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The Ideal PE Rule-Out? RCT – PERC+YEARS+Age-Adjusted D-Dimer

January 28, 2022

Written by Clay Smith

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In PERC positive patients, use of YEARS with age-adjusted D-dimer was noninferior to an age-adjusted D-dimer strategy alone.

Why does this matter?
This study answers so many questions! I think I am in love. It subjects YEARS to a rigorous RCT approach. It shows the performance of a combined PE rule-out criteria (PERC) + YEARS (or D-dimer) strategy. And it adds the wrinkle of using YEARS with an age-adjusted D-dimer. Let’s dig in!

I’ve been waiting YEARS for this…one of the PERCs of doing JournalFeed
This was a cluster randomized, crossover trial using a non-inferiority approach to compare two PE rule out strategies. The primary outcome was any venous thromboembolism (VTE) at 3 months.

Strategy 1: PERC first. If PERC positive, YEARS with an age-adjusted D-dimer*. CTPA if YEARS positive; no imaging if YEARS negative.

Strategy 2: PERC first. If PERC positive, age-adjusted D-dimer. CTPA if D-dimer ≥ age-adjusted cutoff; no imaging if less than cutoff.

They analyzed 1,217 patients and found 1 patient with VTE at 3 months in the PERC+YEARS group and 5 in the age-adjusted D-dimer group, which was well within the non-inferiority margin. There was a lower imaging rate in the YEARS group as well.

Knowledge gains: It’s safe to use a combined PERC plus YEARS or PERC plus D-dimer strategy. It’s safe to use YEARS with an age-adjusted D-dimer. Finally, PERC plus YEARS (with age-adjusted D-dimer) is noninferior to PERC plus age-adjusted D-dimer alone. This RCT is big!

Effect of a Diagnostic Strategy Using an Elevated and Age-Adjusted D-Dimer Threshold on Thromboembolic Events in Emergency Department Patients With Suspected Pulmonary Embolism: A Randomized Clinical Trial. JAMA. 2021 Dec 7;326(21):2141-2149. doi: 10.1001/jama.2021.20750.

* Normally, if one of the YEARS criteria is positive, then the D-dimer threshold goes from an upper limit of 1000 ng/mL down to 500. This study specified it goes from 1000 down to age-adjusted (<50y = 500; ≥50y D-dimer upper limit = age x 10; for example, 610 ng/mL if 61 years old).

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