Jornal Vascular Brasileiro
Jornal Vascular Brasileiro
Original Article

Application of the pulmonary embolism rule-out criteria (PERC rule) and age-adjusted D-Dimer in patients undergoing computed tomography pulmonary angiography for diagnosis of pulmonary embolism

Aplicação dos critérios PERC e do D-Dímero ajustado para idade em pacientes submetidos a angiotomografia pulmonar para o diagnóstico de embolia pulmonar

John Jaime Sprockel Diaz; Luz Amaya Veronesi Zuluaga; Diana Carolina Coral Coral; Diana Marcela Fierro Rodriguez

Downloads: 2
Views: 352


Abstract: Background: Diagnosis of pulmonary embolism (PE) constitutes a challenge for practitioners. Current practice involves use of pre-test probability prediction rules. Several strategies to optimize this process have been explored.

Objectives: To explore whether application of the pulmonary embolism rule-out criteria (PERC rule) and age-adjusted D-dimer (DD) would have reduced the number of computed tomography pulmonary angiography (CTPA) examinations performed in patients with suspected PE.

Methods: A retrospective cross-sectional study of adult patients taken for CTPA under suspicion of PE in 2018 and 2020. The PERC rule and age-adjusted DD were applied. The number of cases without indications for imaging studies was estimated and the operational characteristics for diagnosis of PE were calculated.

Results: 302 patients were included. PE was diagnosed in 29.8%. Only 27.2% of ‘not probable’ cases according to the Wells criteria had D-dimer assays. Age adjustment would have reduced tomography use by 11.1%, with an AUC of 0.5. The PERC rule would have reduced use by 7%, with an AUC of 0.72.

Conclusions: Application of age-adjusted D-dimer and the PERC rule to patients taken for CTPA because of suspected PE seems to reduce the number of indications for the procedure.


pulmonary embolism, fibrin degradation product, diagnosis, clinical decision rules, diagnostic tests


Resumo: Contexto: O diagnóstico de embolia pulmonar (EP) representa um desafio para o profissional. A prática atual envolve o uso de modelos de previsão de probabilidade pré-teste e, para otimizar esse processo, várias estratégias têm sido exploradas.

Objetivos: Investigar se a aplicação dos critérios de exclusão de EP (pulmonary embolism rule-out criteria, PERC) e do D-dímero (DD) ajustado para idade diminui o número de angiografias computadorizadas (ATCs) pulmonares realizadas em pacientes com suspeita de EP.

Métodos: Estudo transversal retrospectivo com pacientes adultos submetidos a ATC pulmonar com suspeita de EP em 2018 e 2020. Foram aplicados os critérios PERC e o DD ajustado para idade. Foi estimado o número de casos não indicados para exames de imagem, e foram calculadas as características operacionais para o diagnóstico de EP.

Resultados: Foram incluídos 302 pacientes, dos quais 29,8% apresentaram diagnóstico de EP. Apenas 27,2% dos casos não prováveis ​​de acordo com os critérios de Wells apresentaram DD; o ajuste implicou em uma diminuição de ACTs de 11,1%, com área sob a curva de 0,5. Os critérios PERC diminuiriam em 7%, com área sob a curva de 0,72.

Conclusões: A aplicação do DD ajustado para idade e dos critérios PERC em pacientes submetidos a ATC pulmonar por suspeita de EP parece diminuir a indicação para tais exames.


embolia pulmonar, produtos de degradação da fibrina, diagnóstico, regras de decisão clínica, testes diagnósticos


1 Konstantinides SV, Torbicki A, Agnelli G, et al. ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2014;35(43):3033-80.

2 White RH. The epidemiology of venous thromboembolism. Circulation. 2003;107(23, Suppl Suppl 1):I4-8. PMid:12814979.

3 Dennis R, Arboleda MN, Rodriguez MN, Salazar MS, Posada PS. Estudio nacional sobre tromboembolismo venoso en población hospitalaria en Colombia. Acta Med Colomb. 1996;21(2):55-63.

4 Dennis RJ, Rojas MX, Molina Á, et al. Curso clínico y supervivencia en embolia pulmonar: Resultados del registro multicéntrico colombiano (EMEPCO). Acta Med Colomb. 2008;33:111-6.

5 Schattner A. Computed tomographic pulmonary angiography to diagnose acute pulmonary embolism: the good, the bad, and the ugly: comment on “The prevalence of clinically relevant incidental findings on chest computed tomographic angiograms ordered to diagnose pulmonary embolism”. Arch Intern Med. 2009;169(21):1966-8. PMid:19933957.

6 Penaloza A, Verschuren F, Dambrine S, Zech F, Thys F, Roy PM. Performance of the Pulmonary Embolism Rule-out Criteria (the PERC rule) combined with low clinical probability in high prevalence population. Thromb Res. 2012;129(5):e189-93. PMid:22424852.

7 Ghali WA, Cornuz J, Perrier A. New methods for estimating pretest probability in the diagnosis of pulmonary embolism. Curr Opin Pulm Med. 2001;7(5):349-53. PMid:11584188.

8 van Belle A, Büller HR, Huisman MV, et al. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. JAMA. 2006;295(2):172-9. PMid:16403929.

9 Glober N, Tainter CR, Brennan J, et al. Use of the d-dimer for Detecting Pulmonary Embolism in the Emergency Department. J Emerg Med. 2018;54(5):585-92. PMid:29502865.

10 Kline JA, Wells PS. Methodology for a rapid protocol to rule out pulmonary embolism in the emergency department. Ann Emerg Med. 2003;42(2):266-75. PMid:12883516.

11 Investigators P. Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). JAMA. 1990;263(20):2753-9. PMid:2332918.

12 Wells PS, Anderson DR, Rodger M, et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer. Ann Intern Med. 2001;135(2):98-107. PMid:11453709.

13 Righini M, Goehring C, Bounameaux H, Perrier A. Effects of age on the performance of common diagnostic tests for pulmonary embolism. Am J Med. 2000;109(5):357-61. PMid:11020391.

14 Nobes J, Messow CM, Khan M, Hrobar P, Isles C. Age-adjusted D-dimer excludes pulmonary embolism and reduces unnecessary radiation exposure in older adults: retrospective study. Postgrad Med J. 2017;93(1101):420-4. PMid:27941007.

15 Le Gal G, Bounameaux H. Diagnosing pulmonary embolism: running after the decreasing prevalence of cases among suspected patients. J Thromb Haemost. 2004;2(8):1244-6. PMid:15304024.

16 Hogg K, Dawson D, Kline J. Application of pulmonary embolism rule-out criteria to the UK Manchester Investigation of Pulmonary Embolism Diagnosis (MIOPED) study cohort. J Thromb Haemost. 2005;3(3):592-3. PMid:15748259.

17 Hall WB, Truitt SG, Scheunemann LP, et al. The prevalence of clinically relevant incidental findings on chest computed tomographic angiograms ordered to diagnose pulmonary embolism. Arch Intern Med. 2009;169(21):1961-5. PMid:19933956.

18 Sharp AL, Vinson DR, Alamshaw F, Handler J, Gould MK. An age-adjusted D-dimer threshold for emergency department patients with suspected pulmonary embolus: accuracy and clinical implications. Ann Emerg Med. 2016;67(2):249-57. PMid:26320520.

19 Douma RA, le Gal G, Söhne M, et al. Potential of an age adjusted D-dimer cut-off value to improve the exclusion of pulmonary embolism in older patients: a retrospective analysis of three large cohorts. BMJ. 2010;340(3):c1475. PMid:20354012.

20 Polo Friz H, Pasciuti L, Meloni DF, et al. A higher d-dimer threshold safely rules-out pulmonary embolism in very elderly emergency department patients. Thromb Res. 2014;133(3):380-3. PMid:24439678.

21 Altmann MM, Wrede CE, Peetz D, Höhne M, Stroszczynski C, Herold T. Age-dependent d-dimer cut-off to avoid unnecessary CT-exams for ruling-out pulmonary embolism. Röfo Fortschr Geb Röntgenstr Nuklearmed. 2015;187(9):795-800. PMid:26308535.

22 Sharp AL, Vinson DR, Alamshaw F, Handler J, Gould MK. An age-adjusted d-dimer threshold for emergency department patients with suspected pulmonary embolus: accuracy and clinical implications. Ann Emerg Med. 2016;67(2):249-57. PMid:26320520.

23 Flores J, García de Tena J, Galipienzo J, et al. Clinical usefulness and safety of an age-adjusted D-dimer cutoff levels to exclude pulmonary embolism: a retrospective analysis. Intern Emerg Med. 2016;11(1):69-75. PMid:26345535.

24 Righini M, Le Gal G, Perrier A, Bounameaux H. More on: clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. J Thromb Haemost. 2005;3(1):188-9, author reply 190-1. PMid:15634291.

25 Wolf SJ, McCubbin TR, Nordenholz KE, Naviaux NW, Haukoos JS. Assessment of the pulmonary embolism rule-out criteria rule for evaluation of suspected pulmonary embolism in the emergency department. Am J Emerg Med. 2008;26(2):181-5. PMid:18272098.

26 Kline JA, Courtney DM, Kabrhel C, et al. Prospective multicenter evaluation of the pulmonary embolism rule-out criteria. J Thromb Haemost. 2008;6(5):772-80. PMid:18318689.

27 Hugli O, Righini M, Le Gal G, et al. The pulmonary embolism rule-out criteria (PERC) rule does not safely exclude pulmonary embolism. J Thromb Haemost. 2011;9(2):300-4. PMid:21091866.

28 Dachs RJ, Kulkarni D, Higgins GL 3rd. The pulmonary embolism rule-out criteria rule in a community hospital ED: a retrospective study of its potential utility. Am J Emerg Med. 2011;29(9):1023-7. PMid:20708891.

29 Crichlow A, Cuker A, Mills AM. Overuse of computed tomography pulmonary angiography in the evaluation of patients with suspected pulmonary embolism in the emergency department. Acad Emerg Med. 2012;19(11):1219-26. PMid:23167851.

30 Aydoğdu M, Topbaşi Sinanoğlu N, Doğan NO, et al. Wells score and Pulmonary Embolism Rule Out Criteria in preventing over investigation of pulmonary embolism in emergency departments. Tuberk Toraks. 2014;62(1):12-21. PMid:24814073.

31 Bokobza J, Aubry A, Nakle N, et al. Pulmonary Embolism Rule-out Criteria vs D-dimer testing in low-risk patients for pulmonary embolism: a retrospective study. Am J Emerg Med. 2014;32(6):609-13. PMid:24736129.

32 Bozarth AL, Bajaj N, Wessling MR, Keffer D, Jallu S, Salzman GA. Evaluation of the pulmonary embolism rule-out criteria in a retrospective cohort at an urban academic hospital. Am J Emerg Med. 2015;33(4):483-7. PMid:25745794.

33 Stojanovska J, Carlos RC, Kocher KE, et al. CT pulmonary angiography: using decision rules in the emergency department. J Am Coll Radiol. 2015;12(10):1023-9. PMid:26435116.

34 Carrier M, Righini M, Wells PS, et al. Subsegmental pulmonary embolism diagnosed by computed tomography: incidence and clinical implications. A systematic review and meta-analysis of the management outcome studies. J Thromb Haemost. 2010;8(8):1716-22. PMid:20546118.

35 Dunn KL, Wolf JP, Dorfman DM, Fitzpatrick P, Baker JL, Goldhaber SZ. Normal D-dimer levels in emergency department patients suspected of acute pulmonary embolism. J Am Coll Cardiol. 2002;40(8):1475-8. PMid:12392839.

36 Parker MS, Hui FK, Camacho MA, Chung JK, Broga DW, Sethi NN. Female breast radiation exposure during CT pulmonary angiography. AJR Am J Roentgenol. 2005;185(5):1228-33. PMid:16247139.

37 Singh J, Daftary A. Iodinated contrast media and their adverse reactions. J Nucl Med Technol. 2008;36(2):69-74, quiz 76-7. PMid:18483141.

38 Perrier A, Nendaz MR, Sarasin FP, Howarth N, Bounameaux H. Cost-effectiveness analysis of diagnostic strategies for suspected pulmonary embolism including helical computed tomography. Am J Respir Crit Care Med. 2003;167(1):39-44. PMid:12502474.

39 Gouveia M, Pinheiro L, Costa J, Borges M. Pulmonary embolism in Portugal: epidemiology and in-hospital mortality. Acta Med Port. 2016;29(7-8):432-40. PMid:27914153.

40 Kara H, Degirmenci S, Bayir A, Ak A. Pulmonary embolism severity index, age-based markers and evaluation in the emergency department. Acta Clin Belg. 2015;70(4):259-64. PMid:25819307.

41 Alhassan S, Sayf AA, Arsene C, Krayem H. Suboptimal implementation of diagnostic algorithms and overuse of computed tomography-pulmonary angiography in patients with suspected pulmonary embolism. Ann Thorac Med. 2016;11(4):254-60. PMid:27803751.

Submitted date:

Accepted date:

Sociedade Brasileira de Angiologia e Cirurgia Vascular (SBACV)"> Sociedade Brasileira de Angiologia e Cirurgia Vascular (SBACV)">
644a801da95395404779be12 jvb Articles
Links & Downloads

J Vasc Bras

Share this page
Page Sections