Clinical Usefulness of D-Dimer Depending on Clinical Probability and Cutoff Value in Outpatients With Suspected Pulmonary Embolism

Righini, Marc; Aujesky, Drahomir; Roy, Pierre‐Marie; Cornuz, Jacques; Moerloose, Philippe de; Bounameaux, Henri; Perrier, Arnaud

doi:10.1001/archinte.164.22.2483

Cited by 101 publications

(59 citation statements)

References 30 publications

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“…11,12 We believed that the cutoff Linkins et al proposed for low PTP patients (more than four times the standard cutoff, based on ROC curve analysis) would represent a sharp change from current practice, so we decided by consensus to test the effect of a simple doubling the threshold low PTP patients. This adjustment would have allowed the NPV of the quantitative D-dimer to remain 99%.…”

Section: Discussionmentioning

confidence: 99%

“…This adjustment strategy was evaluated by Linkins et al, 11 who showed in a retrospective analysis that adjusting the D-dimer's threshold could increase the D-dimer's specificity to 60% without compromising sensitivity (95%), or negative predictive value (NPV; >98%). 11 A similar strategy was also analyzed retrospectively by Righini et al, 12 who demonstrated a marginal increase in the D-dimer's usefulness.…”

Section: Q Uantitative D-dimer Testing Is Commonly Used To Rule Out Amentioning

confidence: 99%

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Potential Impact of Adjusting the Threshold of the Quantitative D‐dimer Based on Pretest Probability of Acute Pulmonary Embolism

Kabrhel

Courtney

Camargo

et al. 2009

Academic Emergency Medicine

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Objectives: The utility of D-dimer testing for suspected pulmonary embolism (PE) can be limited by test specificity. The authors tested if the threshold of the quantitative D-dimer can be varied according to pretest probability (PTP) of PE to increase specificity while maintaining a negative predictive value (NPV) of >99%.Methods: This was a prospective, observational multicenter study of emergency department (ED) patients in the United States. Eligible patients had a diagnostic study ordered to evaluate possible PE. PTP was determined by the clinician's unstructured estimate and the Wells score. Five different D-dimer assays were used. D-dimer test performance was measured using 1) standard thresholds and 2) variable threshold values: twice (for low PTP patients), equal (intermediate PTP patients), or half (high PTP patients) of standard threshold. Venous thromboembolism (VTE) within 45 days required positive imaging plus decision to treat. Results:The authors enrolled 7,940 patients tested for PE, and clinicians ordered a quantitative D-dimer for 4,357 (55%) patients who had PTPs distributed as follows: low (74%), moderate (21%), or high (4%). At standard cutoffs, across all PTP strata, quantitative D-dimer testing had a test sensitivity of 94% (95% confidence interval [CI] = 91% to 97%), specificity of 58% (95% CI = 56% to 60%), and NPV of 99.5% (95% CI = 99.1% to 99.7%). If variable cutoffs had been used the overall sensitivity would have been 88% (95% CI = 83% to 92%), specificity 75% (95% CI = 74% to 76%), and NPV 99.1% (95% CI = 98.7% to 99.4%).Conclusions: This large multicenter observational sample demonstrates that emergency medicine clinicians currently order a D-dimer in the majority of patients tested for PE, including a large proportion with intermediate PTP and high PTP. Varying the D-dimer's cutoff according to PTP can increase specificity with no measurable decrease in NPV.ACADEMIC EMERGENCY MEDICINE 2009; 16:325-332 ª

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Section: Discussionmentioning

confidence: 99%

Section: Q Uantitative D-dimer Testing Is Commonly Used To Rule Out Amentioning

confidence: 99%

Potential Impact of Adjusting the Threshold of the Quantitative D‐dimer Based on Pretest Probability of Acute Pulmonary Embolism

Kabrhel

Courtney

Camargo

et al. 2009

Academic Emergency Medicine

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“…We identifi ed 19 studies that evaluated clinical prediction rules for the diagnosis of DVT, [16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34] and 8 studies evaluating clinical prediction rules for the diagnosis of pulmonary embolism, [35][36][37][38][39][40][41][42] although common patients were reported in 3 studies. [40][41][42] (Supplemental Appendix 1, available online at http://www.annfammed.org/cgi/content/full/5/1/63/DC1). The quality of the studies was fairly high, because all patients had an appropriate reference standard, the study sample was well described, and there was no verifi cation bias.…”

Section: Are Clinical Prediction Rules Valuable For Diagnosing Dvt Ormentioning

confidence: 99%

“…35,37,38 In the 2 studies that evaluated the Geneva rule (Table 2), the prevalence of pulmonary embolism in the high pretest probability stratum was 77% to 85%. 41,42 Those in the moderate pretest probability stratum had a prevalence of 34% to 35%, and those in the low pretest probability stratum had a prevalence of 7%. These 2 studies included common patients.…”

Section: Diagnosis O F DV T a Nd Pementioning

confidence: 99%

Review of the Evidence on Diagnosis of Deep Venous Thrombosis and Pulmonary Embolism

Segal

Eng

Tamariz

et al. 2007

The Annals of Family Medicine

139

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PURPOSE This review summarizes the evidence regarding the effi cacy of techniques for diagnosis of deep venous thrombosis (DVT) and pulmonary embolism. METHODSWe searched for studies using MEDLINE, MICROMEDEX, the Cochrane Controlled Trials Register, and the Cochrane Database of Systematic Reviews through June 2006. We reviewed randomized controlled trials, systematic reviews of trials, and observational studies if no trials were available. Paired reviewers assessed the quality of each included article and abstracted the data into summary tables. Heterogeneity in study designs precluded mathematical combination of the results of the primary literature. RESULTSOur review found 22 relevant systematic reviews and 36 primary studies. The evidence strongly supports the use of clinical prediction rules, particularly the Wells model, for establishing the pretest probability of DVT or pulmonary embolism in a patient before ordering more defi nitive testing. Fifteen studies support that when a D-dimer assay is negative and a clinical prediction rule suggests a low probability of DVT or pulmonary embolism, the negative predictive value is high enough to justify foregoing imaging studies in many patients. The evidence in 5 systematic reviews regarding the use of D-dimer, in isolation, is strong and demonstrates sensitivities of the enzyme-linked immunosorbent assay (ELISA) and quantitative rapid ELISA, pooled across studies, of approximately 95%. Eight systematic reviews found that the sensitivity and specifi city of ultrasonography for diagnosis of DVT vary by vein; ultrasonography performs best for diagnosis of symptomatic, proximal vein thrombosis, with pooled sensitivities of 89% to 96%. The sensitivity of single-detector helical computed tomography for diagnosis of pulmonary embolism varied widely across studies and was below 90% in 4 of 9 studies; more studies are needed to determine the sensitivity of multidetector scanners.CONCLUSIONS While the strength of the evidence varies across questions, it is generally strong.

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“…Не требуется измерения D димера и у больных с высокой клини ческой вероятностью ТЭЛА в связи с низким отри цательным прогностическим значением этого мето да в данной популяции [202]. Показатель D димера также неинформативен у госпитализированных, т. к. для получения клинически значимых отри цательных результатов требуется обследовае очень большого числа больных (number needed to test).…”

Section: предполагаемая тэла без шока и гипотензииunclassified

Pulmonary embolism: clinical guidelines of European Society of Cardiology (2014).The Task Force of the European Society of Cardiology for diagnosis and management of pulmonary embolism

Редакционная¹

2015

Pulʹmonologiâ (Mosk.)

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РезюмеВ данных Клинических рекомендациях суммированы все современные доказательства по диагностике и лечению тромбоэмболии легочной артерии (ТЭЛА). В отличие от предыдущей версии рекомендаций, в данном документе представлены упрощенные варианты клинических прогностических шкал, подробно рассмотрена стратификация риска летального исхода, включая промежуточные степени риска, представлены новые подходы к АКТ, в т. ч. системному тромболизису и катетерным методам лечения, терапии антагонистом витамина К, определено место новых пероральных антикоагулянтов в терапии ТЭЛА. Ключевые слова: рекомендации, тромбоэмболия легочной артерии, венозный тромбоз, шок, гипотензия, торакалгия, одышка, сердеч ная недостаточность, диагностика, антикоагулянты, тромболизис. SummaryThese clinical recommendations summarized currently available evidence on diagnosis and management of patients with pulmonary embolism. When compared to previous version of recommendations, this document has introduced simplified clinical prognostic scales and a new risk stratifi cation system including intermediate risk. Novel approach to anticoagulant therapy have been also reviewed including systemic thrombolysis, catheter directed treatment, vitamin K antagonists and new oral anticoagulants. Key words: recommendations, pulmonary embolism, venous thromboembolism, shock, hypotension, chest pain, dyspnea, heart failure, diagnosis, anticoagulants, thrombolysis.Тромбоэмболия легочной артерии: клинические рекомендации Европейского общества кардиологов (2014) 526Пульмонология. 2015; 25 (5): 525-552 возникавших в ходе работы над Рекомендациями, надлежало информировать ЕОК и вносить соответ ствующие поправки. Финансирование Рабочей груп пы проводилось за счет средств ЕОК полностью, без участия представителей медицинской промышлен ности.Комитетом ЕОК по Практическим рекомендаци ям проведены наблюдение за процессом подготовки новых Клинических рекомендаций и его координа ция. Члены Комитета также несли ответственность за утверждение новых Клинических рекомендаций. Клинические рекомендации ЕОК активно проана лизированы Комитетом по Практическим рекомен дациям и внешними экспертами. После соответст вующих поправок Рекомендации были одобрены всеми экспертами Рабочей группы. Окончательный документ был утвержден Комитетом по Практичес ким рекомендациям для публикации в журнале European Heart Journal.Задача написания Клинических рекомендаций ЕОК заключается не только в объединении результа тов исследований последних лет, но также и в разра ботке образовательных методик и программ внедре ния Рекомендаций в практическое здравоохранение.Для практического использования Рекоменда ций готовится их краткая («карманная») версия, а также слайды, буклеты с ключевыми положения ми, листовки для неспециалистов и электронная версия для смартфонов и других гаджетов (сокра щенные варианты); с полным текст Рекомендаций опубликован на сайте ЕОК и находится в свободном доступе. Национальным обществам рекомендуется утверждать, переводить на национальные языки и внедрять Клинические рекоме...

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Clinical Usefulness of D-Dimer Depending on Clinical Probability and Cutoff Value in Outpatients With Suspected Pulmonary Embolism

Abstract: The safety of D-dimer testing in patients with a high clinical probability of PE is not established, and testing results are rarely negative in such patients. Increasing the enzyme-linked immunosorbent assay D-dimer cutoff value only marginally increased the test's usefulness.

Cited by 101 publications

References 30 publications

Potential Impact of Adjusting the Threshold of the Quantitative D‐dimer Based on Pretest Probability of Acute Pulmonary Embolism

Potential Impact of Adjusting the Threshold of the Quantitative D‐dimer Based on Pretest Probability of Acute Pulmonary Embolism

Review of the Evidence on Diagnosis of Deep Venous Thrombosis and Pulmonary Embolism

Pulmonary embolism: clinical guidelines of European Society of Cardiology (2014).The Task Force of the European Society of Cardiology for diagnosis and management of pulmonary embolism

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