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May 8, 2026Evidence to Action Official Journal of MDCalc0 citations

Updated Review of the PERC Rule

BFBrendan Freeman

Key Result

This clinical policy provides evidence-based recommendations supporting the use of the PERC rule in low-risk patients and age-adjusted D-dimer thresholds in patients over 50 to safely exclude PE.

Key Points

  • This review aims to evaluate the effectiveness of the PERC rule in ruling out pulmonary embolism in low-risk patients.
  • Literature review of the PERC rule validation studies
  • Analysis of pre-test probability definitions and implications
  • Discussion on the clinical applicability of avoiding unnecessary work-ups
  • The PERC rule accurately identifies low-risk patients with a less than 2% chance of pulmonary embolism.
  • Patients with a pre-test probability of less than 15% who meet the PERC criteria require no further testing.

Study Design

Type

Systematic Review

Structured PICO

Can the PERC rule or an age-adjusted D-dimer result safely identify adult ED patients at very low risk for pulmonary embolism for whom no additional diagnostic workup is required?

P
Population
Adult patients presenting to the emergency department with suspected acute venous thromboembolic disease (pulmonary embolism) with low to intermediate pretest probability.
I
Intervention
Pulmonary Embolism Rule-out Criteria (PERC) rule for low-risk patients, and age-adjusted D-dimer testing (age x 10 mg/L or age x 5 mg/L depending on assay) for patients older than 50 years.
C
Comparator
Conventional diagnostic workup, including clinical gestalt assessment or conventional fixed-cutoff D-dimer testing.
O
Outcome
Missed pulmonary embolism (miss rate/failure rate) and diagnostic accuracy (sensitivity, specificity, negative likelihood ratio).

The ACEP clinical policy recommends the use of the PERC rule and age-adjusted D-dimer cutoffs to safely exclude pulmonary embolism in low-to-intermediate risk ED patients, thereby reducing unnecessary imaging and associated harms.

Limitations

  • A majority of the studies included were conducted in Europe, where a higher prevalence of PE was reported compared with US populations, limiting applicability.
  • Some recommendations are based on expert consensus due to a lack of adequate empirical data.
  • This clinical policy is not intended to represent a legal standard of care for emergency physicians.
  • A small increase in the incidence of missed PE
  • Misapplication of the recommendation to individuals with intermediate or high pretest probability of PE
  • Misapplication of the recommendation because of confusion with multiple D-dimer assay units

Abstract

The Pulmonary Embolism Rule-out Criteria (PERC) rule is a validated clinical tool used to rule out pulmonary embolism (PE) in patients who have a low pre-test probability for PE If a patient is deemed low-risk for PE (pre-test probability <15%) and has no positive criteria on the PERC rule, then no further work-up is needed as the patient has <2% chance of PE.

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Cite This Study

Brendan Freeman (2026) conducted a systematic review in Suspected Acute Venous Thromboembolic Disease (VTE). Clinical prediction rules (PERC), age-adjusted D-dimer, and anticoagulation strategies was evaluated. This clinical policy provides evidence-based recommendations supporting the use of the PERC rule in low-risk patients and age-adjusted D-dimer thresholds in patients over 50 to safely exclude PE.

synapsesocial.com/papers/69fd7f65bfa21ec5bbf07e22https://doi.org/10.65357/001c.160870
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