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Multicenter Evaluation of the YEARS Criteria in Emergency Department Patients Evaluated for Pulmonary Embolism
Christopher Kabrhel1, Astrid Van Hylckama Vlieg2, Alona Muzikanski3
1Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA.
Insights
The YEARS criteria, using adjusted D-dimer thresholds, can safely reduce imaging for pulmonary embolism (PE) in low-risk patients. This approach may increase missed PE cases but maintains a nearly 100% negative predictive value.
Area of Science:
- Emergency Medicine
- Diagnostic Imaging
- Cardiology
Background:
- Pulmonary embolism (PE) diagnosis often involves imaging, increasing costs and risks.
- The YEARS criteria, utilizing specific clinical questions and a variable D-dimer threshold, have shown promise in reducing imaging needs for PE in the Netherlands.
- This study aimed to evaluate the YEARS criteria's applicability and safety in a U.S. emergency department setting.
Purpose of the Study:
- To assess the effectiveness of the YEARS criteria with adjusted D-dimer thresholds in reducing imaging for suspected pulmonary embolism (PE) in U.S. patients.
- To compare the diagnostic performance of the YEARS criteria against standard D-dimer thresholds for ruling out PE.
- To determine the impact of the YEARS criteria on the rate of missed PE diagnoses and overall negative predictive value (NPV).
Main Methods:
- A prospective, observational study was conducted across 17 U.S. emergency departments.
- Data collected included patient demographics, YEARS criteria assessment (clinical signs of DVT, hemoptysis, alternative diagnoses likelihood), and D-dimer levels.
- Variable D-dimer thresholds were applied: <1000 mg/dL for YEARS-negative patients and <500 mg/dL for YEARS-positive patients.
Main Results:
- Out of 1,789 patients, 84 (4%) had PE. The YEARS criteria with adjusted D-dimer thresholds reduced the proportion of patients referred for imaging from 53% to 67-69%.
- The number of missed PE cases slightly increased from 0.2% (standard threshold) to 0.5% (YEARS adjusted).
- Sensitivity for both adjusted thresholds was 92.9%, while the negative predictive value (NPV) remained nearly 100% across all approaches.
Conclusions:
- Adjusting D-dimer thresholds based on pretest probability using the YEARS criteria can decrease the need for imaging in suspected PE evaluations.
- While this approach may lead to a slight increase in missed PE diagnoses, it does not compromise the high negative predictive value.
- The findings suggest the potential for safe implementation of the YEARS criteria in U.S. emergency departments to optimize PE diagnostic strategies.
Background:
It may be possible to safely rule out pulmonary embolism (PE) in patients with low pretest probability (PTP) using a higher than standard D-dimer threshold. The YEARS criteria, which include three questions from the Wells PE score to identify low-PTP patients and a variable D-dimer threshold, was recently shown to decrease the need for imaging to rule out PE by 14% in a multicenter study in the Netherlands. However, the YEARS approach has not been studied in the United States.
Methods:
This study was a prospective, observational study of consecutive adult patients evaluated for PE in 17 U.S. emergency departments. Prior to diagnostic testing, we collected the YEARS criteria: "Does the patient have clinical signs or symptoms of DVT?" "Does the patient have hemoptysis?" "Are alternative diagnoses less likely than PE?" with YEARS (+) being any "yes" response. A negative D-dimer was <1000 mg/dL for YEARS (-) patients and <500 mg/dL for YEARS (+) patients. We calculated test characteristics and used Fisher's exact test to compare proportions of patients who would have been referred for imaging and patients who would have had PE "missed."
Results:
Of 1,789 patients, 84 (4%) had PE, 1,134 (63%) were female, 1,038 (58%) were white, and mean (±SD) age was 48 (±16) years. Using the standard D-dimer threshold, 940 (53%) would not have had imaging, with two (0.2%, 95% confidence interval [CI] = 0.02%-0.60%) missed PE. Using YEARS adjustment, 1,204 (67%, 95% CI = 65%-69%) would not have been referred for imaging, with six (0.5%, 95% CI = 0.18%-1.1%) missed PE, and using "alternative diagnoses less likely than PE" adjustment, 1,237 (69%, 95% CI = 67%-71%) would not have had imaging with six (0.49%, 95% CI = 0.18%-1.05%) missed PE. Sensitivity was 97.6% (95% CI = 91.7%-99.7%) for the standard threshold and 92.9% (95% CI = 85%-97%) for both adjusted thresholds. Negative predictive value (NPV) was nearly 100% for all approaches.
Conclusions:
D-dimer adjustment based on PTP may result in a reduced need for imaging to evaluate possible PE, with some additional missed PE but no decrease in NPV.
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