EBQ:PERC Rule Validation

Revision as of 22:22, 26 November 2013 by Ostermayer (talk | contribs) (inclusion and exclusion criteria added)
Under Review Journal Club Article
Kline J.A. et al. "Prospective multicenter evaluation of the pulmonary embolism rule-out criteria". Journal of Thrombosis and Haemostasis. 2008. 6(5):772–780.
PubMed Full text PDF

Clinical Question

Can risk stratification to low risk for pulmonary embolism (PE) in combination with a negative Pulmonary Embolism Rule Out Criteria (PERC) score reduce the probability of PE to less than 2%?

Conclusion

The combination of gestalt estimate of low suspicion for PE and PERC(-) reduces the probability of VTE to below 2% in about 20% of outpatients with suspected PE.

Design

This was a prospective, non-interventional, multicenter study of patients presenting to the emergency department (ED) in 12 hospitals in the USA and one in Christchurch, New Zealand. Investigators were trained in applying the PERC Rule

Population Studied

8138 patients from 12,213 eligible patients

Inclusion Criteria

Inclusion was triggered by an order for a test to establish objective evidence of a PE, written by or under the supervision of a board-certified emergency physician. The decision to order this test was based upon information obtained from the initial history and physical examination, and medical records immediately available in the ED. Objective Evidence included:

  1. Pulmonary vascular imaging study (CT angiography or VQ scan)
  2. D-dimer assay ordered to evaluate for possible PE

tests to simply exclude a deep venous thromboembolsm did not trigger patient enrollment

Exclusion Criteria

  1. Knowledge of a diagnostic positive pulmonary vascular imaging study performed within the previous 7 days.
  2. The patient indicated that the enrollment hospital was not his or her hospital system of choice for follow-up.
  3. Any circumstance that suggested that the patient would be lost to follow-up

.

Baseline Characteristics

Interventions

Outcomes

Primary Outcomes

Secondary Outcomes

Discussion

The PERC rule was derived in 2004 with the

PERC Rule:

  1. Is the patient older than 49 years of age?
  2. Is the pulse rate above 99 beats min)1?
  3. Is the pulse oximetry reading <95% while the patient breathes room air?
  4. Is there a present history of hemoptysis?
  5. Is the patient taking exogenous estrogen?
  6. Does the patient have a prior diagnosis of venous thromboembolism (VTE)?
  7. Has the patient had recent surgery or trauma? (Requiring endotracheal intubation or hospitalization in the previous 4 weeks.)
  8. Does the patient have unilateral leg swelling? (Visual observation of asymmetry of the calves.)

Criticism

Funding

CME

1

PERC stands for pulmonary embolism rule out criteria. In this study of 8138 patients, 1666 were found to be low clinical suspicion and PERC negative. The conclusion of the study was

patients with a medium probablity of PE and PERC negative can be discharged home
patients with a high probability of PE and PERC positive should be anticoagulated
patients with low probability of PE and PERC negative will have a probability of less than 2% of VTE
PERC failed to be predictive of PE in this cohort of patients

2

PERC consists of the following rules:

Age < 50, HR < 100, O2 sat >95%, No history of DVT/PE, No recent trauma or surgery, no hemoptysis, no exogenous estrogen, no unilateral leg swelling
Age < 65, HR < 100, O2 sat >95%, No history of DVT/PE, No recent trauma or surgery, no hemoptysis, no exogenous estrogen, no unilateral leg swelling
Age < 50, HR < 100, O2 sat >90%, No history of DVT/PE, No recent trauma or surgery, no hemoptysis, no exogenous estrogen, no unilateral leg swelling
Age < 50, HR < 60, O2 sat >95%, No history of DVT/PE, No recent trauma or surgery, no hemoptysis, no exogenous estrogen, no unilateral leg swelling

3

The utility of the PERC rule is greatest in which of the following patients suspected of a pulmonary embolism?

High pretest probability
Intermediate pretest probability
Low pretest probability


Related Publications

  • ACEP clinical policy; Ann Emerg Med 2011; 57:628-650.

Sources


Further Reading

  • Kline JA, Mitchell AM, Kabrhel C., Richman PB, Courtney DM. Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. J Thromb Haemost 2004; 2: 1247–55