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Is stand-alone D-dimer testing safe to rule out acute pulmonary embolism?
J Thromb Haemost. 2017 02; 15(2):323-328.JT

Abstract

Essentials A stand-alone D-dimer below 750 μg/L has been proposed to rule out acute pulmonary embolism (PE). This was a post-hoc analysis on data from 6 studies comprising 7268 patients with suspected PE. The negative predictive value of a D-dimer <750 μg/L ranged from 79% to 96% in various subgroups. Stand-alone D-dimer testing seems to be unsafe to rule out PE in all patients.

SUMMARY

Background Recently, stand-alone D-dimer testing at a positivity threshold of 750 μg L-1 has been proposed as a safe and efficient approach to rule out acute pulmonary embolism (PE), without additional imaging, but this approach needs validation. Objectives To evaluate stand-alone D-dimer testing at a positivity threshold of 750 μg L-1 to rule out PE. Methods Individual data from 7268 patients with suspected PE previously enrolled in six prospective management studies were used. Patients were assessed by the Wells rule followed by quantitative D-dimer testing in those with a 'PE unlikely' score. Patients were classified post hoc as having a negative (< 750 μg L-1) or positive (≥ 750 μg L-1) D-dimer. Using a one-stage meta-analytic approach, the negative predictive value (NPV) of stand-alone D-dimer testing was evaluated overall and in different risk subgroups. Results The pooled incidence of PE was 23% (range, 13-42%). Overall, 44% of patients had a D-dimer < 750 μg L-1 , of whom 2.8% were diagnosed with PE at baseline or during 3-month follow-up (NPV, 97.2%; 95% confidence interval [CI], 94.9-98.5). The NPV was highest in patients with a low probability of PE according to the Wells rule (99.2%; 95% CI, 98.6-99.5%) and lowest in those with a high probability of PE (79.3%; 95% CI, 53.0-92.8%). The NPVs in patients with active cancer, patients with previous venous thromboembolism and inpatients were 96.2% (95% CI, 85.6-99.1%), 94.7% (95% CI, 88.6-97.6%) and 92.7% (95% CI, 79.3-97.7%), respectively. Conclusions Our findings suggest that stand-alone D-dimer testing at a positivity threshold of 750 μg L-1 is not safe to rule out acute PE.

Authors+Show Affiliations

Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands.Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, the Netherlands.Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands.Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, the Netherlands.Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, the Netherlands.Service of Anesthesiology, Hospital MD Anderson Cancer Center, Madrid, Spain.Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands. Department of Medical, Oral and Biotechnological Sciences, Gabriele D'Annunzio University, Chieti, Italy.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

27873439

Citation

van Es, N, et al. "Is Stand-alone D-dimer Testing Safe to Rule Out Acute Pulmonary Embolism?" Journal of Thrombosis and Haemostasis : JTH, vol. 15, no. 2, 2017, pp. 323-328.
van Es N, van der Hulle T, Büller HR, et al. Is stand-alone D-dimer testing safe to rule out acute pulmonary embolism? J Thromb Haemost. 2017;15(2):323-328.
van Es, N., van der Hulle, T., Büller, H. R., Klok, F. A., Huisman, M. V., Galipienzo, J., & Di Nisio, M. (2017). Is stand-alone D-dimer testing safe to rule out acute pulmonary embolism? Journal of Thrombosis and Haemostasis : JTH, 15(2), 323-328. https://doi.org/10.1111/jth.13574
van Es N, et al. Is Stand-alone D-dimer Testing Safe to Rule Out Acute Pulmonary Embolism. J Thromb Haemost. 2017;15(2):323-328. PubMed PMID: 27873439.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Is stand-alone D-dimer testing safe to rule out acute pulmonary embolism? AU - van Es,N, AU - van der Hulle,T, AU - Büller,H R, AU - Klok,F A, AU - Huisman,M V, AU - Galipienzo,J, AU - Di Nisio,M, Y1 - 2016/12/24/ PY - 2016/07/11/received PY - 2016/11/23/pubmed PY - 2018/2/1/medline PY - 2016/11/23/entrez KW - D-dimer KW - diagnosis KW - pulmonary embolism KW - sensitivity and specificity KW - venous thromboembolism SP - 323 EP - 328 JF - Journal of thrombosis and haemostasis : JTH JO - J Thromb Haemost VL - 15 IS - 2 N2 - : Essentials A stand-alone D-dimer below 750 μg/L has been proposed to rule out acute pulmonary embolism (PE). This was a post-hoc analysis on data from 6 studies comprising 7268 patients with suspected PE. The negative predictive value of a D-dimer <750 μg/L ranged from 79% to 96% in various subgroups. Stand-alone D-dimer testing seems to be unsafe to rule out PE in all patients. SUMMARY: Background Recently, stand-alone D-dimer testing at a positivity threshold of 750 μg L-1 has been proposed as a safe and efficient approach to rule out acute pulmonary embolism (PE), without additional imaging, but this approach needs validation. Objectives To evaluate stand-alone D-dimer testing at a positivity threshold of 750 μg L-1 to rule out PE. Methods Individual data from 7268 patients with suspected PE previously enrolled in six prospective management studies were used. Patients were assessed by the Wells rule followed by quantitative D-dimer testing in those with a 'PE unlikely' score. Patients were classified post hoc as having a negative (< 750 μg L-1) or positive (≥ 750 μg L-1) D-dimer. Using a one-stage meta-analytic approach, the negative predictive value (NPV) of stand-alone D-dimer testing was evaluated overall and in different risk subgroups. Results The pooled incidence of PE was 23% (range, 13-42%). Overall, 44% of patients had a D-dimer < 750 μg L-1 , of whom 2.8% were diagnosed with PE at baseline or during 3-month follow-up (NPV, 97.2%; 95% confidence interval [CI], 94.9-98.5). The NPV was highest in patients with a low probability of PE according to the Wells rule (99.2%; 95% CI, 98.6-99.5%) and lowest in those with a high probability of PE (79.3%; 95% CI, 53.0-92.8%). The NPVs in patients with active cancer, patients with previous venous thromboembolism and inpatients were 96.2% (95% CI, 85.6-99.1%), 94.7% (95% CI, 88.6-97.6%) and 92.7% (95% CI, 79.3-97.7%), respectively. Conclusions Our findings suggest that stand-alone D-dimer testing at a positivity threshold of 750 μg L-1 is not safe to rule out acute PE. SN - 1538-7836 UR - https://www.unboundmedicine.com/medline/citation/27873439/Is_stand_alone_D_dimer_testing_safe_to_rule_out_acute_pulmonary_embolism L2 - https://doi.org/10.1111/jth.13574 DB - PRIME DP - Unbound Medicine ER -