with their failure rate (i.e missed PE) and proportion of patients with a negative score. The safety and efficiency of the YEARS and PEgED CDR were also assessed.

Results: 1235 patients were ≤ 35 years and were analyzed. There were 22 (1.8%, 95%CI 1.2-2.7%) diagnosed PE at 3 months. There were 6 (1.0%, 95%CI 0.5-2.2%) and 5 (0.9%, 95%CI 0.4-2.1%) missed PE with the PERC and PERC-35 score respectively. These scores allowed to rule out PE in 591 (48.2%, 95%CI 45.4% to 51.0%) and 554 (46.2%, 95%CI 43.4% to 49.0%) respectively. The failure rate of YEARS and PEgED were 0.4% (95%CI 0.1% to 1.1%) and 0.5% (95%CI 0.2% to 1.2%) respectively, with similar efficiency.

Conclusion: In patients aged ≤ 35 years, PERC and PERC-35 exhibited similar safety and efficiency profiles. However, the wide confidence interval reported in this study cannot confirm the safety of these rules in patients aged ≤ 35 years.

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