Background 

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.

Objective: 

To validate the safety of different diagnostic strategies and compare the efficacy in terms of chest imaging testing.

Design and patients: 

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).

Exposure: 

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.

Outcome measure and analysis: 

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.

Results: 

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.

Conclusion: 

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.

中文翻译：

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YEARS、PEGeD、4PEPS 或单项“PE 是最可能的诊断”策略在急诊科诊断肺栓塞的安全性和有效性比较：两项欧洲队列研究的事后分析

背景 

急诊科 (ED)诊断肺栓塞(PE)的最佳策略仍存在争议。为了减少成像测试的需要，最近使用升高的 D-二聚体阈值验证了一些规则。

客观的： 

验证不同诊断策略的安全性，并比较胸部影像学检查的疗效。

设计和患者： 

对法国和西班牙 3 个月 ED 随访中 3330 名没有高临床 PE 可能性的成年患者的个体数据进行事后分析（1916 名来自 PROPER 队列，1414 名来自 MODIGLIANI 队列）。

接触： 

如果不太可能发生 PE，则采用升高的 D-二聚体阈值的四种诊断策略。YEARS 结合肺栓塞排除标准 (PERC)肺栓塞分级 D-二聚体 (PEGeD) 结合 PERC 和 4 级肺栓塞概率评分 (4PEPS) 规则进行评估。还测试了修改后的简化 (MODS) 规则，其中简化的 YEARS 减少为“PE 是最可能的诊断吗”的唯一项目，并与 PERC 相结合。

结果测量和分析： 

主要结果是 3 个月时诊断为 PE 或深静脉血栓形成的患者的比例，根据测试的策略，这些患者无需胸部影像学检查即可排除 PE。如果失败率低于 1.85%，则确认策略的安全性。次要结果是根据每条规则使用成像测试。

结果： 

在 3330 名分析的患者中，150 名 (4.5%) 患有 PE。PERC+YEARS、PERC+PEGeD、4PEPS 和 MODS 规则的漏检 PE 数分别为 25、29、30 和 26，失败率为 0.75%（95% CI 0.51% 至 1.10%）、0.87%（分别为 0.61% 至 1.25%）、0.90%（0.63% 至 1.28%）和 0.78%（0.53% 至 1.14%）。规则之间的失败率没有显着差异。与 YEARS 相比，4PEPS 的胸部影像学使用率显着降低（14.9% 对 16.3%，差异 -1.4% [95%CI -2.1% 至 -0.8%]），影像学检查的比例没有差异。

结论： 

在这项对疑似 PE 患者的事后分析中，YEARS 和 PEGeD 结合 PERC 和 4PEPS 可以安全地排除 PE。修改后的简化 MODS 策略的安全性也得到了证实。策略之间的失败率没有显着差异。