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Written by Millie Cossé
The PERC-35 rule was designed to reduce unnecessary testing in individuals ≤35 years old but had an unacceptably high miss-rate.
Do they really need further testing?
We know from prior studies that the prevalence of pulmonary embolism is 10 times lower in patients aged 18-35 years than in patients >65 years, though imaging rates for PE between the two groups are almost the same (2.3% vs. 3.2). Therefore, a risk-stratification score specifically suited to young patients would be helpful to reduce over-imaging rates.
Enter PERC-35, a modification of the PERC rule, which changes the age cutoff from <50 years to ≤35 years and replaces pulse ≤100 with temperature ≤38˚C.
This retrospective cohort study utilized data from the RIETE registry to evaluate the failure rate of the PERC-35. All patients in the RIETE registry had been objectively diagnosed with a pulmonary embolism. A total of 58,918 adult patients with acute PE were included in the study, and PERC-35 performed well when applied to all adult patients. However, when considering how it performed when applied to the 2,935 patients aged 18-35 years, PERC-35 had a failure rate of 7.0% (95%CI 6.0-7.9).
How will this change my practice?
The authors concluded that the PERC-35 rule had a low miss rate when applied to ALL patients in the RIETE database, but when the PERC-35 rule was applied to patients in the database aged 18-35, the authors found a staggering 7% failure rate. Therefore, I will not be implementing this tool in my practice.
Another Spoonful
From senior author Olivier Hugli: “PERC-35 is probably safe to use if applied to a population with the same age distribution as the one used in the RIETE registry. Age was the single item for which patients failed the rule in this population. However, if the age distribution is different, with a younger population, then it should be avoided.”
Source
Failure rate of the pulmonary embolism rule-out criteria rule for adults 35 years or younger: Findings from the RIETE Registry. Acad Emerg Med. 2024 Nov 24. doi: 10.1111/acem.15046. Epub ahead of print. PMID: 39582095
