A Highly Sensitive ELISA D‐Dimer Increases Testing but Not Diagnosis of Pulmonary Embolism

Kabrhel, Christopher; Matts, Christina; McNamara, Mariah; Katz, Jeremy; Ptak, Thomas

doi:10.1197/j.aem.2005.12.012

Cited by 34 publications

(17 citation statements)

References 31 publications

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“…[18][19][20][21] Van Beek et al 22 and Miron et al 23 demonstrated that d-dimer testing was not useful in hospitalized patients. Kabrhel et al 24 reported similar results in an Emergency Department cohort and concluded that d-dimer testing increased the percent of patients who were investigated for PE and the percent that were sent for pulmonary vascular imaging without increasing the percent of patients diagnosed as having a PE. In our cohort, 74 patients (26%) were classified as PE-unlikely, and we theorize that 67 (90%) of these underwent CTPE studies solely on the basis of having a positive d-dimer.…”

Section: Discussionmentioning

confidence: 72%

The modified wells score accurately excludes pulmonary embolus in hospitalized patients receiving heparin prophylaxis

Bahia¹,

Albert²

2011

Journal of Hospital Medicine

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BACKGROUND:The usefulness of the Wells score has not been assessed in hospitalized patients receiving prophylactic heparin.METHODS:Retrospective, observational study of hospitalized patients receiving prophylactic heparin who underwent contrast‐enhanced chest computed tomography (CT) for a concern of pulmonary embolism (PE) more than 2 days after admission. Patients with contraindications to, or interruptions in, prophylactic heparin were excluded. The modified (eg, dichotomous) Wells score was retrospectively calculated by reviewing each patient's record. Requesting a d‐dimer was taken to mean that alternate diagnoses were of equal or greater likelihood than acute PE.RESULTS:From January 2006 through December 2007, 286 patients met inclusion criteria. Pulmonary embolus diagnosed by CT was present in 20 patients (7%). The sensitivity, specificity, positive and negative predictive values of a Wells score ≥4.0 were 95%, 27%, 9% and 99%, respectively. A d‐dimer was ordered in 70 of the 74 PE‐unlikely cases, was elevated in 67, and falsely positive in all but 1.CONCLUSIONS:The prevalence of PE in hospitalized patients receiving prophylactic heparin is lower than in cohorts from which the Wells prediction criteria were derived and validated. A modified Wells score <4 safely excludes PE in such patients and reduces the need for CT. D‐dimer testing adds nothing to the evaluation. Journal of Hospital Medicine 2011;. © 2011 Society of Hospital Medicine.

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Section: Discussionmentioning

confidence: 72%

The modified wells score accurately excludes pulmonary embolus in hospitalized patients receiving heparin prophylaxis

Bahia¹,

Albert²

2011

Journal of Hospital Medicine

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“…Clinicians should be mindful that inappropriate application of a D-dimer test to patients with nonspecific symptoms for whom they would not normally consider commencing a diagnostic evaluation for acute aortic dissection could result in a paradoxic increase in the amount of CT scans performed to exclude acute aortic dissection because of false-positive D-dimer test results. 28 Rule-out testing with D-dimer should be considered only in low-risk patients whom the clinician would otherwise image if the D-dimer test were unavailable.…”

Section: Discussionmentioning

confidence: 99%

A Systematic Review and Meta-analysis of D-dimer as a Rule-out Test for Suspected Acute Aortic Dissection

Asha

Miers

2015

Annals of Emergency Medicine

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“…The introduction of rapid D-dimer testing has been associated with increased overall testing without a decrease in the number of ED patients who undergo pulmonary vascular imaging. 5,6 Thus, the reason to introduce a second screening test would be to effectively decrease the current rate of unnecessary pulmonary vascular imaging. However, we recognize that physicians are unlikely to accept any alternative screening methods unless the test sensitivity is near 100%, given the risks associated with the misdiagnosis of PE.…”

Section: Discussionmentioning

confidence: 99%

“…[2][3][4][5] This rate has increased more than fivefold in the past 5 years, thus increasing the overall exposure of ED patients to ionizing radiation and contrast material. [6][7][8][9] Emergency physicians need well-studied, noninvasive strategies to effectively screen ED patients suspected of PE. In an associated report of this study, we found that myeloperoxidase (MPO) and C-reactive protein (CRP) demonstrated high and nearly equivalent areas under the curve in a head-to-head receiver operating characteristic curve analysis of 50 potential biomarkers of PE.…”

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confidence: 99%

Tandem Measurement of D‐dimer and Myeloperoxidase or C‐reactive Protein to Effectively Screen for Pulmonary Embolism in the Emergency Department

Mitchell

Nordenholz

Kline

2008

Academic Emergency Medicine

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Objectives: The hypothesis was that the tandem measurement of D-dimer and myeloperoxidase (MPO) or C-reactive protein (CRP) could significantly decrease unnecessary pulmonary vascular imaging in emergency department (ED) patients evaluated for pulmonary embolism (PE) compared to D-dimer alone.Methods: The authors measured the sequential combinations of D-dimer and MPO and D-dimer and CRP in a prospective sample of ED patients evaluated for PE at two centers. Patients were followed for 90 days for venous thromboembolism (VTE, either PE or deep venous thrombosis [DVT]), which required the consensus of two of three blinded physician reviewers. Results:The authors enrolled 304 patients, 22 with VTE (7%; 95% confidence interval [CI] = 5% to 10%). The sensitivity and specificity of a D-dimer alone (cutoff ‡ 500 ng ⁄ mL) were 100% (95% CI = 85% to 100%) and 59% (95% CI = 53% to 65%), respectively, and was followed by pulmonary vascular imaging negative for PE in 38% (115 ⁄ 304; 95% CI = 32% to 44%). The combination of either a negative D-dimer, or MPO < 22 mg ⁄ dL, had a sensitivity of 100% and specificity of 73% (95% CI = 67% to 78%). Thus, tandem measurement of D-dimer and MPO would have decreased the frequency of subsequent negative pulmonary vascular imaging from 38% to 25% (95% CI of the difference of )13% = )5% to )20%). The combination of CRP and D-dimer would not have significantly improved the rate of negative imaging. Conclusions:The tandem measurement of D-dimer and MPO would have significantly decreased negative pulmonary vascular imaging compared with D-dimer alone and should be validated prospectively. ACADEMIC EMERGENCY MEDICINE 2008; 15:800-805 ª 2008 by the Society for Academic Emergency MedicineKeywords: biological markers, pulmonary embolism E mergency physicians' awareness of pulmonary embolism (PE) as an important and potentially life-threatening illness is increasing. Currently, emergency physicians employ a diagnostic strategy that involves an assessment of pretest probability based on clinical evaluation followed by D-dimer testing in low-and moderate-risk patients. Patients with a positive D-dimer, or those at high risk, generally defined as a pretest probability for venous thromboembolism (VTE) of about 40% or greater, go on to pulmonary vascular imaging.1 While the D-dimer has proven to be a sensitive marker for PE, a low specificity leads to frequent negative pulmonary vascular imaging.Pulmonary vascular imaging is a significant source of the overall increase in imaging studies performed in emergency departments (EDs). Currently, approximately 10% of ED patients receive either a computed tomography (CT) scan or magnetic resonance imaging as a part of their ED care, and more than 1% receive

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A Highly Sensitive ELISA D‐Dimer Increases Testing but Not Diagnosis of Pulmonary Embolism

Abstract: In the study's academic ED, introduction of ELISA D-dimer testing was accompanied by an increase in PE evaluations, D-dimer testing, and pulmonary vascular imaging; there was no observed change in the rate of PE diagnosis.

Cited by 34 publications

References 31 publications

The modified wells score accurately excludes pulmonary embolus in hospitalized patients receiving heparin prophylaxis

The modified wells score accurately excludes pulmonary embolus in hospitalized patients receiving heparin prophylaxis

A Systematic Review and Meta-analysis of D-dimer as a Rule-out Test for Suspected Acute Aortic Dissection

Tandem Measurement of D‐dimer and Myeloperoxidase or C‐reactive Protein to Effectively Screen for Pulmonary Embolism in the Emergency Department

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