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Retrospective validation of the pulmonary embolism rule-out criteria rule in ‘PE unlikely’ patients with suspected pulmonary embolism

Crane, Steven; Jaconelli, Tom; Eragat, Mazin

European Journal of Emergency Medicine: June 2018 - Volume 25 - Issue 3 - p 185–190
doi: 10.1097/MEJ.0000000000000442

Introduction Patients presenting to emergency departments (EDs) with suspected pulmonary embolism (PE) can be risk stratified and those who are deemed to be at low risk for PE usually undergo D-dimer testing. A negative D-dimer in this low-risk group rules out PE with a high degree of certainty because of its high sensitivity. The D-dimer is, however, a poorly specific test and positive results often lead to unnecessary radiological imaging (notably computed tomography pulmonary angiography). The Pulmonary Embolism Rule-Out Criteria (PERC) rule has been suggested as an alternative to D-dimer testing in these patients. This study looked at whether the PERC rule could safely replace the use of D-dimer in patients suspected of PE, but deemed ‘PE unlikely’ by the dichotomized Wells score in a UK ED setting.

Patients and methods This was a retrospective review of 986 patients with suspected PE who had a blood sample for D-dimer level taken. In patients deemed ‘PE unlikely’ (using the dichotomized Wells score), the diagnostic performance of the PERC rule was compared with a standard D-dimer level in the detection of PE at index presentation and up to 3 months afterwards.

Results Of the 986 patients, 940 patients were deemed ‘PE unlikely’ using the dichotomized Wells score. Three patients with confirmed PE would have been missed by the PERC rule compared with only one missed by the D-dimer test. In these patients, the sensitivity of the PERC rule for detecting PE was 91.4% [95% confidence interval (CI): 76.9–98.2%], with a negative likelihood ratio of 0.25 (95% CI: 0.08–0.73). However, the negative predictive value of the PERC rule was 99.1% (95% CI: 97.3–99.8%). In comparison, the sensitivity for the standard D-dimer test was 97.1% (95% CI: 85.1–99.9%), with a negative likelihood ratio of 0.04 (95% CI: 0.01–0.27). The negative predictive value for the standard D-dimer test was 99.8% (95% CI: 99.2–100%).

Conclusion The PERC rule has a high negative predictive value for excluding PE in patients presenting with suspected PE to the ED. However, the PERC rule may still miss around 8% of confirmed PE in patients who are deemed ‘PE unlikely’ by a dichotomized Wells score. Caution is advised in using the PERC rule as a substitute for the standard D-dimer test in all these patients.

Department of Emergency Medicine, York Hospital, York, UK

Correspondence to Steven Crane, MRCP, FRCEM, Department of Emergency Medicine, York Hospital, Wigginton Road, North Yorkshire, York YO31 8HE, UK Tel: +44 190 472 5616; fax +44 190 472 6858; e-mail:

Received June 6, 2016

Accepted November 24, 2016

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.