Episode 148.0 – ACEP VTE Clinical Policy 2018

Show Notes

Take Home Points

1. The PERC risk stratifies low risk PE patients (~10%) to a level low enough (1.9%) as to obviate the need for additional testing.
2. Age-adjusted D-dimers are ready for use and it doesn’t matter if your assay uses FEU (cutoff 500) or DDU (cutoff 250). For FEU use an upper limit of 10 X age and for DDU use an upper limit of 5 X age.
3. For now, subsegmental PEs should continue to routinely be anticoagulated even in the absence of a DVT. Keep an eye out for more research on this area.
4. Although outpatient management of select PE patients (using sPESI or Hestia criteria) may be standard practice, the evidence wasn’t strong enough for ACEP to give it’s support
5. Patients with DVT can be started on a NOAC and discharged from the ED

sPESI Tool (MDCalc.com)

PERC Decision Tool (MDCalc.com)

Read More

• REBEL EM: ACEP Clinical Policy on Acute VTE 2018
• Core EM: PE Rule-Out Criteria RCT
• Core EM: Age-Adjusted D-dimer (Using D-dimer Units)
• Core EM: Age Adjusted D-dimer in PE – The ADJUST-PE Trial
• REBEL EM: Is It PROER to PERC It Up

References

1. ACEP Clinical Policies Subcommittee. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Suspected Acute Venous Thromboembolic Disease. Ann Emerg Med 2018; 71(5): e59-109. PMID: 29681319
2. Jaconelli T, Eragat M, Crane S. Can an age-adjusted D-dimer level be adopted in managing venous thromboembolism in the emergency department? A retrospective cohort study. European journal of emergency medicine : official journal of the Eur Soc Emerg Med. 2017. PMID: 28079562
3. Freund Y et al. Effect of the Pulmonary Embolism Rule-Out Criteria on Subsequent Thromboembolic Events Among Low-Risk Emergency Department Patients: The PROPER Randomized Clinical Trial. JAMA 2018; 319(6): 559-66. PMID: 29450523