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Variable D-dimer thresholds for diagnosis of clinically suspected acute pulmonary embolism.
J Thromb Haemost. 2013 Nov; 11(11):1986-92.JT

Abstract

BACKGROUND

Computed tomography pulmonary angiography (CTPA) is frequently requested using diagnostic algorithms for suspected pulmonary embolism (PE). For suspected deep vein thrombosis, it was recently shown that doubling the D-dimer threshold in patients with low pretest probability safely decreased the number of ultrasonograms. We evaluated the safety and efficiency of a similar strategy in patients with suspected PE.

METHODS

We performed a post-hoc analysis of 2213 consecutive patients of two cohort studies with suspected PE who were managed according to current standards: PE ruled out in case of unlikely probability (Wells rule ≤ 4 points) and a D-dimer level < 0.5 μg mL(-1) . CTPA was performed in all other cases. All patients were followed for 3 months. We calculated 3-month venous thromboembolism (VTE) incidence and the number of required CTPAs for selective D-dimer thresholds in patients with low clinical probability (< 2 points, D-dimer threshold < 1.0 μg mL(-1)) and intermediate probability (2-6 points, D-dimer threshold < 0.5 μg mL(-1)).

RESULTS

Using standard management, PE could be excluded without CTPA in 26% of patients, with a 3-month VTE incidence of 0.88% (95% confidence interval [CI] 0.29-2.1%). Using selective D-dimer thresholds, PE could be excluded without CTPA in 36% of patients, with a 3-month VTE incidence of 2.1% (95% CI 1.2-3.4%) in patients managed without CTPA, an increase of 1.2 percentage points (95% CI -0.3 to 2.2).

CONCLUSIONS

Applying selective D-dimer thresholds reduces the need for CTPA by 11 percentage points but is associated with an increased failure rate. Prospective studies should evaluate the safety and net clinical benefit of this approach.

Authors+Show Affiliations

Department of Thrombosis and Hemostasis, LUMC, Leiden, The Netherlands.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Multicenter Study

Language

eng

PubMed ID

23965032

Citation

van der Hulle, T, et al. "Variable D-dimer Thresholds for Diagnosis of Clinically Suspected Acute Pulmonary Embolism." Journal of Thrombosis and Haemostasis : JTH, vol. 11, no. 11, 2013, pp. 1986-92.
van der Hulle T, den Exter PL, Erkens PG, et al. Variable D-dimer thresholds for diagnosis of clinically suspected acute pulmonary embolism. J Thromb Haemost. 2013;11(11):1986-92.
van der Hulle, T., den Exter, P. L., Erkens, P. G., van Es, J., Mos, I. C., ten Cate, H., Kamphuisen, P. W., Hovens, M. M., Büller, H. R., Klok, F. A., & Huisman, M. V. (2013). Variable D-dimer thresholds for diagnosis of clinically suspected acute pulmonary embolism. Journal of Thrombosis and Haemostasis : JTH, 11(11), 1986-92. https://doi.org/10.1111/jth.12394
van der Hulle T, et al. Variable D-dimer Thresholds for Diagnosis of Clinically Suspected Acute Pulmonary Embolism. J Thromb Haemost. 2013;11(11):1986-92. PubMed PMID: 23965032.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Variable D-dimer thresholds for diagnosis of clinically suspected acute pulmonary embolism. AU - van der Hulle,T, AU - den Exter,P L, AU - Erkens,P G M, AU - van Es,J, AU - Mos,I C M, AU - ten Cate,H, AU - Kamphuisen,P W, AU - Hovens,M M C, AU - Büller,H R, AU - Klok,F A, AU - Huisman,M V, PY - 2013/05/21/received PY - 2013/8/23/entrez PY - 2013/8/24/pubmed PY - 2015/2/24/medline KW - diagnoses KW - fibrin fibrinogen degradation products KW - multidetector computed tomography KW - prevalence KW - pulmonary embolism SP - 1986 EP - 92 JF - Journal of thrombosis and haemostasis : JTH JO - J Thromb Haemost VL - 11 IS - 11 N2 - BACKGROUND: Computed tomography pulmonary angiography (CTPA) is frequently requested using diagnostic algorithms for suspected pulmonary embolism (PE). For suspected deep vein thrombosis, it was recently shown that doubling the D-dimer threshold in patients with low pretest probability safely decreased the number of ultrasonograms. We evaluated the safety and efficiency of a similar strategy in patients with suspected PE. METHODS: We performed a post-hoc analysis of 2213 consecutive patients of two cohort studies with suspected PE who were managed according to current standards: PE ruled out in case of unlikely probability (Wells rule ≤ 4 points) and a D-dimer level < 0.5 μg mL(-1) . CTPA was performed in all other cases. All patients were followed for 3 months. We calculated 3-month venous thromboembolism (VTE) incidence and the number of required CTPAs for selective D-dimer thresholds in patients with low clinical probability (< 2 points, D-dimer threshold < 1.0 μg mL(-1)) and intermediate probability (2-6 points, D-dimer threshold < 0.5 μg mL(-1)). RESULTS: Using standard management, PE could be excluded without CTPA in 26% of patients, with a 3-month VTE incidence of 0.88% (95% confidence interval [CI] 0.29-2.1%). Using selective D-dimer thresholds, PE could be excluded without CTPA in 36% of patients, with a 3-month VTE incidence of 2.1% (95% CI 1.2-3.4%) in patients managed without CTPA, an increase of 1.2 percentage points (95% CI -0.3 to 2.2). CONCLUSIONS: Applying selective D-dimer thresholds reduces the need for CTPA by 11 percentage points but is associated with an increased failure rate. Prospective studies should evaluate the safety and net clinical benefit of this approach. SN - 1538-7836 UR - https://www.unboundmedicine.com/medline/citation/23965032/Variable_D_dimer_thresholds_for_diagnosis_of_clinically_suspected_acute_pulmonary_embolism_ L2 - https://doi.org/10.1111/jth.12394 DB - PRIME DP - Unbound Medicine ER -