The combination of four different clinical decision rules and an age-adjusted D-dimer cut-off increases the number of patients in whom acute pulmonary embolism can safely be excluded

Es, Josien van; Mos, Inge C. M.; Douma, Renée A.; Erkens, Petra M. G.; Durian, Marc; Nizet, T.A.C.; Houten, Anja van; Hofstee, H.M.A.; Cate, Hugo Ten; Ullmann, E.; Büller, Harry R.; Huisman, Menno V.; Kamphuisen, Pieter Willem

doi:10.1160/th11-08-0587

Cited by 29 publications

(9 citation statements)

References 26 publications

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“…The evaluation of patients with VTE has been improved by the introduction of standardized probability scoring systems. Different PTP scoring systems have been introduced and evaluated for VTE detection sensitivity and specificity and minimizing the need for radiological confirmation [ 16 - 18 ]. Several studies have investigated PTP score assessment in patients with suspected VTE [ 19 - 22 ].…”

Section: Discussionmentioning

confidence: 99%

Evaluation of the usefulness of a D dimer test in combination with clinical pretest probability score in the prediction and exclusion of Venous Thromboembolism by medical residents

et al. 2014

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IntroductionVenous thromboembolism (VTE) requires urgent diagnosis and treatment to avoid related complications. Clinical presentations of VTE are nonspecific and require definitive confirmation by imaging techniques. A clinical pretest probability (PTP) score system helps predict VTE and reduces the need for costly imaging studies. d-dimer (DD) assay has been used to screen patients for VTE and has shown to be specific for VTE. The combined use of PTP and DD assay may improve exclusion of VTE and safely avoid imaging studies.Materials and methodsWe prospectively used the Wells PTP score and a DD test to evaluate 230 consecutive patients who presented with VTE symptoms. The receiver operating characteristic curve was used to identify a new DD cutoff value, which was applied to VTE diagnosis and compared with the upper limit of locally established reference range for prediction of thrombosis alone and in combination with the clinical PTP score.ResultsWe evaluated 118 patients with VTE symptoms fulfilling the inclusion criteria, 64 (54.2%) with clinically suspected deep vein thrombosis (DVT) and 54 (45.8%) with symptoms of pulmonary embolism (PE). The PTP was low in 28 (43.8%) and moderate/high in 36 (56.25%) of the suspected DVT patients, and low in 29 (53.7%) and moderate/high in 25 (46.3%) of the suspected PE patients. Eighteen cases were confirmed by imaging studies: 9 DVT and 9 PE. The agreement between confirmed cases and PTP was significant with PE but not DVT. The negative predictive value for both DVT and PE with current DD cutoff value of <250 μg/L DDU was 100%, whereas with the calculated cutoff the NPV was 88%.ConclusionsWe confirm that PTP score is valuable tool for medical residents to improve the detection accuracy of VTE, especially for PE. The DD cutoff value of 250 μg/L FEU is ideal for excluding most cases of low PTP; however, the calculated cutoff was less specific for the exclusion of VTE.

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Section: Discussionmentioning

confidence: 99%

Evaluation of the usefulness of a D dimer test in combination with clinical pretest probability score in the prediction and exclusion of Venous Thromboembolism by medical residents

et al. 2014

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“…This revealed an increase of the optimal cut-off value of approximately 100 μg/L per decade (10 μg/L per year). This age adjusted cut-off value was subsequently validated in secondary care patients with suspected pulmonary embolism,16 17 and in both primary and secondary care cohorts of patients with suspected deep vein thrombosis 1819 However, higher cut-off values may also lead to an increased percentage of false negative cases (that is, missed cases of venous thromboembolism), which might make this strategy less safe 20…”

Section: Introductionmentioning

confidence: 99%

Diagnostic accuracy of conventional or age adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism: systematic review and meta-analysis

Schouten

Geersing

Koek

et al. 2013

BMJ

275

185

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Objective To review the diagnostic accuracy of D-dimer testing in older patients (>50 years) with suspected venous thromboembolism, using conventional or age adjusted D-dimer cut-off values.Design Systematic review and bivariate random effects meta-analysis. Data sourcesWe searched Medline and Embase for studies published before 21 June 2012 and we contacted the authors of primary studies.Study selection Primary studies that enrolled older patients with suspected venous thromboembolism in whom D-dimer testing, using both conventional (500 µg/L) and age adjusted (age×10 µg/L) cut-off values, and reference testing were performed. For patients with a non-high clinical probability, 2×2 tables were reconstructed and stratified by age category and applied D-dimer cut-off level.Results 13 cohorts including 12 497 patients with a non-high clinical probability were included in the meta-analysis. The specificity of the conventional cut-off value decreased with increasing age, from 57.6% (95% confidence interval 51.4% to 63.6%) in patients aged 51-60 years to 39.4% (33.5% to 45.6%) in those aged 61-70, 24.5% (20.0% to 29.7% in those aged 71-80, and 14.7% (11.3% to 18.6%) in those aged >80. Age adjusted cut-off values revealed higher specificities over all age categories: 62.3% (56.2% to 68.0%), 49.5% (43.2% to 55.8%), 44.2% (38.0% to 50.5%), and 35.2% (29.4% to 41.5%), respectively. Sensitivities of the age adjusted cut-off remained above 97% in all age categories. ConclusionsThe application of age adjusted cut-off values for D-dimer tests substantially increases specificity without modifying sensitivity, thereby improving the clinical utility of D-dimer testing in patients aged 50 or more with a non-high clinical probability. IntroductionD-dimer concentrations are highly sensitive for thrombus formation. Hence D-dimer tests are often used to rule-out venous thromboembolism (pulmonary embolism or deep vein thrombosis) in suspected patients with a non-high clinical probability. Patients with a high clinical probability do not require a D-dimer test. In these patients imaging examination is warranted to confirm or refute the diagnosis, irrespective of the D-dimer results ( fig 1⇓).1-3 However, D-dimer concentrations increase with age, which leads to a high proportion of older patients with D-dimer concentrations higher than conventional cut-off values (500 µg/L).4 5 This in turn leads to a low specificity (that is, more false positive results) of D-dimer testing in older patients suspected of having venous thromboembolism; the specificity is 49% to 67% for patients aged less than 50 years but in older old patients (≥80 years) between 0% and 18%.4-8 As imaging is indicated in patients suspected of having venous thromboembolism with a D-dimer concentration above the cut-off value, 9 a high proportion of older patients with a non-high clinical probability undergo unnecessary diagnosticCorrespondence to: H J Schouten h.j.schouten-3@umcutrecht.nl Extra material supplied by the author (see

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“…The question of a higher D-dimer cut-off in elderly patients was raised a decade ago [34], but studies confirming the potential security of such a strategy by retrospectively applying age-adjusted cut-offs to large prospective cohorts of consecutive patients with suspected VTE were published between 2010 and 2012 [35][36][37][38][39]. A recent systematic review and meta-analysis of studies in patients with suspected VTE (PE and DVT) showed a dramatic decrease of the pooled specificity from 66.8% (95% CI 61.3-72) in patients b50 years to 14.7% (95% CI 11.3-18.6) in patients N80 years with the conventional D-dimer cut-off [40].…”

Section: Performance Of D-dimers In the Elderlymentioning

confidence: 99%

Diagnosis and management of pulmonary embolism in the elderly

Robert‐Ebadi

Righini

2014

European Journal of Internal Medicine

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a b s t r a c t a r t i c l e i n f oElderly patients are a population not only at particularly high risk of venous thromboembolism including pulmonary embolism (PE), but also at high risk of adverse clinical outcomes and treatment-related complications. Major progresses have been achieved in the diagnosis and treatment of PE over the last two decades. Nevertheless, some of elderly patients' specificities still represent important challenges in the management of PE in this population, from its suspicion to its diagnosis and treatment, and are discussed in this review. Perspectives for the future are from a diagnostic point of view the potential implementation of age-adjusted D-dimer cut-offs that will allow ruling out PE in a greater proportion of elderly patients without the need for thoracic imaging. From a therapeutic point of view, acquisition of post-marketing clinical experience with the use of new oral anticoagulants is still necessary, and in the meantime, these drugs should be prescribed with great caution in thoroughly selected elderly patients.

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The combination of four different clinical decision rules and an age-adjusted D-dimer cut-off increases the number of patients in whom acute pulmonary embolism can safely be excluded

Cited by 29 publications

References 26 publications

Evaluation of the usefulness of a D dimer test in combination with clinical pretest probability score in the prediction and exclusion of Venous Thromboembolism by medical residents

Evaluation of the usefulness of a D dimer test in combination with clinical pretest probability score in the prediction and exclusion of Venous Thromboembolism by medical residents

Diagnostic accuracy of conventional or age adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism: systematic review and meta-analysis

Diagnosis and management of pulmonary embolism in the elderly

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