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Heightened clinical suspicion of pulmonary embolism and disregard of the D-dimer assay: a contemporary trend in an era of increased access to computed tomography pulmonary angiogram?
Intern Med J. 2013 Nov; 43(11):1231-6.IM

Abstract

BACKGROUND

Prospective studies have shown that utilising qualitative D-dimers in those with a low Wells pre-test probability (PTP) of pulmonary embolism (PE) have significantly reduced the number of computed tomography pulmonary angiograms (CTPA) being performed. These studies have been based on a PE prevalence of approximately 6% in the low PTP group.

AIM

This study compares the diagnostic approach to PE in the study institution to well-established guidelines. The study also re-examines the cost-benefit analyses of qualitative d-dimers and CTPA in the low PTP group.

METHODS

A retrospective study of 169 consecutive CTPA requested in the emergency department of a major teaching hospital during a 12-month period.

RESULTS

The prevalence of PE was 0% (0/65), 11.7% (9/77) and 0% (0/2) in the low, moderate and high Wells PTP groups respectively, and 6.3% (9/144) overall. PTP was documented in 10 (6.9%) cases, and the qualitative Clearview Simplify D-dimer was only ordered in 33.8% (22/65) of low PTP subjects. The false positive D-dimer rate was 90.2% (37/41). Cost-benefit analysis and assay performance defines a narrow range of low PTP PE prevalence between 1% and 5% for the utilisation of the qualitative D-dimer assay.

CONCLUSIONS

The overall prevalence of PE in subjects undergoing CTPA was significantly lower compared with data in the literature. The authors recommend warranted clinical suspicion of PE should be confirmed by a senior physician prior to placing a patient in the PE work-up pathway. In such patients, the qualitative D-dimer assay should be utilised if PTP is low, and the exclusionary efficiency of the D-dimer will be improved in the setting of higher PE prevalence in this subgroup. Hospitals should audit local PE prevalence, as cost-benefit analyses raises questions about the effectiveness of D-dimers when PE prevalence is very low in the low PTP subgroup.

Authors+Show Affiliations

Resident Support Unit, Westmead Hospital, Sydney, New South Wales, Australia.No affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article

Language

eng

PubMed ID

23800111

Citation

Sud, R, et al. "Heightened Clinical Suspicion of Pulmonary Embolism and Disregard of the D-dimer Assay: a Contemporary Trend in an Era of Increased Access to Computed Tomography Pulmonary Angiogram?" Internal Medicine Journal, vol. 43, no. 11, 2013, pp. 1231-6.
Sud R, Langfield J, Chu G. Heightened clinical suspicion of pulmonary embolism and disregard of the D-dimer assay: a contemporary trend in an era of increased access to computed tomography pulmonary angiogram? Intern Med J. 2013;43(11):1231-6.
Sud, R., Langfield, J., & Chu, G. (2013). Heightened clinical suspicion of pulmonary embolism and disregard of the D-dimer assay: a contemporary trend in an era of increased access to computed tomography pulmonary angiogram? Internal Medicine Journal, 43(11), 1231-6. https://doi.org/10.1111/imj.12225
Sud R, Langfield J, Chu G. Heightened Clinical Suspicion of Pulmonary Embolism and Disregard of the D-dimer Assay: a Contemporary Trend in an Era of Increased Access to Computed Tomography Pulmonary Angiogram. Intern Med J. 2013;43(11):1231-6. PubMed PMID: 23800111.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Heightened clinical suspicion of pulmonary embolism and disregard of the D-dimer assay: a contemporary trend in an era of increased access to computed tomography pulmonary angiogram? AU - Sud,R, AU - Langfield,J, AU - Chu,G, PY - 2013/03/24/received PY - 2013/06/13/accepted PY - 2013/6/27/entrez PY - 2013/6/27/pubmed PY - 2014/8/13/medline KW - computer tomography pulmonary angiogram KW - d-dimer KW - emergency service KW - guideline adherence KW - pulmonary embolism/diagnosis KW - retrospective study SP - 1231 EP - 6 JF - Internal medicine journal JO - Intern Med J VL - 43 IS - 11 N2 - BACKGROUND: Prospective studies have shown that utilising qualitative D-dimers in those with a low Wells pre-test probability (PTP) of pulmonary embolism (PE) have significantly reduced the number of computed tomography pulmonary angiograms (CTPA) being performed. These studies have been based on a PE prevalence of approximately 6% in the low PTP group. AIM: This study compares the diagnostic approach to PE in the study institution to well-established guidelines. The study also re-examines the cost-benefit analyses of qualitative d-dimers and CTPA in the low PTP group. METHODS: A retrospective study of 169 consecutive CTPA requested in the emergency department of a major teaching hospital during a 12-month period. RESULTS: The prevalence of PE was 0% (0/65), 11.7% (9/77) and 0% (0/2) in the low, moderate and high Wells PTP groups respectively, and 6.3% (9/144) overall. PTP was documented in 10 (6.9%) cases, and the qualitative Clearview Simplify D-dimer was only ordered in 33.8% (22/65) of low PTP subjects. The false positive D-dimer rate was 90.2% (37/41). Cost-benefit analysis and assay performance defines a narrow range of low PTP PE prevalence between 1% and 5% for the utilisation of the qualitative D-dimer assay. CONCLUSIONS: The overall prevalence of PE in subjects undergoing CTPA was significantly lower compared with data in the literature. The authors recommend warranted clinical suspicion of PE should be confirmed by a senior physician prior to placing a patient in the PE work-up pathway. In such patients, the qualitative D-dimer assay should be utilised if PTP is low, and the exclusionary efficiency of the D-dimer will be improved in the setting of higher PE prevalence in this subgroup. Hospitals should audit local PE prevalence, as cost-benefit analyses raises questions about the effectiveness of D-dimers when PE prevalence is very low in the low PTP subgroup. SN - 1445-5994 UR - https://www.unboundmedicine.com/medline/citation/23800111/Heightened_clinical_suspicion_of_pulmonary_embolism_and_disregard_of_the_D_dimer_assay:_a_contemporary_trend_in_an_era_of_increased_access_to_computed_tomography_pulmonary_angiogram L2 - https://doi.org/10.1111/imj.12225 DB - PRIME DP - Unbound Medicine ER -