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D-dimer threshold increase with pretest probability unlikely for pulmonary embolism to decrease unnecessary computerized tomographic pulmonary angiography.
J Thromb Haemost. 2012 Apr; 10(4):572-81.JT

Abstract

BACKGROUND

Increasing the threshold to define a positive D-dimer could reduce unnecessary computed tomographic pulmonary angiography (CTPA) for a suspected pulmonary embolism (PE) but might increase rates of a missed PE and missed pneumonia, the most common non-thromboembolic diagnosis seen on CTPA.

OBJECTIVE

Measure the effect of doubling the standard D-dimer threshold for 'PE unlikely' Revised Geneva (RGS) or Wells' scores on the exclusion rate, frequency and size of a missed PE and missed pneumonia.

METHODS

Patients evaluated for a suspected PE with 64-channel CTPA were prospectively enrolled from emergency departments (EDs) and inpatient units of four hospitals. Pretest probability data were collected in real time and the D-dimer was measured in a central laboratory. Criterion standard was CPTA interpretation by two independent radiologists combined with clinical outcome at 30 days.

RESULTS

Of 678 patients enrolled, 126 (19%) were PE+ and 93 (14%) had pneumonia. Use of either Wells' ≤ 4 or RGS ≤ 6 produced similar results. For example, with RGS ≤ 6 and standard threshold (< 500 ng mL(-1)), D-dimer was negative in 110/678 (16%), and 4/110 were PE+ (posterior probability 3.8%) and 9/110 (8.2%) had pneumonia. With RGS ≤ 6 and a threshold < 1000 ng mL(-1) , D-dimer was negative in 208/678 (31%) and 11/208 (5.3%) were PE+, but 10/11 missed PEs were subsegmental and none had concomitant DVT. Pneumonia was found in 12/208 (5.4%) with RGS ≤ 6 and D-dimer < 1000 ng mL(-1).

CONCLUSIONS

Doubling the threshold for a positive D-dimer with a PE unlikely pretest probability could reduce CTPA scanning with a slightly increased risk of missed isolated subsegmental PE, and no increase in rate of missed pneumonia.

Authors+Show Affiliations

Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, USA. jkline@carolinas.orgNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Multicenter Study
Research Support, N.I.H., Extramural
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

22284935

Citation

Kline, J A., et al. "D-dimer Threshold Increase With Pretest Probability Unlikely for Pulmonary Embolism to Decrease Unnecessary Computerized Tomographic Pulmonary Angiography." Journal of Thrombosis and Haemostasis : JTH, vol. 10, no. 4, 2012, pp. 572-81.
Kline JA, Hogg MM, Courtney DM, et al. D-dimer threshold increase with pretest probability unlikely for pulmonary embolism to decrease unnecessary computerized tomographic pulmonary angiography. J Thromb Haemost. 2012;10(4):572-81.
Kline, J. A., Hogg, M. M., Courtney, D. M., Miller, C. D., Jones, A. E., & Smithline, H. A. (2012). D-dimer threshold increase with pretest probability unlikely for pulmonary embolism to decrease unnecessary computerized tomographic pulmonary angiography. Journal of Thrombosis and Haemostasis : JTH, 10(4), 572-81. https://doi.org/10.1111/j.1538-7836.2012.04647.x
Kline JA, et al. D-dimer Threshold Increase With Pretest Probability Unlikely for Pulmonary Embolism to Decrease Unnecessary Computerized Tomographic Pulmonary Angiography. J Thromb Haemost. 2012;10(4):572-81. PubMed PMID: 22284935.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - D-dimer threshold increase with pretest probability unlikely for pulmonary embolism to decrease unnecessary computerized tomographic pulmonary angiography. AU - Kline,J A, AU - Hogg,M M, AU - Courtney,D M, AU - Miller,C D, AU - Jones,A E, AU - Smithline,H A, PY - 2012/1/31/entrez PY - 2012/1/31/pubmed PY - 2012/9/1/medline SP - 572 EP - 81 JF - Journal of thrombosis and haemostasis : JTH JO - J Thromb Haemost VL - 10 IS - 4 N2 - BACKGROUND: Increasing the threshold to define a positive D-dimer could reduce unnecessary computed tomographic pulmonary angiography (CTPA) for a suspected pulmonary embolism (PE) but might increase rates of a missed PE and missed pneumonia, the most common non-thromboembolic diagnosis seen on CTPA. OBJECTIVE: Measure the effect of doubling the standard D-dimer threshold for 'PE unlikely' Revised Geneva (RGS) or Wells' scores on the exclusion rate, frequency and size of a missed PE and missed pneumonia. METHODS: Patients evaluated for a suspected PE with 64-channel CTPA were prospectively enrolled from emergency departments (EDs) and inpatient units of four hospitals. Pretest probability data were collected in real time and the D-dimer was measured in a central laboratory. Criterion standard was CPTA interpretation by two independent radiologists combined with clinical outcome at 30 days. RESULTS: Of 678 patients enrolled, 126 (19%) were PE+ and 93 (14%) had pneumonia. Use of either Wells' ≤ 4 or RGS ≤ 6 produced similar results. For example, with RGS ≤ 6 and standard threshold (< 500 ng mL(-1)), D-dimer was negative in 110/678 (16%), and 4/110 were PE+ (posterior probability 3.8%) and 9/110 (8.2%) had pneumonia. With RGS ≤ 6 and a threshold < 1000 ng mL(-1) , D-dimer was negative in 208/678 (31%) and 11/208 (5.3%) were PE+, but 10/11 missed PEs were subsegmental and none had concomitant DVT. Pneumonia was found in 12/208 (5.4%) with RGS ≤ 6 and D-dimer < 1000 ng mL(-1). CONCLUSIONS: Doubling the threshold for a positive D-dimer with a PE unlikely pretest probability could reduce CTPA scanning with a slightly increased risk of missed isolated subsegmental PE, and no increase in rate of missed pneumonia. SN - 1538-7836 UR - https://www.unboundmedicine.com/medline/citation/22284935/D_dimer_threshold_increase_with_pretest_probability_unlikely_for_pulmonary_embolism_to_decrease_unnecessary_computerized_tomographic_pulmonary_angiography_ L2 - https://doi.org/10.1111/j.1538-7836.2012.04647.x DB - PRIME DP - Unbound Medicine ER -