BACKGROUND: Over-investigation of low-risk patients with suspected pulmonary embolism (PE) represents a growing problem. The combination of gestalt estimate of low suspicion for PE, together with the PE rule-out criteria [PERC(-): age < 50 years, pulse < 100 beats min(-1), SaO(2) >or= 95%, no hemoptysis, no estrogen use, no surgery/trauma requiring hospitalization within 4 weeks, no prior venous thromboembolism (VTE), and no unilateral leg swelling], may reduce speculative testing for PE. We hypothesized that low suspicion and PERC(-) would predict a post-test probability of VTE(+) or death below 2.0%. METHODS: We enrolled outpatients with suspected PE in 13 emergency departments. Clinicians completed a 72-field, web-based data form at the time of test order. Low suspicion required a gestalt pretest probability estimate of <15%. The main outcome was the composite of image-proven VTE(+) or death from any cause within 45 days. RESULTS: We enrolled 8138 patients, 85% of whom had a chief complaint of either dyspnea or chest pain. Clinicians reported a low suspicion for PE, together with PERC(-), in 1666 patients (20%). At initial testing and within 45 days, 561 patients (6.9%, 95% confidence interval 6.5-7.6) were VTE(+), and 56 others died. Among the low suspicion and PERC(-) patients, 15 were VTE(+) and one other patient died, yielding a false-negative rate of 16/1666 (1.0%, 0.6-1.6%). As a diagnostic test, low suspicion and PERC(-) had a sensitivity of 97.4% (95.8-98.5%) and a specificity of 21.9% (21.0-22.9%). CONCLUSIONS: 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.
BACKGROUND: Over-investigation of low-risk patients with suspected pulmonary embolism (PE) represents a growing problem. The combination of gestalt estimate of low suspicion for PE, together with the PE rule-out criteria [PERC(-): age < 50 years, pulse < 100 beats min(-1), SaO(2) >or= 95%, no hemoptysis, no estrogen use, no surgery/trauma requiring hospitalization within 4 weeks, no prior venous thromboembolism (VTE), and no unilateral leg swelling], may reduce speculative testing for PE. We hypothesized that low suspicion and PERC(-) would predict a post-test probability of VTE(+) or death below 2.0%. METHODS: We enrolled outpatients with suspected PE in 13 emergency departments. Clinicians completed a 72-field, web-based data form at the time of test order. Low suspicion required a gestalt pretest probability estimate of <15%. The main outcome was the composite of image-proven VTE(+) or death from any cause within 45 days. RESULTS: We enrolled 8138 patients, 85% of whom had a chief complaint of either dyspnea or chest pain. Clinicians reported a low suspicion for PE, together with PERC(-), in 1666 patients (20%). At initial testing and within 45 days, 561 patients (6.9%, 95% confidence interval 6.5-7.6) were VTE(+), and 56 others died. Among the low suspicion and PERC(-) patients, 15 were VTE(+) and one other patient died, yielding a false-negative rate of 16/1666 (1.0%, 0.6-1.6%). As a diagnostic test, low suspicion and PERC(-) had a sensitivity of 97.4% (95.8-98.5%) and a specificity of 21.9% (21.0-22.9%). CONCLUSIONS: 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.
Authors: Arjun K Venkatesh; Jeffrey A Kline; D Mark Courtney; Carlos A Camargo; Michael C Plewa; Kristen E Nordenholz; Christopher L Moore; Peter B Richman; Howard A Smithline; Daren M Beam; Christopher Kabrhel Journal: Arch Intern Med Date: 2012-07-09
Authors: Christopher Kabrhel; D Mark Courtney; Carlos A Camargo; Michael C Plewa; Kristen E Nordenholz; Christopher L Moore; Peter B Richman; Howard A Smithline; Daren M Beam; Jeffrey A Kline Journal: Acad Emerg Med Date: 2010-06 Impact factor: 3.451
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Authors: Jeffrey A Kline; Melanie M Hogg; D Mark Courtney; Chadwick D Miller; Alan E Jones; Howard A Smithline; Nicole Klekowski; Randy Lanier Journal: Am J Respir Crit Care Med Date: 2010-05-06 Impact factor: 21.405
Authors: Tyler W Barrett; Kristin L Rising; M Fernanda Bellolio; M Kennedy Hall; Aaron Brody; Kenneth W Dodd; Mira Grieser; Phillip D Levy; Ali S Raja; Wesley H Self; Gail Weingarten; Erik P Hess; Judd E Hollander Journal: Acad Emerg Med Date: 2016-11-25 Impact factor: 3.451
Authors: Frances M Russell; Christopher L Moore; D Mark Courtney; Christopher Kabrhel; Howard A Smithline; Kristen E Nordenholz; Peter B Richman; Brian J O'Neil; Michael C Plewa; Daren M Beam; Ronald Mastouri; Jeffrey A Kline Journal: Am J Emerg Med Date: 2015-01-22 Impact factor: 2.469