New Recommendations for Evaluation of Patients with Suspected Acute Pulmonary Emboli

by Joseph Esherick, M.D., FAAFP, FHM

The ACP CPG on the evaluation of patients with a suspected acute PE has the following primary recommendations:

  • Use a validated clinical prediction rule to estimate pretest probability in patients with a possible acute PE (options include the Wells criteria or the Revised Geneva Score) to determine if patients are low-risk, intermediate-risk, or high-risk pretest probability for a PE
  • Do not order any lab or imaging tests for patients at low-risk who have a PERC score (pulmonary emboli rule-out criteria) of zero.  This rule essentially rules out PE in low-risk patients
  • Obtain a high-sensitivity D-dimer test for all patients at low-risk with a PERC score of 1 or more or have intermediate pretest probability.
  • Use age-adjusted D-dimer thresholds (10 ng/mL x age) for all patients above the age of 50.
  • Avoid ordering any imaging studies for patients with a high-sensitivity D-dimer level less than the age-based D-dimer threshold.
  • Obtain a multi-slice CT pulmonary angiogram for all patients with a high pretest probability, or an intermediate pretest probability with an elevated D-dimer test.  Clinical judgement should determine how to address patients with a low pretest probability with a PERC score of 1 or more and an elevated D-dimer test.

PERC tool is negative if the patient meets all of the following criteria:

  • Age<50
  • HR<100
  • SpO2>94% on room air
  • No unilateral leg swelling
  • No hemoptysis
  • No surgery or trauma in the past 4 weeks
  • No history of venous thromboembolism (VTE)
  • No estrogen use

Reference: Raja AS et al. Evaluation of Patients with Suspected Acute Pulmonary Embolism: Best Practice Advice from the Clinical Practice Guidelines Committee of the American College of Physicians. Annals of Internal Medicine. 2015; 163(9): 701-711.