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Safety of excluding acute pulmonary embolism based on an unlikely clinical probability by the Wells rule and normal D-dimer concentration: a meta-analysis.
Thromb Res. 2010 Apr; 125(4):e123-7.TR

Abstract

INTRODUCTION

The Wells clinical decision rule (CDR) and D-dimer tests can be used to exclude pulmonary embolism (PE). We performed a meta-analysis to determine the negative predictive value (NPV) of an "unlikely" CDR (<or=4 points) combined with a normal D-dimer test and the safety of withholding anti-coagulants based on these criteria.

METHODS

Prospective studies that withheld anti-coagulant treatment from patients with clinically suspected PE and an "unlikely" CDR in combination with a normal D-dimer concentration without performing further tests were searched for in Medline, Cochrane and Embase. Primary endpoints were the recurrence rate of venous thromboembolism (VTE) and PE-related mortality during 3-months follow-up.

RESULTS

Four studies including 1660 consecutive patients were identified. The pooled incidence of VTE after initial exclusion of acute PE based on an "unlikely" CDR and normal D-dimer was 0.34% (95%CI 0.036-0.96%), resulting in a NPV of 99.7% (95%CI: 99.0-99.9%, random effects-model). The risk for PE related mortality was very low: 1/1660 patients had fatal PE (0.06%, 95%CI 0.0017-0.46%).

CONCLUSION

Acute PE can be safely excluded in patients with clinically suspected acute PE who have an "unlikely" probability and a negative D-dimer test and anticoagulant treatment can be withheld. There is no need for additional radiological tests in these patients to rule out PE.

Authors+Show Affiliations

Section of Vascular Medicine, Department of General Internal Medicine - Endocrinology, LUMC, Leiden, The Netherlands.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Meta-Analysis

Language

eng

PubMed ID

19942258

Citation

Pasha, S M., et al. "Safety of Excluding Acute Pulmonary Embolism Based On an Unlikely Clinical Probability By the Wells Rule and Normal D-dimer Concentration: a Meta-analysis." Thrombosis Research, vol. 125, no. 4, 2010, pp. e123-7.
Pasha SM, Klok FA, Snoep JD, et al. Safety of excluding acute pulmonary embolism based on an unlikely clinical probability by the Wells rule and normal D-dimer concentration: a meta-analysis. Thromb Res. 2010;125(4):e123-7.
Pasha, S. M., Klok, F. A., Snoep, J. D., Mos, I. C., Goekoop, R. J., Rodger, M. A., & Huisman, M. V. (2010). Safety of excluding acute pulmonary embolism based on an unlikely clinical probability by the Wells rule and normal D-dimer concentration: a meta-analysis. Thrombosis Research, 125(4), e123-7. https://doi.org/10.1016/j.thromres.2009.11.009
Pasha SM, et al. Safety of Excluding Acute Pulmonary Embolism Based On an Unlikely Clinical Probability By the Wells Rule and Normal D-dimer Concentration: a Meta-analysis. Thromb Res. 2010;125(4):e123-7. PubMed PMID: 19942258.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Safety of excluding acute pulmonary embolism based on an unlikely clinical probability by the Wells rule and normal D-dimer concentration: a meta-analysis. AU - Pasha,S M, AU - Klok,F A, AU - Snoep,J D, AU - Mos,I C M, AU - Goekoop,R J, AU - Rodger,M A, AU - Huisman,M V, Y1 - 2009/11/26/ PY - 2009/09/16/received PY - 2009/10/26/revised PY - 2009/11/09/accepted PY - 2009/11/28/entrez PY - 2009/11/28/pubmed PY - 2010/7/3/medline SP - e123 EP - 7 JF - Thrombosis research JO - Thromb Res VL - 125 IS - 4 N2 - INTRODUCTION: The Wells clinical decision rule (CDR) and D-dimer tests can be used to exclude pulmonary embolism (PE). We performed a meta-analysis to determine the negative predictive value (NPV) of an "unlikely" CDR (<or=4 points) combined with a normal D-dimer test and the safety of withholding anti-coagulants based on these criteria. METHODS: Prospective studies that withheld anti-coagulant treatment from patients with clinically suspected PE and an "unlikely" CDR in combination with a normal D-dimer concentration without performing further tests were searched for in Medline, Cochrane and Embase. Primary endpoints were the recurrence rate of venous thromboembolism (VTE) and PE-related mortality during 3-months follow-up. RESULTS: Four studies including 1660 consecutive patients were identified. The pooled incidence of VTE after initial exclusion of acute PE based on an "unlikely" CDR and normal D-dimer was 0.34% (95%CI 0.036-0.96%), resulting in a NPV of 99.7% (95%CI: 99.0-99.9%, random effects-model). The risk for PE related mortality was very low: 1/1660 patients had fatal PE (0.06%, 95%CI 0.0017-0.46%). CONCLUSION: Acute PE can be safely excluded in patients with clinically suspected acute PE who have an "unlikely" probability and a negative D-dimer test and anticoagulant treatment can be withheld. There is no need for additional radiological tests in these patients to rule out PE. SN - 1879-2472 UR - https://www.unboundmedicine.com/medline/citation/19942258/Safety_of_excluding_acute_pulmonary_embolism_based_on_an_unlikely_clinical_probability_by_the_Wells_rule_and_normal_D_dimer_concentration:_a_meta_analysis_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0049-3848(09)00510-6 DB - PRIME DP - Unbound Medicine ER -