Value of D-Dimer Testing for the Exclusion of Pulmonary Embolism in Patients With Previous Venous Thromboembolism

Gal, Grégoire Le; Righini, Marc; Roy, Pierre‐Marie; Sanchez, Olivier; Aujesky, Drahomir; Perrier, Arnaud; Bounameaux, Henri

doi:10.1001/archinte.166.2.176

Cited by 76 publications

(22 citation statements)

References 25 publications

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“…The recurrence risk was 0% during the next 3 months in patients with previous VTE and a negative D-dimer test who did not receive anticoagulation. [66] Surprisingly, the 2-fold lower chance of a negative D-dimer test result in patients with previous VTE was not influenced by older age, cancer, recent surgery, or acute inflammation or infection. Patients with normal D-dimer 1 month after stopping anticoagulation who did not resume anticoagulation had an annual recurrence rate of 4.4% in 1 study.…”

Section: Recurrent Venous Thromboembolismmentioning

confidence: 99%

Effectiveness of D-dimer as a screening test for venous thromboembolism: An update

2014

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Venous thromboembolism (VTE) is the leading cause of morbidity and mortality among hospitalized patients. We searched the PubMed database and reviewed the articles published until June 2011. Articles related to the D-dimer and VTE were considered to write this paper. Many factors play a key role in changing the sensitivity and specificity of D-dimer testing, including the extent of thrombosis and fibrinolytic activity, duration of symptoms, anticoagulant therapy, comorbidity due to surgical or medical illnesses, inflammatory diseases, cancer, elderly age, pregnancy and the postpartum period, and previous VTE. Many previous studies have shown that the D-dimer test is highly sensitive (>95%) in acute deep venous thrombosis or pulmonary embolism, usually with a cut-off value of 500 μg FEU/l, which reasonably rules out acute VTE, particularly in patients with low clinical probability (LCP) or intermediate clinical probability. Patients with high D-dimer levels upon presentation may prompt a more intense diagnostic approach, irrespective of pretest probability. Studies performed after a negative D-dimer for 3 months proved the high negative predictive value (NPV) of D-dimer testing together with LCP in patients with suspected VTE. Among oncology patients, D-dimer testing has the highest sensitivity and NPV in excluding VTE. The new cutoff values of D-dimer testing were analyzed in a recent prospective study of pregnant women; they are 286 ng DDU/ml, 457 ng DDU/ml, and 644 ng DDU/ml for the first, second, and third trimesters, respectively.

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Section: Recurrent Venous Thromboembolismmentioning

confidence: 99%

Effectiveness of D-dimer as a screening test for venous thromboembolism: An update

2014

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“…If D‐dimer results had been available for all patients, this may have improved overall classifiability and perhaps altered our study results. However, although evidence suggests that a negative D‐dimer result safely rules out VTE in patients with a prior VTE, the clinical utility of the test is halved in this group: in a post hoc analysis of a diagnostic management outcome study, only 15.9% of patients with a previous history of VTE had PE ruled out on the basis of the combination of a non‐high clinical probabillity of PE and a negative D‐dimer result, as compared with 32.7% of patients with no previous episode [5]. Finally, whether baseline imaging is cost‐effective or not deserves further attention.…”

Section: Discussionmentioning

confidence: 99%

“…Patients with a prior VTE are less likely to be classified as low risk by clinical decision rules, and are therefore more likely to require further diagnostic tests in order to rule out recurrent VTE [2–4]. The specificity and clinical utility of D‐dimer testing is also lower in patients with a suspected recurrent VTE [5,6]. Furthermore, residual venous obstruction (RVO) is a common finding in patients with prior DVT.…”

Section: Introductionmentioning

confidence: 99%

Baseline imaging after therapy for unprovoked venous thromboembolism: a randomized controlled comparison of baseline imaging for diagnosis of suspected recurrence

Hamadah

Alwasaidi

Gal

et al. 2011

Journal of Thrombosis and Haemostasis

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Summary. Background: After a first unprovoked venous thromboembolism (VTE), many patients have residual pulmonary and/or lower limb vascular obstruction following completion of short‐term anticoagulation. Residual vascular obstruction may complicate the diagnosis of recurrent VTE. Whether baseline imaging, conducted after completion of anticoagulation, helps in interpreting diagnostic testing in patients who subsequently have suspected recurrent VTE is unknown. Study design: The REVERSE study is a cohort study whose primary aim was to derive a clinical decision rule to guide the duration of anticoagulation after a first unprovoked VTE. All patients underwent baseline imaging after completing 5–7 months of anticoagulant therapy. We performed a post hoc randomized controlled comparison among 121 patients investigated for a suspected recurrent VTE during follow‐up: the decision on recurrent VTE with or without baseline imaging was made available to two independent adjudicators. Results: The proportion of patients not classifiable for recurrent VTE was statistically significantly higher in the group with no baseline imaging than in the group with baseline imaging: one in five as compared with one in 25. The interobserver agreement between the two adjudicators was better in the group with baseline imaging than in the group with no baseline imaging: κ‐values were 0.78 and 0.54, respectively. Conclusions: In patients with a first unprovoked VTE, baseline imaging at completion of anticoagulant therapy helps in interpreting diagnostic tests performed in cases of suspected recurrent VTE.

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“…Diagnosing recurrent PE is more challenging than diagnosing a first episode of PE for several reasons. First, the sensitivity of D‐dimer tests in patients with recurrent thrombotic disease is decreased compared with a first episode . Second, recurrent emboli may be radiographically difficult to differentiate from residual emboli, which may be identified in up to 50% of patients diagnosed with PE .…”

Section: Imaging Test For Clinically Suspected Pementioning

confidence: 99%

Diagnostic management of acute deep vein thrombosis and pulmonary embolism

Huisman

Klok

2013

Journal of Thrombosis and Haemostasis

147

128

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To cite this article: Huisman MV, Klok FA. Diagnostic management of acute deep vein thrombosis and pulmonary embolism. J Thromb Haemost 2013; 11: 412-22.Summary. Acute deep vein thrombosis (DVT) and pulmonary embolism (PE) represent two expressions of a similar clinical pathological process, often referred to as venous throm-boembolism (VTE). It has long been recognized that, as clinical signs and symptoms of PE and DVT are not specific for the diagnosis, objective diagnosis in both patients presenting with leg symptoms and those with chest symptoms is mandatory. Since the last review on this subject in this journal in 2009, several large trials have been performed that shed new light on all aspects of the diagnostic management of suspected VTE, especially in the field of simplified clinical decision rules, agedependent D-dimer cut-offs and magnetic resonance imaging. A literature search covering the period 2007-2012 was performed using the Medline/PubMed database to identify all relevant papers regarding the diagnostic management of acute PE and DVT. Established concepts and the latest evidence on this subject will be the main focus of this review.Keywords: clinical decision rule, D-dimer, deep vein thrombosis, diagnostic management, imaging, pulmonary embolism, venous thromboembolism. Clinical probability assessment and D-dimer testsA certain diagnosis of acute PE or DVT can only be established by means of imaging [1]. On the other hand, ruling out acute VTE can be safely achieved by using a standardized clinical probability assessment and a D-Dimer blood test. The main advantage of such an approach is a reduction in the required number of imaging tests, which are in general time consuming, costly and associated with radiation exposure and other complications. D-dimerFibrin D-dimer is the final product of the plasmin-mediated degradation of cross-linked fibrin. Its plasma concentration is dependent on fibrin generation and subsequent degradation by the endogenous fibrinolytic system [2]. Ddimer levels are typically elevated in patients with acute venous thrombosis. Accordingly, the sensitivity of an elevated D-dimer concentration for VTE is very high [3]. In contrast, as D-dimer levels can be elevated in other clinical conditions that are associated with enhanced fibrin (e.g. malignancy, trauma, increased age, disseminated intravascular coagulation, inflammation, infection, sepsis, postoperative states and pre-eclampsia), the specificity for acute thrombosis is rather poor [3]. Thus the diagnostic strength of D-dimer tests lies in ruling out DVT or PE.A large variety of assays are available for D-dimer measurement, and they are all based on the use of monoclonal antibodies that recognize epitopes of the D-dimer fragment that are not present on fibrinogen or noncrossed fragments of fibrin [4]. From numerous accuracy and management studies, it has been demonstrated that the sensitivities of the D-dimer enzyme-linked immunofluorescence assay (ELFA) (DVT 96%; PE 97%), microplate enzyme-linked immunosorbent assay (...

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Value of D-Dimer Testing for the Exclusion of Pulmonary Embolism in Patients With Previous Venous Thromboembolism

Abstract: In patients with suspected PE and previous VTE, a negative D-dimer test result seems to allow safely ruling out a recurrent event. However, the proportion of negative results is lower in such patients, definitely reducing the clinical usefulness of the D-dimer test in that subgroup.

Cited by 76 publications

References 25 publications

Effectiveness of D-dimer as a screening test for venous thromboembolism: An update

Effectiveness of D-dimer as a screening test for venous thromboembolism: An update

Baseline imaging after therapy for unprovoked venous thromboembolism: a randomized controlled comparison of baseline imaging for diagnosis of suspected recurrence

Diagnostic management of acute deep vein thrombosis and pulmonary embolism

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