Prospective multicenter evaluation of the pulmonary embolism rule-out criteria

Jeffrey A. Kline, D. M. Courtney, C. Kabrhel, C. L. Moore, H. A. Smithline, M. C. Plewa, P. B. Richman, B. J. O'Neil, K. Nordenholz

Research output: Contribution to journalArticlepeer-review

308 Scopus citations


Backgound: 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 beatsmin-1, SaO2 ≥ 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.

Original languageEnglish (US)
Pages (from-to)772-780
Number of pages9
JournalJournal of Thrombosis and Haemostasis
Issue number5
StatePublished - May 2008
Externally publishedYes


  • Computerized tomography angiography
  • D-dimer
  • Decision rule
  • Decision-making
  • Diagnosis
  • Medical malpractice
  • Pulmonary embolism
  • Venous thromboembolism

ASJC Scopus subject areas

  • Hematology


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