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Grand Rounds
CMECNE

Results from the PROPER Trial: What are the Pulmonary Embolism Rule-Out Criteria (PERC) and Do They Really Work?

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Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. State what elements are involved in the PERC criteria to rule out PE and how they are scored
2. Discuss the findings of the PROPER trial and the role of the PERC criteria to rule out PE

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.

The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from March 12 2018 through 07/15/2022, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Read Disclaimer & Fine Print

BACKGROUND AND PURPOSE: 

  • The Pulmonary Embolism Rule-Out Criteria (PERC), an 8-item set of clinical criteria that serves as a predictive tool, has not been evaluated using a randomized trial (RCT)  
  • Each PERC criteria is scores as ‘0’ (no) or ‘+1’ (yes) and a 0 score indicates no further work-up is needed, with a <2% chance of PE  
  • Arterial oxygen saturation (Sp02) of ≤94% 
  • Pulse rate of at least 100/min 
  • Patient age of 50 years or older 
  • Unilateral leg swelling 
  • Hemoptysis 
  • Recent trauma or surgery 
  • Prior PE or deep venous thrombosis (DVT) 
  • Exogenous estrogen use 
  • Freund et al. (JAMA, 2018) aimed to validate the safety of the PERC-based strategy to exclude PE 

METHODS: 

  • A noninferiority, crossover cluster randomized controlled trial  
  • 14 EDs in France were involved for two 6-month periods separated by a 2-month washout period 
  • Patients who came to the ED with a suspicion of PE were eligible  
  • Inclusion criteria included  
    • new-onset presence or worsening of shortness of breath or chest pain  
    • Low probability of PE (clinician’s pre-test probability is <15%), based on physicians unstructured impression of risk (low, moderate, or high) 
      • Evidence that unstructured ‘gestalt’ performs as well as structured assessment 
  • Each center was randomized to determine sequence of intervention periods 
  • During the PERC period, the diagnosis of PE was excluded with a PERC score of 0, with no further follow up  
  • During the non-PERC period, usual diagnostic strategy was followed for low level of suspicion for PE 
    • D-dimer testing 
    • If D-dimer testing is positive, computed tomographic pulmonary angiography (CTPA) was performed 
    • If both negative, PE was ruled out and no further follow-up  
  • Primary outcome 
    •  Percentage of failure of the diagnostic strategy 
  • Secondary outcomes  
    • Rate of CTPA use  
    • Median length of stay in the emergency department 
    • Rate of hospital admission 

RESULTS: 

  • 1916 patients were cluster-randomized (mean age 44 years, 980 [51%] women) 
    • 962 were assigned to the PERC group 
    • 954 were assigned to the control group 
    • A total of 1,749 patients completed the trial 
  • A PE was diagnosed at initial presentation in  
    • 26 (2.7%) of patients in the control group vs 14 (1.5%) in the PERC group 
      • Mean difference, 1.3% (95% CI, −0.1% to 2.7%; P = .052) 
  • Primary outcome: One symptomatic PE (0.1%) at 3 months was diagnosed during follow-up in the PERC group vs none in the control group 
  • The proportion of patients undergoing CTPA in the PERC group vs control group was 13% vs 23%  
    • Mean difference, 9.7% (95% CI, 6.1% to 13.2% P < .001) 
  • In the PERC group 
    • Median length of emergency department stay rates were significantly reduced  
      • Mean reduction, 36 minutes (95% CI, 4 – 68)  
    • Hospital admission rates were significantly reduced (13% vs 16%)  
      • Mean difference, 3.3% (95% CI, 0.1% to 6.6%) 

CONCLUSION: 

  • Among low-risk patients for PE, using the PERC strategy did not result in an inferior rate of thromboembolic events over 3 months 
  • Authors point out limitations of this study, including low initial prevalence of PE at 2.7% and may be explained by low average age  
  • This study supports the use of PERC for very low-risk patients presenting at the emergency department 
  • NOTE: PERC HAS NOT BEEN VALIDATED IN PREGNANCY OR POSTPARTUM

Learn More – Primary Sources: 

Effect of the Pulmonary Embolism Rule-Out Criteria on Subsequent Thromboembolic Events Among Low-Risk Emergency Department Patients The PROPER Randomized Clinical Trial 

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Outcomes and Mode of Delivery in Pulmonary Hypertension
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Can a CT Scan Be Used In Pregnancy?

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Computer System Requirements

OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

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