Diagnostic Validation of PERC and Resource Utilization in Suspected Acute Pulmonary Embolism: A Systematic Review and Meta-Analysis

Abstract

Background and Aims Pulmonary embolism (PE) is a frequent and potentially fatal diagnosis in the emergency department (ED). The Pulmonary Embolism Rule-out Criteria (PERC), an eight-item clinical decision rule used to identify patients at very low risk of pulmonary embolism, is widely applied to exclude PE in low-risk patients; however, its real-world diagnostic performance and impact on imaging utilization remain incompletely defined. This systematic review aimed to evaluate the diagnostic accuracy of PERC and its effect on reducing computed tomography pulmonary angiography (CTPA) use. Materials and Methods This review followed the Joanna Briggs Institute (JBI) methodology for diagnostic test accuracy studies. Eligible studies enrolled ED patients with suspected PE who were classified as low risk according to the original study-specific approaches, including clinician gestalt, Wells score, revised Geneva score, or YEARS-based assessment. PubMed, Web of Science Core Collection, the Cochrane Library, and ClinicalTrials.gov were searched for eligible studies published between 2004 and 2025. Results Ten studies involving 13,672 patients were included. The pooled PE prevalence was 7%. The pooled sensitivity, specificity, and negative predictive value of PERC were 95% (95% CI: 89%–98%), 26% (95% CI: 16%–40%), and 98.2% (95% CI: 97.8%–99.0%), respectively. PERC application was associated with a significant reduction in imaging utilization (RR = 0.85, 95% CI: 0.80–0.91). Conclusions PERC provides a highly sensitive and safe strategy for ruling out PE in low-risk ED patients and significantly reduces unnecessary use of advanced imaging without compromising diagnostic safety.