Role of fibrin D-dimer testing in emergency medicine

Abstract

Objectives: Systemic values of the fibrinolytic plasma marker fibrin D-dimer are raised in a variety of acute clinical conditions. D-dimer values can now be rapidly determined and used to aid diagnosis in emergency medicine. However, despite clinical guidelines, inappropriate and unnecessary measurement of D-dimer 1 Systemic DD values are raised in a variety of clinical conditions 2-7 and inclusion of DD testing may provide cost effective diagnostic strategies.8 9 In addition to the diagnostic use of DD, it may also be of potential prognostic use in many conditions. 10-14 Currently, despite the implementation of clinical guidelines, inappropriate DD testing is a significant problem. 15 It is, consequently, valuable for emergency physicians to be knowledgeable about the pathophysiological basis and limitations of DD testing to ensure its appropriate clinical use.The place of DD measurement in the diagnostic investigation of suspected venous thromboembolism (VTE) is now well established. This review updates experience on DD testing for VTE and discusses potential areas for the extension of indications for DD testing in emergency medicine. PATHOPHYSIOLOGY OF FIBRIN DDPlasmin is the fibrinolytic enzyme derived from its inactive precursor, plasminogen, by the action of thrombin and plasminogen activators. The main plasminogen activators are tissue plasminogen activator (tPA) and pro-urokinase, which is activated into urokinase by, among others, the contact system of coagulation. 16 Plasmin is neutralised by α 2 antiplasmin thereby restricting its fibrinogenolytic activity and localising the fibrinolysis on the fibrin clot. 16Fibrin is the main component of a thrombus. It is formed by the activation of the coagulation system. Its production is followed by activation of the fibrinolytic system, resulting in plasmin generation and subsequent fibrin lysis (fig 1). Under normal physiological conditions there is a balance of the two opposing processes. Dissolution of crosslinked fibrin (XL-Fg) leads to formation of specific degradation products, including DD, 17 which can be measured in both whole blood and plasma using monoclonal antibodies directed against epitopes located in the DD fragment. The activity of DD is considered to reflect the overall activity of clot formation and lysis. Because DD is not artificially generated in vitro during blood collection, its measurement more consistently reflects in vivo haemostatic activity than do other assays for coagulation or fibrinolytic activities that may be activated in vitro. Its absence excludes the presence of intravascular thrombus. Abbreviations: DD, D-dimer; VTE, venous thromboembolism; tPA, tissue plasminogen activator; XL-Fg, crosslinked fibrin; FDP, fibrin degradation product; ELISA, enzyme linked immunosorbent assay; HMW, high molecular weight; LMW, low molecular weight; FACT, Fibrin Assay Comparison Trial; CT, computed tomography; PE, pulmonary embolism; DVT, deep vein thrombosis; PTP, pretest probability; CHD, coronary heart disease; ACS, acute coronary syndrom...

Evaluation of Plasma Fibrinogen Degradation Products and Total Serum Protein Concentration in Oral Submucous Fibrosis

“…Studies by Wakai et al, accord the statement that D-dimer assays especially qualitative latex agglutination assays that are not 100% sensitive, limiting their use as a single screening test [22].…”

The place of D-dimer and L-lactate levels in the early diagnosis of acute mesenteric ischemia

“…As an indicator of ongoing thrombus formation and degradation, most common usage area of systemic D-dimer measurements at emergency wards are venous thromboembolic issues like pulmonary embolism and acute deep vein thrombosis and acute coronary syndromes (33,34). Recent studies from Acosta et al show that D-dimer can be used in patients with suspected AMI for exclusion (10,29).…”

“…Previous studies have shown similar results in the meaning of D-dimer elevations in SMA occluded rats, but in our study this elevation was not statistically signifi cant. In addition, different techniques and different monoclonal antibodies are being used at different D-dimer analyses and this can be the cause of encountered variations of results (34). In our study, quantitative assay of D-dimer was made with immunoturbidimetric method.…”

“…In our study, quantitative assay of D-dimer was made with immunoturbidimetric method. Despite ELISA is being considered a golden standart for D-dimer analyses, immunoturbidimetric analyses are preferable at emergency wards because of their faster and less complex nature and high sensitivity and specivity (34).…”

Increased Plasma Level of D-Dimer as a Marker of High Arterial Thrombosis Risk

“…Повышение уровня D-димера не может само по себе служить убедительным доказательством наличия у больного тромбоэмболии легочной артерии (ТЭЛА) или тромбоза глубоких вен нижних конечностей (ТГВНК), так как очень многие заболевания или клинические си-туации могут приводить к положительным результатам анализа на D-димер [20,22,23]. К непатологическим факторам, способствующим повышению уровня D-ди-мера, относятся, например, курение, пожилой возраст, послеоперационные состояния и инвазивные мани-пуляции, такие как установка периферического ве-нозного катетера.…”