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Three Part Question

In [adults in whom there is clinical concern for a pulmonary embolism] is the [YEARS criteria] compared to [traditional clinical decision rules or clinical gestalt, in conjunction with D-dimer testing] valid in [ruling out pulmonary embolism (PE)]?

Clinical Scenario

A 55-year-old female presents to the emergency department with shortness of breath and fever. She has no hemoptysis or signs of deep venous thrombosis (DVT). The D-dimer is 600 ng/mL. Can PE reliably be excluded using YEARS criteria?

Search Strategy

Medline 1966-06/24 using PubMed, Cochrane Library (2024), and Embase
[(pulmonary Embolism/diagnosis"[Mesh]) AND (years criteria.mp OR years criterion.mp OR years algorithm.mp)] LIMIT to English language.

Search Outcome

44 total articles were found; five prospective clinical trials were identified as both relevant and of sufficient quality for inclusion.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Kabrhel C, et al September 2018 USA	1,789 adult patients evaluated for PE in the ED. Prior to diagnostic testing, the YEARS criteria was collected.	Prospective observational study	Proportions of patients who would not have CT imaging	Using the standard D-dimer threshold 53% would not have had imaging; using YEARS adjustment 67% would not have imaging	Observational study design, so the diagnostic workup was determined by the clinical team, rather than the study protocol; only enrolled patients with low or intermediate pretest probability;21% of patients lost to follow up
			Patients who would have had PE “missed.”	Using the standard D-dimer threshold, 2 PEs would have been missed. Using YEARS adjustment 6 PEs missed.
			Sensitivity	97.6% for the standard threshold and 92.9% for both adjusted thresholds.
			Negative predictive value (NPV)	Nearly 100% for all approaches.
Freund Y, et al December 2021 France, Spain	1,414 adult patients at low risk for PE evaluated in 18 emergency departments (EDs) in France and Spain	Cluster-randomized, crossover, noninferiority trial	venous thromboembolism (VTE) at 3 months	100 PEs diagnosed in the ED. At 3 month follow up, 1 VTE diagnosed in YEARS group and 5 VTEs diagnosed in age-adjusted d-dimer control group.	Patients and clinicians were not blinded to the study objectives or to group allocation; pseudorandomized trial; 10% of patients enrolled were excluded for protocol violations and missing data
			Chest imaging	Less frequently in the intervention group (30.4%) than the control group (40.0%)
Van der Hulle T, et al. July 2017 Netherlands	3616 consecutive patients with clinically suspected pulmonary embolism in 12 hospitals in the Netherlands	Prospective, multicentre, cohort stud	Number of VTE at 3 mos after PE excluded	18 patients (0.61%) were diagnosed with VTE	The gold standard test (CTPA) was only performed in 52% of the cohort; radiologists were not blinded; no control group; there were 43 violations of the study protocol.
			Number of required CTPA	CTPA was not indicated in 1651 (48%) patients with the YEARS algorithm versus 1174 (34%) patients using the Wells’ diagnostic algorithm
Eddy M, et al. December 2020 Belgium, France, and Switzerland	Data from three previous prospective cohort studies of outpatients with suspected PE were analyzed. The YEARS algorithm was retrospectively applied to 3314 patients	Post hoc analysis of data from 3 prospective cohort studies	Number of patients who would have PE ruled out without imaging	1423 (42.9%) patients could have had PE ruled out without imaging	Performed early to mid-2000s with less advanced CT scanners; the gold standard test (CTPA) was only performed in 57% of the cohort; radiologists were not blinded; missing values for 2.9% of cohort
			Number of patients with missed PE at initial testing	17 (1.2%) were diagnosed with PE at initial testing
Fayiad H, et al March 2024 Egypt	50 adult patients presenting to the chest department with symptoms suggestive of pulmonary embolism	Prospective observational cross-sectional study	Overall accuracy of YEARS score	80% (95% CI, 66.28 to 89.97%)	Small sample size
			Sensitivity of YEARS score	90% (95% CI, 73.47 to 97.89%)
			Specificity of YEARS score	65% (95% CI, 40.78 to 84.61%)

Comment(s)

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.

Clinical Bottom Line

The YEARS criteria is a valid tool in ruling out PE in adult patients presenting to the ED with signs and symptoms of pulmonary embolism.

References

1. Kabrhel C, Van Hylckama Vlieg A, Muzikanski A, Singer A, Fermann GJ, Francis S, Limkakeng A, Chang AM, Giordano N, Parry B. Multicenter Evaluation of the YEARS Criteria in Emergency Department Patients Evaluated for Pulmonary Embolism. Acad Emerg Med 2018 Sep;25(9):987-994
2. Freund Y, Chauvin A, Jimenez S, et al Effect of a Diagnostic Strategy Using an Elevated and Age-Adjusted D-Dimer Threshold on Thromboembolic Events in Emergency Department Patients With Suspected Pulmonary Embolism JAMA 2021;326(21):2141–2149.
3. Van der Hulle T, Cheung WY, Kooij S, et al Simplified diagnostic management of suspected pulmonary embolism (the YEARS study): a prospective, multicentre, cohort study Lancet 2017 Jul 15;390(10091):289-297.
4. Eddy M, Robert-Ebadi H, Richardson L, Bellesini M, Verschuren F, Moumneh T, Meyer G, Righini M, Le Gal G. External validation of the YEARS diagnostic algorithm for suspected pulmonary embolism J Thromb Haemost 2020 Dec;18(12):3289-3295
5. Fayiad H, Moussa H, Nosair Y, Mostafa AI. Predictive accuracy of years score in diagnosis of pulmonary embolism. Egypt J Bronchol 2024 March; 18 (1):18