Background: D-dimer is elevated in a variety of conditions. The purpose of this study was to assess the positive predictive value of D-dimer to rule in patients with confirmed pulmonary embolism, deep vein thrombosis, acute aortic dissection or thrombosis of the upper extremity in comparison to patients with elevated D-dimer for other reasons. Methods and results: We studied 1334 patients presenting to the emergency department with pulmonary embolism ( n=193), deep vein thrombosis ( n=73), acute aortic dissection ( n=22), thrombosis of the upper extremity ( n=8) and 1038 controls. The positive predictive value was increased with higher D-dimer concentrations improving the ability to identify diseases with high thrombus burden. Patients with venous thromboembolism, acute aortic dissection and thrombosis of the upper extremity showed a maximum positive predictive value of 85.2% at a D-dimer level of 7.8 mg/L (95% confidence interval (CI) 78.1 to 90.4). The maximum positive predictive value was lower in cancer patients with venous thromboembolism, acute aortic dissection and thrombosis of the upper extremity, reaching 68.9% at a D-dimer level of 7.5 mg/L (95% CI 57.4 to 78.4). The positive likelihood ratio was very consistent with the positive predictive value. Using a cut-off level of 0.5 mg/L, D-dimer showed a high sensitivity of at least 93%, but a very low specificity of nearly 0%. Conversely, an optimised cut-off value of 4.6 mg/L increased specificity to 95% for the detection of life-threatening venous thromboembolism, acute aortic dissection or thrombosis of the upper extremity at the costs of moderate sensitivities (58% for pulmonary embolism, 41% for deep vein thrombosis, 65% for pulmonary embolism with co-existent deep vein thrombosis, 50% for acute aortic dissection and 13% for thrombosis of the upper extremity). Using the same cut-off in cancer patients, higher values were observed for sensitivity at a specificity level of more than 95%. The area under the curve for the discrimination of venous thromboembolism/acute aortic dissection/thrombosis of the upper extremity from controls was significantly higher in cancer versus non-cancer patients (area under the curve 0.905 in cancer patients, 95% CI 0.89 to 0.92, vs. area under the curve 0.857 in non-cancer patients, 95% CI 0.84 to 0.88; P=0.0349). Conclusion: D-dimers are useful not only to rule out but also to rule in venous thromboembolism and acute aortic dissection with an at least moderate discriminatory ability, both in patients with and without cancer.

In patients with heart failure MCF discriminates CA from other forms of LVH. As it can easily be derived from standard, non-contrast cine images, it may be a very useful marker in the diagnostic workup of patients with LVH.

AimsTo compare the performance of the natriuretic peptides (NPs) NT‐proBNP and MR‐proANP for the diagnosis of acute heart failure (AHF) in subsets of conditions potentially confounding the interpretation of NPs.Methods and resultsWe studied 312 patients, presenting to the emergency department with new onset of dyspnoea or worsening of chronic dyspnoea within the last 2 weeks. Performance of NPs for the diagnosis of AHF was tested and compared using C‐statistics in the entire cohort and in conditions previously described to confound interpretation of NPs such as older age, renal failure, obesity, atrial fibrillation or paced rhythm, and in the NT‐proBNP grey zone. AHF was diagnosed in 139 patients. In the entire cohort, the diagnostic performance of NT‐proBNP was comparable with that of MR‐proANP. Receiver operating characteristic analysis demonstrated that optimal diagnostic cut‐offs were higher in the presence of older age, kidney failure or rhythm disorder. However, there were no statistically relevant differences between the receiver operating characteristic curves analysed in the total population and those studied in the pre‐specified subsets severe kidney failure, advanced age, obesity, atrial fibrillation and paced rhythm, and grey zone NT‐proBNP values. Moreover, the diagnostic performance of NT‐proBNP was comparable with that of MR‐proANP in the subsets.ConclusionsThe performance of NT‐proBNP and MR‐proANP for AHF is comparable in the total population as well as in the subsets with potentially confounding characteristics such as older age, renal dysfunction, obesity, atrial fibrillation and paced rhythm, or those with NT‐proBNP values in the grey zone.