Wells ve PERC skorlarının bir göğüs hastalıkları hastanesi acil servisinde pulmoner emboliyi dışlamada etkinliği

Year 2020, Volume: 11 Issue: 2, 12 - 17, 21.03.2020

Pınar Akın Kabalak , Tuğba Çiçek Ömer Faruk Çiçek , Derya Kızılgöz Ülkü Yılmaz

https://doi.org/10.18663/tjcl.532339

Abstract

Amaç: Pulmoner emboli dışlama kriteri, emboli tanısını dışlamada kullanılan bir tanısal algoritmadır. Rutin pratiğimizde sıklıkla kullanılmasa da düşük klinik riske sahip hastalarda mevcut diğer algoritmalara göre daha iyi bir negative prediktif değere sahiptir. Bir göğüs hastalıkları acil servisinde PERC ve Wells skorunu birlikte değerlendirmeyi amaçladık.

Gereç ve Yöntemler: Hastane kayıt sistemi kullanılarak retsopektif olarak incelenen 163 hasta dahil edildi. Olguların hepsinde pulmoner emboli şüphesi ile görüntüleme yöntemi kullanılmıştı. PERC pozitif ve negatif olan her iki grupta emboli prevelansı hesaplandı. Ayrıc PERC skorunun her bir parametresi pulmoner emboli için risk olması açısından ayrı ayrı ele alındı.

Bulgular: Emboli tanısı alan olgularda PERC pozitiflik oranı % 82.4 saptandı. Pulmoner emboli olan ve olmayan gruplar arasında PERC pozitifliği açısından fark saptanmadı (p=0.336). Wells skoru orta-yüksek olan grupta yalancı pozitiflik oranı %36.1’di. Emboli tanısı alan grupta PERC negatiflik oranı %36.1 iken emboli saptanmayan grupta bu oran %17.6’ydı (p=0.75 and r=-0.025). PERC skor sensitivitesi %82.3, spesifitesi %19.6, PPV %63.1, NPV %40, yanlış pozitiflik oranı %36.8 ve yanlış negatiflik oranı %60 saptandı. Wells skoru orta-yüksek olan grupta 61 hastada emboli tanısı koyuldu ve bu hastaların 14’ünde PERC negatifti.

Sonuç: Çalışma sonuçlarımızdan yola çıkarak, Wells skoru ile birlikte ele alınsa bile PERC skoru emboli tanı sürecinde gereksiz görüntülemeyi azaltma konusunda yeterli etkinlikte görülmemiştir.

Keywords

Wells, PERC, Pulmoner embolizm

Efficiacy of Wells score and Pulmonary Embolism Rule Out Criteria(PERC) to exclude pulmonary embolism in a pulmonary emergency ward

Abstract

Aim: The Pulmonary Embolism Rule-out Criteria (PERC) rule is a diagnostic algorithm to exclude pulmonary embolism (PE). Even it is not widely used in routine practice, has better negative predictive value in low-risk populations among existed clinical assessment tests. We aimed to examine availability of PERC rules combined with Wells score in a pulmonary emergency ward.

Material and Methods: A retrospective hospitalized database study was conducted with 163 patients. All patients who underwent radiological investigation due to suspicious for PE were included. We calculated prevalence of PE in group of PERC negative and PERC positive. All PERC parameters were evaluated solely for risk of PE.

Results: PERC positivity was 82.4% in patients diagnosed with PE. There were no significant differences in terms of PERC positivity between PE+ and PE- groups (p=0.336). False positivity rate for moderate to high Wells score was 36.1%. Frequency of PERC negativity among PE negative patients was only %36.1 and %17.6 in PE positive group (p=0.75 and r=-0.025). The sensitivity of the PERC test was 82.3%, specificity 19.6%, PPV 63.1%, NPV 40%, false positivity rate 36.8% and false negativity rate 60%. Among patients with moderate to high wells, 61 patients were diagnosed PE and 14 of them were PERC negative.

Conclusion: Our study suggests that PERC scoring system even combined with Wells score does not sufficient enough to prevent unnecessary irradiative imaging studies in a pulmonary emergency ward.

Keywords

Wells, PERC, pulmonary embolism

References

• 1. Freund Y, Rousseau A, Guyot-Rousseau F et al. PERC rule to exclude the diagnosis of pulmonary embolism in emergency low-risk patients: study protocol for the PROPER randomized controlled study.Trials 2015; 16: 537
• 2. Theunissen JMG, Scholing C, van Hasselt WE, van der Maten J, ter Avest E. A retrospective analysis of the combined use of PERC rule and Wells score to exclude pulmonary embolism in the Emergency Department. Emerg Med J 2016; 33: 696–70.
• 3. Wiener RS, Schwartz LM, Woloshin S. When a test is too good: how CT pulmonary angiograms find pulmonary emboli that do not need to be found. BMJ 2013; 347: 3368.
• 4. Wiener RS, Schwartz LM, Woloshin S. Time trends in pulmonary embolism in the United States: evidence of overdiagnosis. Arch Intern Med 2011; 171: 831–37.
• 5. Kline JA, Mitchell AM, Kabrhel C, Richman PB, Courtney DM. Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. J Thromb Haemost 2004; 2: 1247–55.
• 6. 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: 592–93.
• 7. Kline JA, Courtney DM, Kabrhel C, Moore CL, Smithline HA, Plewa MC, Richman PB, O’Neil BJ, Nordenholz K. Prospective multicentre evaluation of the pulmonary embolism rule-out criteria. J Thromb Haemost 2008; 6: 772–80
• 8. Dachs RJ, Kulkarni D, Higgins GL III. The pulmonary embolism rule-out criteria rule in a community hospital ED: a retrospective study of its potential utility. Am J Emerg 2010; 5: 18.
• 9. 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: 188–89
• 10. Aydoğdu M, Topbaşi Sinanoğlu N et al.Wells score and Pulmonary Embolism Rule Out Criteria in preventing over investigation of pulmonary embolism in emergency departments. Tuberk Toraks 2014; 62: 12-21.
• 11. 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: 300-4.
• 12. Buchanan I, Teeples T, Carlson M, Steenblik J, Bledsoe J, Madsen T. Pulmonary Embolism Testing Among Emergency Department Patients Who Are Pulmonary Embolism Rule-out Criteria Negative. Acad Emerg Med 2017; 24: 1369-76.
• 13. 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: 609-13.