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Clinical decision rule and D-dimer have lower clinical utility to exclude pulmonary embolism in cancer patients. Explanations and potential ameliorations.
Thromb Haemost. 2010 Oct; 104(4):831-6.TH

Abstract

Patients with malignancy frequently present with clinically suspected pulmonary embolism (PE). However, the safe and efficient combination of a clinical decision rule (CDR) and D-dimer test to rule out PE performs less well in patients with malignancy. We examined potential explanations and analysed whether elevating the D-dimer cut-off could improve the clinical utility. We used data on consecutive patients with suspected PE included in a multicenter management study. The performance of the Wells CDR and the D-dimer test was compared between patients with and without malignancy and multivariable analysis was used to compare the weights of the CDR variables. Furthermore, we combined the CDR (cut-off ≤4) with different D-dimer cut-off levels for the exclusion of PE. Of 3,306 patients with suspected PE, 475 (14%) had cancer. The Wells rule variables were less diagnostic in cancer patients. Increasing the D-dimer cut-off level to 700 μg/l for all ages or using an age-dependent cut-off resulted in an increase in the proportion of patients in whom PE could be excluded from 8.4% to 13% and 12%, respectively. The corresponding false-negative rates were 1.6% (95% confidence interval 0.3-8.7%) and 0.0% (0.0-6.3%). The Wells CDR and D-dimer perform less well in patients with suspected PE if they have cancer. Individual variables in the Wells rule are less diagnostic in cancer patients than in non-cancer patients with suspected PE. A CDR combined with an age-dependent D-dimer cut-off shows a modest improvement of the strategy in cancer patients.

Authors+Show Affiliations

Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands. r.a.douma@amc.uva.nlNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Comparative Study
Journal Article
Multicenter Study

Language

eng

PubMed ID

20664894

Citation

Douma, Renée A., et al. "Clinical Decision Rule and D-dimer Have Lower Clinical Utility to Exclude Pulmonary Embolism in Cancer Patients. Explanations and Potential Ameliorations." Thrombosis and Haemostasis, vol. 104, no. 4, 2010, pp. 831-6.
Douma RA, van Sluis GL, Kamphuisen PW, et al. Clinical decision rule and D-dimer have lower clinical utility to exclude pulmonary embolism in cancer patients. Explanations and potential ameliorations. Thromb Haemost. 2010;104(4):831-6.
Douma, R. A., van Sluis, G. L., Kamphuisen, P. W., Söhne, M., Leebeek, F. W., Bossuyt, P. M., & Büller, H. R. (2010). Clinical decision rule and D-dimer have lower clinical utility to exclude pulmonary embolism in cancer patients. Explanations and potential ameliorations. Thrombosis and Haemostasis, 104(4), 831-6. https://doi.org/10.1160/TH10-02-0093
Douma RA, et al. Clinical Decision Rule and D-dimer Have Lower Clinical Utility to Exclude Pulmonary Embolism in Cancer Patients. Explanations and Potential Ameliorations. Thromb Haemost. 2010;104(4):831-6. PubMed PMID: 20664894.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Clinical decision rule and D-dimer have lower clinical utility to exclude pulmonary embolism in cancer patients. Explanations and potential ameliorations. AU - Douma,Renée A, AU - van Sluis,Geerte L, AU - Kamphuisen,Pieter W, AU - Söhne,Maaike, AU - Leebeek,Frank W G, AU - Bossuyt,Patrick M M, AU - Büller,Harry R, Y1 - 2010/07/20/ PY - 2010/02/04/received PY - 2010/05/29/accepted PY - 2010/7/29/entrez PY - 2010/7/29/pubmed PY - 2011/5/12/medline SP - 831 EP - 6 JF - Thrombosis and haemostasis JO - Thromb Haemost VL - 104 IS - 4 N2 - Patients with malignancy frequently present with clinically suspected pulmonary embolism (PE). However, the safe and efficient combination of a clinical decision rule (CDR) and D-dimer test to rule out PE performs less well in patients with malignancy. We examined potential explanations and analysed whether elevating the D-dimer cut-off could improve the clinical utility. We used data on consecutive patients with suspected PE included in a multicenter management study. The performance of the Wells CDR and the D-dimer test was compared between patients with and without malignancy and multivariable analysis was used to compare the weights of the CDR variables. Furthermore, we combined the CDR (cut-off ≤4) with different D-dimer cut-off levels for the exclusion of PE. Of 3,306 patients with suspected PE, 475 (14%) had cancer. The Wells rule variables were less diagnostic in cancer patients. Increasing the D-dimer cut-off level to 700 μg/l for all ages or using an age-dependent cut-off resulted in an increase in the proportion of patients in whom PE could be excluded from 8.4% to 13% and 12%, respectively. The corresponding false-negative rates were 1.6% (95% confidence interval 0.3-8.7%) and 0.0% (0.0-6.3%). The Wells CDR and D-dimer perform less well in patients with suspected PE if they have cancer. Individual variables in the Wells rule are less diagnostic in cancer patients than in non-cancer patients with suspected PE. A CDR combined with an age-dependent D-dimer cut-off shows a modest improvement of the strategy in cancer patients. SN - 2567-689X UR - https://www.unboundmedicine.com/medline/citation/20664894/Clinical_decision_rule_and_D_dimer_have_lower_clinical_utility_to_exclude_pulmonary_embolism_in_cancer_patients__Explanations_and_potential_ameliorations_ L2 - http://www.thieme-connect.com/DOI/DOI?10.1160/TH10-02-0093 DB - PRIME DP - Unbound Medicine ER -