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A simple decision rule including D-dimer to reduce the need for computed tomography scanning in patients with suspected pulmonary embolism.
J Thromb Haemost. 2015 Aug; 13(8):1428-35.JT

Abstract

BACKGROUND

An 'unlikely' clinical decision rule with a negative D-dimer result safely excludes pulmonary embolism (PE) in 30% of presenting patients. We aimed to simplify this diagnostic approach and to increase its efficiency.

METHODS

Data for 723 consecutive patients with suspected PE were analyzed (prevalence of PE, 22%). After constructing a logistic regression model with the D-dimer test result and items from the Wells' score, we identified the most prevalent combinations of influential items and selected new D-dimer positivity thresholds. The performance was separately validated with data from 2785 consecutive patients with suspected PE.

RESULTS

Three Wells items significantly added incremental value to the D-dimer test: hemoptysis, signs of deep vein thrombosis and 'PE most likely'. Based on the most frequent combinations of these three items, we identified two groups: (i) none of these three items positive (41%); (ii) one or more of these items positive (59%). When applying a 1000 μg/L D-dimer threshold in group 1 and 500 μg/L in group 2, PE could be excluded without CT scanning in 36%, at a false-negative rate of 1.2% (95%, 0.04-3.3%). In the validation set, these proportions were 46% and 1.9% (95% CI, 1.2-2.7%), respectively. Using the conventional Wells score with a normal D-dimer result, these rates were, respectively, 22% and 0.6% (95% CI, 0.10-2.4%).

CONCLUSION

Combining Wells items with the D-dimer test resulted in a simplified decision rule, which reduces the need for CT scanning in patients with suspected PE. A prospective validation is required before it can be implemented in clinical practice.

Authors+Show Affiliations

Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands.Department of Radiology, Academic Medical Center, Amsterdam, the Netherlands.Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands.Section of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.Section of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.Department of Internal Medicine, Rijnstate Hospital, Arnhem, the Netherlands.Section of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.Department of Vascular Medicine, University Medical Center, Groningen, the Netherlands.Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands.Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.

Pub Type(s)

Journal Article
Validation Study

Language

eng

PubMed ID

25990714

Citation

van Es, J, et al. "A Simple Decision Rule Including D-dimer to Reduce the Need for Computed Tomography Scanning in Patients With Suspected Pulmonary Embolism." Journal of Thrombosis and Haemostasis : JTH, vol. 13, no. 8, 2015, pp. 1428-35.
van Es J, Beenen LF, Douma RA, et al. A simple decision rule including D-dimer to reduce the need for computed tomography scanning in patients with suspected pulmonary embolism. J Thromb Haemost. 2015;13(8):1428-35.
van Es, J., Beenen, L. F., Douma, R. A., den Exter, P. L., Mos, I. C., Kaasjager, H. A., Huisman, M. V., Kamphuisen, P. W., Middeldorp, S., & Bossuyt, P. M. (2015). A simple decision rule including D-dimer to reduce the need for computed tomography scanning in patients with suspected pulmonary embolism. Journal of Thrombosis and Haemostasis : JTH, 13(8), 1428-35. https://doi.org/10.1111/jth.13011
van Es J, et al. A Simple Decision Rule Including D-dimer to Reduce the Need for Computed Tomography Scanning in Patients With Suspected Pulmonary Embolism. J Thromb Haemost. 2015;13(8):1428-35. PubMed PMID: 25990714.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - A simple decision rule including D-dimer to reduce the need for computed tomography scanning in patients with suspected pulmonary embolism. AU - van Es,J, AU - Beenen,L F M, AU - Douma,R A, AU - den Exter,P L, AU - Mos,I C M, AU - Kaasjager,H A H, AU - Huisman,M V, AU - Kamphuisen,P W, AU - Middeldorp,S, AU - Bossuyt,P M M, Y1 - 2015/06/19/ PY - 2015/01/14/received PY - 2015/05/13/accepted PY - 2015/5/21/entrez PY - 2015/5/21/pubmed PY - 2016/6/10/medline KW - D-dimer KW - diagnostic test KW - pulmonary embolism KW - tomography scanners, X-ray computed KW - venous thromboembolism SP - 1428 EP - 35 JF - Journal of thrombosis and haemostasis : JTH JO - J Thromb Haemost VL - 13 IS - 8 N2 - BACKGROUND: An 'unlikely' clinical decision rule with a negative D-dimer result safely excludes pulmonary embolism (PE) in 30% of presenting patients. We aimed to simplify this diagnostic approach and to increase its efficiency. METHODS: Data for 723 consecutive patients with suspected PE were analyzed (prevalence of PE, 22%). After constructing a logistic regression model with the D-dimer test result and items from the Wells' score, we identified the most prevalent combinations of influential items and selected new D-dimer positivity thresholds. The performance was separately validated with data from 2785 consecutive patients with suspected PE. RESULTS: Three Wells items significantly added incremental value to the D-dimer test: hemoptysis, signs of deep vein thrombosis and 'PE most likely'. Based on the most frequent combinations of these three items, we identified two groups: (i) none of these three items positive (41%); (ii) one or more of these items positive (59%). When applying a 1000 μg/L D-dimer threshold in group 1 and 500 μg/L in group 2, PE could be excluded without CT scanning in 36%, at a false-negative rate of 1.2% (95%, 0.04-3.3%). In the validation set, these proportions were 46% and 1.9% (95% CI, 1.2-2.7%), respectively. Using the conventional Wells score with a normal D-dimer result, these rates were, respectively, 22% and 0.6% (95% CI, 0.10-2.4%). CONCLUSION: Combining Wells items with the D-dimer test resulted in a simplified decision rule, which reduces the need for CT scanning in patients with suspected PE. A prospective validation is required before it can be implemented in clinical practice. SN - 1538-7836 UR - https://www.unboundmedicine.com/medline/citation/25990714/A_simple_decision_rule_including_D_dimer_to_reduce_the_need_for_computed_tomography_scanning_in_patients_with_suspected_pulmonary_embolism_ L2 - https://doi.org/10.1111/jth.13011 DB - PRIME DP - Unbound Medicine ER -