The Use of the YEARS Criteria to Rule out Pulmonary Embolism
Date First Published:
July 1, 2024
Last Updated:
July 25, 2024
Report by:
Amanda Dean DO; Mariah Barnes MD, EM senior resident, EM faculty (Corewell Health - Michigan State University Emergency Medicine Residency Program, Grand Rapids, MI)
Search checked by:
Jeffrey S. Jones MD, Corewell Health - Michigan State University Emergency Medicine Residency Program, Grand Rapids, MI
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
Search Details:
[(pulmonary Embolism/diagnosis"[Mesh]) AND (years criteria.mp OR years criterion.mp OR years algorithm.mp)] LIMIT to English language.
Outcome:
44 total articles were found; five prospective clinical trials were identified as both relevant and of sufficient quality for inclusion.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Multicenter Evaluation of the YEARS Criteria in Emergency Department Patients Evaluated for Pulmonary Embolism. Kabrhel C, Van Hylckama Vlieg A, Muzikanski A, Singer A, Fermann GJ, Francis S, Limkakeng A, Chang AM, Giordano N, Parry B. Sep-18 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. | ||||
| 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 Freund Y, Chauvin A, Jimenez S, et al Dec-21 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%) | ||||
| Simplified diagnostic management of suspected pulmonary embolism (the YEARS study): a prospective, multicentre, cohort study Van der Hulle T, Cheung WY, Kooij S, et al Jul-17 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 | ||||
| External validation of the YEARS diagnostic algorithm for suspected pulmonary embolism Eddy M, Robert-Ebadi H, Richardson L, Bellesini M, Verschuren F, Moumneh T, Meyer G, Righini M, Le Gal G. Dec-20 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 | ||||
| Predictive accuracy of years score in diagnosis of pulmonary embolism. Fayiad H, Moussa H, Nosair Y, Mostafa AI. Mar-24 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%) |
Author Commentary:
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.
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:
- 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.
- 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
- 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
- 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
- Fayiad H, Moussa H, Nosair Y, Mostafa AI. . Predictive accuracy of years score in diagnosis of pulmonary embolism.