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YEARS for suspected PE in pregnancy
Do you ever get up in the morning and think,
“I wish there was another clinical decision rule (CDR) for suspected PE”?
Or even,
“I wish someone would do another blog post/podcast about PE decision rules!”
No? Fair enough, neither do I – we already have Wells, PERC, D-dimer, age-adjusted D-dimer after all. But wait! Today’s paper has something new to offer us…
It describes the first clinical decision tool for PE that has been validated for use in pregnancy.
Why are pregnant women challenging?
Pregnant women are usually excluded from CDR studies so we are (rightly) nervous about applying decision rules to them. Clinical details are often of little help:
Main clinical signs of PE: breathlessness, leg swelling, tachycardia
Features of late pregnancy: breathlessness, leg swelling, tachycardia
We all know that pregnancy increases the risk of PE (although the risk is actually much greater in the post-partum period), and D-dimer rises as the pregnancy progresses.[1] This means it is difficult to ‘rule out’ PE and so we tend to over-investigate suspected cases.
The paper
Van der Pol LM, Tromeur C, Bistervels IM, et al. Pregnancy-adapted YEARS algorithm for diagnosis of suspected pulmonary embolism. N Engl J Med. 2019;380(12):1139-1149[2]
(Yes, I know. It's nearly a year since this was published. But I see that pregnancy-adapted YEARS is still relatively unknown and under-utilised in the ED, so forgive me for bringing attention to it here.)
A prospective multi-centre study of pregnant women with suspected PE. Nearly 500 patients from the Netherlands and France were enrolled. The authors applied the pregnancy-adapted YEARS algorithm (see diagram below) to each patient, and followed them up for 3 months to ensure no PEs were missed.
The overall incidence of PE was only 4.0% - very low but in line with similar studies. When compared to the hypothetical situation of imaging every patient, the algorithm excluded PE in 65% of 1st trimester, 46% of 2nd trimester, and 32% of 3rd trimester women.
Limitations
A truly robust study would require every patient to receive the gold standard imaging (CT) for the diagnosis or exclusion of PE, but this is unlikely to be in the best interests of the patients involved. Additionally, the efficient follow-up process of this trial (none were lost) meant that clinically relevant PEs were probably not missed.
The bottom line
The pregnancy-adapted YEARS algorithm is safe. Using it in low risk patients would lead to a reduction in the number of CTs requested.
Please tell me about this wonderful algorithm
Swaminathan A. Pregnancy-adapted YEARS algorithm for PE - ready for prime time?. 2019. REBEL EM. Available at https://rebelem.com/pregnancy-adapted-years-algorithm-for-pe-ready-for-prime-time/
So here it is. We now have a clinical decision rule for PE that has been validated for use in pregnancy!
More FOAMed on this topic
The SGEM: In the Pregnant Years – Diagnosing Pulmonary Embolism
REBEL EM: Pregnancy-Adapted YEARS Algorithm for PE – Ready for Prime Time?
EM Literature of Note: PE in Pregnancy & YEARS Protocol
Kline J, Kabrhel C. Emergency Evaluation for Pulmonary Embolism, Part 2: Diagnostic Approach. J Emerg Med [Internet] 2015;49(1):104–17. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25800524
van der, Tromeur C, Bistervels I, Ni A, van B, Bertoletti L, et al. Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism. N Engl J Med [Internet] 2019;380(12):1139–49. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30893534
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By Barrie StevensonDo you ever get up in the morning and think,
“I wish there was another clinical decision rule (CDR) for suspected PE”?
Or even,
“I wish someone would do another blog post/podcast about PE decision rules!”
No? Fair enough, neither do I – we already have Wells, PERC, D-dimer, age-adjusted D-dimer after all. But wait! Today’s paper has something new to offer us…
It describes the first clinical decision tool for PE that has been validated for use in pregnancy.
Why are pregnant women challenging?
Pregnant women are usually excluded from CDR studies so we are (rightly) nervous about applying decision rules to them. Clinical details are often of little help:
Main clinical signs of PE: breathlessness, leg swelling, tachycardia
Features of late pregnancy: breathlessness, leg swelling, tachycardia
We all know that pregnancy increases the risk of PE (although the risk is actually much greater in the post-partum period), and D-dimer rises as the pregnancy progresses.[1] This means it is difficult to ‘rule out’ PE and so we tend to over-investigate suspected cases.
The paper
Van der Pol LM, Tromeur C, Bistervels IM, et al. Pregnancy-adapted YEARS algorithm for diagnosis of suspected pulmonary embolism. N Engl J Med. 2019;380(12):1139-1149[2]
(Yes, I know. It's nearly a year since this was published. But I see that pregnancy-adapted YEARS is still relatively unknown and under-utilised in the ED, so forgive me for bringing attention to it here.)
A prospective multi-centre study of pregnant women with suspected PE. Nearly 500 patients from the Netherlands and France were enrolled. The authors applied the pregnancy-adapted YEARS algorithm (see diagram below) to each patient, and followed them up for 3 months to ensure no PEs were missed.
The overall incidence of PE was only 4.0% - very low but in line with similar studies. When compared to the hypothetical situation of imaging every patient, the algorithm excluded PE in 65% of 1st trimester, 46% of 2nd trimester, and 32% of 3rd trimester women.
Limitations
A truly robust study would require every patient to receive the gold standard imaging (CT) for the diagnosis or exclusion of PE, but this is unlikely to be in the best interests of the patients involved. Additionally, the efficient follow-up process of this trial (none were lost) meant that clinically relevant PEs were probably not missed.
The bottom line
The pregnancy-adapted YEARS algorithm is safe. Using it in low risk patients would lead to a reduction in the number of CTs requested.
Please tell me about this wonderful algorithm
Swaminathan A. Pregnancy-adapted YEARS algorithm for PE - ready for prime time?. 2019. REBEL EM. Available at https://rebelem.com/pregnancy-adapted-years-algorithm-for-pe-ready-for-prime-time/
So here it is. We now have a clinical decision rule for PE that has been validated for use in pregnancy!
More FOAMed on this topic
The SGEM: In the Pregnant Years – Diagnosing Pulmonary Embolism
REBEL EM: Pregnancy-Adapted YEARS Algorithm for PE – Ready for Prime Time?
EM Literature of Note: PE in Pregnancy & YEARS Protocol
Kline J, Kabrhel C. Emergency Evaluation for Pulmonary Embolism, Part 2: Diagnostic Approach. J Emerg Med [Internet] 2015;49(1):104–17. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25800524
van der, Tromeur C, Bistervels I, Ni A, van B, Bertoletti L, et al. Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism. N Engl J Med [Internet] 2019;380(12):1139–49. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30893534