Sex‐specific performance of pre‐imaging diagnostic algorithms for pulmonary embolism

Abstract

Background In patients suspected of pulmonary embolism (PE), clinical decision rules are combined with D-dimer testing to rule out PE, avoiding the need for imaging in those at low risk. Despite sex differences in several aspects of the disease, including its diagnosis, these algorithms are used indiscriminately in women and men. Objectives To compare the performance, defined as efficiency and failure rate, of three pre-imaging diagnostic algorithms for PE between women and men: the Wells rule with fixed or with age-adjusted D-dimer cut-off, and a recently validated algorithm (YEARS). A secondary aim was to determine the sex-specific prevalence of PE. Methods Individual patient data were obtained from six studies using the Wells rule (fixed D-dimer, n = 5; age adjusted, n = 1) and from one study using the YEARS algorithm. All studies prospectively enrolled consecutive patients with suspected PE. Main outcomes were efficiency (proportion of patients in which the algorithm ruled out PE without imaging) and failure rate (proportion of patients with PE not detected by the algorithm). Outcomes were estimated using (multilevel) logistic regression models. Results The main outcomes showed no sex differences in any of the separate algorithms. With all three, the prevalence of PE was lower in women (OR, 0.66, 0.68 and 0.74). In women, estrogen use, adjusted for age, was associated with lower efficiency and higher prevalence and D-dimer levels. Conclusions The investigated pre-imaging diagnostic algorithms for patients suspected of PE show no sex differences in performance. Male sex and estrogen use are both associated with a higher probability of having the disease.

Sex differences in guideline‐consistent diagnostic testing for acute pulmonary embolism among adult emergency department patients aged 18–49

“…47 As expected, the yield across risk groups in the study cohort was thus lower as well (rGS derivation: low 9.0%, moderate 27.5%, high 71.7%), though it did increase appropriately with increasing pretest risk. 18,28 In contrast to the primary study hypothesis, we found that females in our cohort were more likely to receive guidelineconsistent care, which would be expected to decrease the amount of testing required to rule out PE. This finding was likely driven by the fact that a significantly higher proportion of females had Ddimer assays performed as part of their ED evaluations.…”

“…30 This and other studies also found that women who undergo imaging are 35%-55% less likely to be diagnosed with PE compared to similarly aged men. [28][29][30] Older data consistently demonstrate this trend as well, showing that women were more likely to undergo lung ventilation/perfusion scintigraphy (V/Q) for PE. 37 This is a particular problem among younger women, who are tested at nearly the same rates as older women despite having a considerably lower risk of PE.…”

“…28,29 Women receive more diagnostic testing for PE, both noninvasive and invasive, and the yield of testing is lower in women. [28][29][30] Literature suggests that PE incidence is similar in nonpregnant adult women and men 30,31 or slightly more common in men, 17,28 yet women represent more than 60% of patients enrolled in several large studies of ED patients with suspected PE. 14,[17][18][19][31][32][33][34][35][36] An analysis of the Nationwide Emergency Department Sample (NEDS) found that women were 17%-87% more likely to undergo PE diagnostic imaging (computed tomography pulmonary angiography [CTPA]) than similarly aged men.…”

“…Structured clinical decision tools for assessing pretest risk of PE have equal efficiency and failure rates in women and men, although they have lower specificity and are more likely to require invasive testing in women 28,29 . Women receive more diagnostic testing for PE, both noninvasive and invasive, and the yield of testing is lower in women 28–30 . Literature suggests that PE incidence is similar in nonpregnant adult women and men 30,31 or slightly more common in men, 17,28 yet women represent more than 60% of patients enrolled in several large studies of ED patients with suspected PE 14,17–19,31–36 .…”

Clinical pre‐test probability adjusted versus age‐adjusted D‐dimer interpretation strategy for DVT diagnosis: A diagnostic individual patient data meta‐analysis

“…While several comparisons exist between CPTP‐adjusted D‐dimer and age‐adjusted D‐dimer in patients with suspected PE, less data are available for this comparison in patients with suspected DVT. In a previous analysis that combined IPD data from a DVT and a PE study, we showed an increase in specificity and utility of CPTP‐adjusted D‐dimer compared to age‐adjusted D‐dimer interpretation .…”