image by: The Skeptics' Guide to EM

HWN Suggests

In the Pregnant YEARS – Diagnising Pulmonary Embolism

The YEARS algorithm starts with the clinician suspecting an acute PE. Then they order a D-dimer and apply the YEARS clinical decision instrument. It has three items with each getting one point... If there are zero YEARS items and the d-dimer is <1,000ng/ml then a PE is excluded. If there are zero YEARS items but the d-dimer is equal to or greater than 1,000ng/ml then a CT pulmonary angiography (CTPA) scan is needed to rule out a PE. If there are one or more YEARS items and the d-dimer is <500ng/ml then a PE is excluded. If there are one or more YEARS items but the d-dimer is equal to or greater than 500ng/ml then a CTPA scan is needed to rule out a PE.

read full article

Previously Featured

YEARS criteria for pulmonary embolism

A pregnancy adapted YEARS criteria is one of the few tools for risk stratification of PE in pregnancy. It uses the same items and variable D-dimer threshold, with the addition of a compression ultrasonogram in pregnant patients with signs of DVT. If there is evidence of DVT on ultrasound, patients are treated as having a PE without further diagnostic imaging.

Comparison of YEARS and Adjust-Unlikely D-dimer Testing for Pulmonary Embolism in the Emergency Department

The “Adjust-Unlikely” rule would modestly reduce imaging and identify all cases of PE. YEARS would substantially reduce imaging but miss 1 in 14 cases of PE.

Effectiveness of the YEARS Algorithm Added to Classical Clinical Decision-making Rules in Suspected Pulmonary Embolism

In this study, the YEARS protocol used in addition to the classical algorithm resulted in a 31% reduction in the need for PCTA. However, we also showed that the YEARS algorithm may be insufficient for the diagnosis of low rate, positive PE.

Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism

Pulmonary embolism was safely ruled out by the pregnancy-adapted YEARS diagnostic algorithm across all trimesters of pregnancy. CT pulmonary angiography was avoided in 32 to 65% of patients.

Pregnancy-Adapted YEARS Algorithm for PE – Ready for Prime Time?

Overall, we agree with the authors conclusions. The pregnancy-adapted YEARS algorithm safely ruled out PE in this cohort of patients with a small risk of VTE at 3 months if the patient was negative on initial visit.

Pregnancy-adapted YEARS Algorithm: A Retrospective Analysis

There is no current consensus in the initial workup of pregnant patients suspected of a PE. Prospective studies have been conducted in Europe using a pregnancy-adapted YEARS algorithm, which showed safe reductions in computed tomography pulmonary angiography (CTPA) imaging in pregnant patients suspected of PE.

The Pragmatic Combination of YEARS Score and Age-Adjusted D-Dimer

The YEARS criteria in combination with age-adjusted D-dimer is noninferior to age-adjusted D-dimer alone and has the potential to decrease chest imaging in PERC-positive patients with low or moderate clinical probability for PE.

The Use of the YEARS Criteria to Rule out Pulmonary Embolism

Excluding PE in patients presenting to the ED can be challenging and requires balancing the risks and benefits of extra testing versus potentially missing a serious diagnosis. The YEARS criteria is a diagnostic algorithm that determines the risk of pulmonary embolism (PE) derived from a combination of clinical symptoms and a variable D-dimer threshold. The YEARS criteria is simple and efficient when compared to other diagnostic tools for PE, making it useful in clinical practice. The YEARS criteria is already commonly applied to pregnant patients. These 6 studies indicate a significant decrease in imaging utilization when using the YEARS criteria without significant increase in missed PEs in standard emergency department patients. This can be considered as an alternative to use of an age-adjusted d-dimer.

The YEARS Algorithm for Evaluation of PE

Your new attending suggests that given his low-risk probability you could have applied the YEARS algorithm, which would have allowed you to forego the CT scan given that his d-dimer was < 1000 ng/mL. You go online and find a recent REBELEM post on the topic, but decide later to do a deep dive into the literature to understand more about this new algorithm…

The YEARS algorithm for suspected pulmonary embolism: shorter visit time and reduced costs at the emergency department

In conclusion, we demonstrated a shorter ED visit time for patients with suspected PE using the YEARS diagnostic algorithm than using the conventional diagnostic algorithm, leading to faster treatment initiation in cases of confirmed PE and savings on emergency ward resources. A shorter ED visit time creates important capacity to treat other patients and lowers the risk of crowding in the ED, which is a benefit for all patients visiting the ED.

The YEARS Study – Simplified Diagnostic Approach to PE

This study offers promising data defending the use of a simplified assessment for PE along with a variable D-dimer threshold. However, we have serious concerns about the availability of D-dimer results prior to risk stratification with the YEARS items. Knowledge of the D-dimer results likely influenced the already subjective assessment of whether PE was the “most likely diagnosis”.

YEARS Rule + D-Dimer as Good as Conventional Dx to Rule Out Pulmonary Embolism

This rule uses a raised D-dimer cutoff of 1,000 ng/mL (instead of 500 ng/mL) in patients with no YEARS criteria (PE is the most likely diagnosis, clinical sign of deep venous thrombosis, and hemoptysis)... In patients with suspected pulmonary embolism (PE) presenting to the emergency department, combining the YEARS rule with age-adjusted D-dimer threshold in those positive for PERC (the absence of all eight rule-out criteria for PE) was as good as a conventional diagnostic strategy in identifying thrombotic events.

YEARS, But Wells

At the very least, please considering using PEGeD or YEARS as the basis for your imaging algorithm – and add age-adjusted D-dimer on top for even better reductions in unnecessary imaging.

Resources

YEARS Algorithm for Pulmonary Embolism (PE)

Helps rule out pulmonary embolism; also validated in pregnant patients with clinically suspected PE.