What level of D-dimers can safely exclude pulmonary embolism in COVID-19 patients presenting to the emergency department?

Revel, Marie-Pierre; Beeker, Nathanaël; Porcher, Raphaël; Jilet, Léa; Fournier, Laure; Rance, Bastien; Chassagnon, Guillaume; Fontenay, Michaëla; Sanchez, Olivier

doi:10.1007/s00330-021-08377-9

Cited by 26 publications

(21 citation statements)

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“…However, we found a D-Dimer threshold of 1000 µg/L led to an unacceptable failure rate of 8.1%, much higher than the failure rate of 2% reported by Revel et al [7]. Therefore, increasing the D-Dimer threshold in the specific setting of COVID-19 pneumonia should be avoided.…”

Section: Discussioncontrasting

confidence: 64%

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Strategies to safely rule out pulmonary embolism in COVID-19 outpatients: a multicenter retrospective study

et al. 2023

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ObjectivesThe objective was to define a safe strategy to exclude pulmonary embolism (PE) in COVID-19 outpatients, without performing CT pulmonary angiogram (CTPA). Methods COVID-19 outpatients from 15 university hospitals who underwent a CTPA were retrospectively evaluated. D-Dimers, variables of the revised Geneva and Wells scores, as well as laboratory findings and clinical characteristics related to COVID-19 pneumonia, were collected. CTPA reports were reviewed for the presence of PE and the extent of COVID-19 disease. PE rule-out strategies were based solely on D-Dimer tests using different thresholds, the revised Geneva and Wells scores, and a COVID-19 PE prediction model built on our dataset were compared. The area under the receiver operating characteristics curve (AUC), failure rate, and efficiency were calculated. Results In total, 1369 patients were included of whom 124 were PE positive (9.1%). Failure rate and efficiency of D-Dimer > 500 µg/l were 0.9% (95%CI, 0.2-4.8%) and 10.1% (8.5-11.9%), respectively, increasing to 1.0% (0.2-5.3%) and 16.4% (14.4-18.7%), respectively, for an age-adjusted D-Dimer level. D-dimer > 1000 µg/l led to an unacceptable failure rate to 8.1% (4.4-14.5%). The best performances of the revised Geneva and Wells scores were obtained using the age-adjusted D-Dimer level. They had the same failure rate of 1.0% (0.2-5.3%) for efficiency of 16.8% (14.7-19.1%), and 16.9% (14.8-19.2%) respectively. The developed COVID-19 PE prediction model had an AUC of 0.609 (0.594-0.623) with an efficiency of 20.5% (18.4-22.8%) when its failure was set to 0.8%. Conclusions The strategy to safely exclude PE in COVID-19 outpatients should not differ from that used in non-COVID-19 patients. The added value of the COVID-19 PE prediction model is minor. Key Points• D-dimer level remains the most important predictor of pulmonary embolism in COVID-19 patients.• The AUCs of the revised Geneva and Wells scores using an age-adjusted D-dimer threshold were 0.587 (95%CI, 0.572 to 0.603) and 0.588 (95%CI, 0.572 to 0.603). • The AUC of COVID-19-specific strategy to rule out pulmonary embolism ranged from 0.513 (95%CI: 0.503 to 0.522) to 0.609 (95%CI: 0.594 to 0.623).

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Section: Discussioncontrasting

confidence: 64%

“…However, the reported increased risk of PE and the systematic dosage of D-dimers due to their important prognostic value, has led to an increase in CTPA referrals in COVID-19 patients as shown by the data from the French National Hospital Discharge database [7].…”

Section: Introductionmentioning

confidence: 99%

Strategies to safely rule out pulmonary embolism in COVID-19 outpatients: a multicenter retrospective study

et al. 2023

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“…The use of D-Dimer assays to exclude VTE in patients with concurrent COVID-19 remains relatively under investigated and use of age adjusted D-Dimer has not been validated in this setting. Some retrospective analysis suggests the same validated threshold for non-COVID-19 patient should be used to exclude PE in patients with COVID-19 [ 21 ], and other suggests that age adjusted D-Dimers may improve diagnostic assessment for patients with PE [ 22 ]. Further investigation of the utility of the AADD in the COVID-19 patient population and methods to improve the performance of the tests is required.…”

Section: Discussionmentioning

confidence: 99%

The application of an age adjusted D-dimer threshold to rule out suspected venous thromboembolism (VTE) in an emergency department setting: a retrospective diagnostic cohort study

2022

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Background Venous Thromboembolic disease (VTE) poses a diagnostic challenge for clinicians in acute care. Over reliance on reference standard investigations can lead to over treatment and potential harm. We sought to evaluate the pragmatic performance and implications of using an age adjusted D-dimer (AADD) strategy to rule out VTE in patients with suspected disease attending an emergency department (ED) setting. We aimed to determine diagnostic test characteristics and assess whether this strategy would result in proportional imaging reduction and potential cost savings. Methods Design: Single centre retrospective diagnostic cohort study. All patients > 50 years old evaluated for possible VTE who presented to the emergency department over a consecutive 12-month period between January and December 2016 with a positive D-dimer result. Clinical assessment records and reference standard imaging results were followed up by multiple independent adjudicators and coded as VTE positive or negative. Results During the study period, there were 2132 positive D-dimer results. One thousand two hundred thirty-six patients received reference standard investigations. A total increase of 314/1236 (25.1%) results would have been coded as true negatives as opposed to false positive if the AADD cut off point had been applied, with 314 reference standard tests subsequently avoided. The AADD cut off had comparable sensitivity to the current cut off despite this increase in specificity; sensitivities for the diagnosis of DVT were 99.28% (95% CI 96.06–99.98%) and 97.72% for PE (95% CI 91.94% to 97.72). There were 3 false negative results using the AADD strategy. Conclusions In patients with suspected VTE with a low or moderate pre-test probability, the application of AADD appears to increase the proportion of patients in which VTE can be excluded without the need for reference standard imaging. This management strategy is likely to be associated with substantial reduction in anticoagulation treatment, investigations and cost/time savings.

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“…The increase in pulmonary thromboembolism risk was highly dependent on severe COVID-19 (25% vs 15%) in another meta-analysis ( 92 ) ( Fig 9 ). In addition, in an international cohort study of 3358 patients who underwent CT pulmonary angiography, patients with COVID-19 had similar rates of pulmonary thromboembolism compared to patients without COVID-19 (15% in both groups), leading to the recommendation that for patients with COVID-19 and suspected pulmonary thromboembolism, no adjustment to a standard pulmonary thromboembolism diagnostic strategy is required and the same threshold of the d -dimer in the general population could be applied ( 92 – 95 ).…”

Section: Complications and Their Clinical And Imaging Featuresmentioning

confidence: 99%

Current and Emerging Knowledge in COVID-19

Jeong

Park

et al. 2023

Radiology

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COVID-19 has emerged as a pandemic leading to a global public health crisis of unprecedented morbidity. A comprehensive insight into the imaging of COVID-19 has enabled early diagnosis, stratification of disease severity, and identification of potential sequelae. The evolution of COVID-19 can be divided into early infectious, pulmonary, and hyperinflammatory phases. Clinical features, imaging features, and management are different among the three phases. In the early stage, peripheral ground-glass opacities are predominant CT findings, and therapy directly targeting SARS-CoV-2 is effective. In the later stage, organizing pneumonia or diffuse alveolar damage pattern are predominant CT findings and anti-inflammatory therapies are more beneficial. The risk of severe disease or hospitalization is lower in breakthrough or Omicron variant infection compared with nonimmunized or Delta variant infections. The protection rates of the fourth dose of mRNA vaccination were 34% and 67% against overall infection and hospitalizations for severe illness, respectively. After acute COVID-19 pneumonia, most residual CT abnormalities gradually decreased in extent, but they may remain as linear or multifocal reticular or cystic lesions. Advanced insights into the pathophysiologic and imaging features of COVID-19 along with vaccine benefits have improved patient care, but emerging knowledge of post–COVID-19 condition, or long COVID, also presents radiology with new challenges. © RSNA, 2023 Supplemental material is available for this article.

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What level of D-dimers can safely exclude pulmonary embolism in COVID-19 patients presenting to the emergency department?

Cited by 26 publications

References 40 publications

Strategies to safely rule out pulmonary embolism in COVID-19 outpatients: a multicenter retrospective study

Strategies to safely rule out pulmonary embolism in COVID-19 outpatients: a multicenter retrospective study

The application of an age adjusted D-dimer threshold to rule out suspected venous thromboembolism (VTE) in an emergency department setting: a retrospective diagnostic cohort study

Current and Emerging Knowledge in COVID-19

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