Safety of the pulmonary embolism rule-out criteria rule: Findings from the Registro Informatizado de la Enfermedad TromboEmbolica venosa (RIETE) registry

Perrine Truong, Lucia Mazzolai, Carme Font, Maurizio Ciammaichella, José González-Martínez, Antonella Tufano, Olga Gavín-Sebastián, Raphael Le Mao, Manuel Monreal, Olivier Hugli

Research output: Contribution to journalArticlepeer-review


Background: The diagnostic strategy for pulmonary embolism (PE) includes a D-dimer test when PE probability is low or intermediate, but false-positive D-dimer results are frequent and can result in an unnecessary computed tomography pulmonary angiogram. The PE rule-out criteria (PERC) rule excludes PE without D-dimer testing when pretest probability is <15%. The aim of this study was to assess the safety of the PERC rule strategy in patients included in the Registro Informatizado de la Enfermedad TromboEmbolica venosa (RIETE) registry. Methods: This retrospective cohort study used data from the RIETE registry, an ongoing, international prospective registry of patients with objectively confirmed venous thromboembolism. The primary outcome was the failure rate of the PERC strategy, represented by the proportion of PERC-negative (PERC-N) patients with a PE included in the registry. Secondary outcomes were a comparison of the clinical characteristics, treatment strategy, and outcome of PERC-N versus PERC-positive (PERC-P) patients at 3 months. Results: From 2001 to 2021, a total of 49,793 patients with acute PE were enrolled in the RIETE registry. We included 48,903 in the final analysis after exclusion of 890 patients with an undetermined PERC status. Only 346 patients were PERC-N with a failure rate of 0.7% (95% confidence interval 0.6%–0.8%). PERC-N patients presented more frequently with chest pain but less often with dyspnea, syncope, or hypotension. They also had subsegmental or segmental PE more frequently, were more often treated with direct oral anticoagulants, and received mechanical or pharmacological thrombolysis less often. In addition, PERC-N patients had a lower incidence of recurrent deep vein thrombosis, major bleeding, and death attributed to PE during the 3-month follow-up. Conclusions: A low failure rate of the PERC rule was observed in the RIETE registry, thus supporting its use to safely identify patients with an unlikely probability of PE.

Original languageEnglish
Pages (from-to)935-945
Number of pages11
JournalAcademic Emergency Medicine
Issue number9
Early online date24 Apr 2023
StatePublished - Sep 2023
Externally publishedYes

Bibliographical note

Publisher Copyright:
© 2023 The Authors. Academic Emergency Medicine published by Wiley Periodicals LLC on behalf of Society for Academic Emergency Medicine.


The authors express gratitude to Sanofi Spain and ROVI for supporting the RIETE registry with an unrestricted educational grant. We also thank the RIETE Registry Coordinating Center and S&H Medical Science Service for their quality control data and logistic and administrative support and Professor Salvador Ortiz, Universidad Autónoma, Madrid, and statistical advisor in the S&H Medical Science Service, for the statistical analysis of the data presented in this paper. Open access funding provided by Universite de Lausanne.

FundersFunder number
S&H Medical Science Service
Universidad Autónoma
Université de Lausanne


    • PERC
    • RIETE
    • diagnostic algorithm
    • pretest probability
    • pulmonary embolism
    • pulmonary embolism rule-out criteria rule


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