What Is the Best Imaging Study to Rule Out Pulmonary Embolism in Pregnancy?

ObjectiveRecent studies suggest that combinations of clinical probability assessment (the YEARS algorithm or Geneva score) and D-dimer can safely rule out suspected pulmonary embolism (PE) in pregnant women. We performed a secondary analysis of the DiPEP (Diagnosis of Pulmonary Embolism in Pregnancy) study data to determine the diagnostic accuracy of these strategies.MethodsThe DiPEP study prospectively recruited and collected data and blood samples from pregnant/postpartum women with suspected PE across 11 hospitals and retrospectively collected data from pregnant/postpartum women with diagnosed PE across all UK hospitals (15 February 2015 to 31 August 2016). We selected prospectively recruited pregnant women who had definitive diagnostic imaging for this analysis. We used clinical data and D-dimer results to determine whether the rule out strategies would recommend further investigation. Two independent adjudicators used data from imaging reports, treatments and adverse events up to 30 days to determine the reference standard.ResultsPEs were diagnosed in 12/219 (5.5%) women. The YEARS/D-dimer strategy would have ruled out PE in 96/219 (43.8%) but this would have included 5 of the 12 with PEs. Sensitivity for PE was 58.3% (95% CI 28.6% to 83.5%) and specificity 44.0% (37.1% to 51.0%). The Geneva/D-dimer strategy would have ruled out PE in 46/219 (21.0%) but this would have included three of the 12 with PE. Sensitivity was 75.0% (95% CI 42.8% to 93.3%) and specificity 20.8% (95% CI 15.6% to 27.1%). Administration of anticoagulants prior to blood sampling may have reduced D-dimer sensitivity for small PE.ConclusionStrategies using clinical probability and D-dimer have limited diagnostic accuracy and do not accurately rule out all PE in pregnancy. It is uncertain whether PE missed by these strategies lead to clinically important consequences.

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D-Dimer and CT Rule Out Pulmonary Embolism

Hospitalist News ◽

10.1016/s1875-9122(08)70058-0 ◽

2008 ◽

Vol 1 (2) ◽

pp. 11

Author(s):

DAMIAN MCNAMARA

Keyword(s):

Pulmonary Embolism ◽

D Dimer ◽

Rule Out

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D-Dimer Determination to Exclude Pulmonary Embolism: a Two-Step Approach Using Latex Assay as a Screening Tool

Thrombosis and Haemostasis ◽

10.1055/s-0038-1648817 ◽

1994 ◽

Vol 72 (01) ◽

pp. 089-091 ◽

Cited By ~ 21

Author(s):

P de Moerloose ◽

Ph Minazio ◽

G Reber ◽

A Perrier ◽

H Bounameaux

Keyword(s):

Pulmonary Embolism ◽

Screening Tool ◽

Screening Tests ◽

Enzyme Linked Immunosorbent Assay ◽

Elisa Assay ◽

Elisa Technique ◽

Diagnostic Step ◽

D Dimer ◽

Rule Out ◽

Latex Test

SummaryD-dimer (DD), when measured by a quantitative enzyme-linked immunosorbent assay (ELISA), is a valuable test to exclude venous thromboembolism (VTE). However, DD ELISA technique is not appropriate for emergency use and the available agglutination latex assays are not sensitive enough to be used as an alternative to rule out the diagnosis of VTE. Latex assays could still be used as screening tests. We tested this hypothesis by comparing DD levels measured by ELISA and latex assays in 334 patients suspected of pulmonary embolism. All but one patient with a positive (DD ≥500 ng/ml) latex assay had DD levels higher than 500 ng/ml with the ELISA assay. Accordingly, ELISA technique could be restricted to patients with a negative result in latex assay. This two-step approach would have spared about 50% of ELISA in our cohort. In conclusion, our data indicate that a latex test can be used as a first diagnostic step to rule out pulmonary embolism provided a negative result is confirmed by ELISA and the performance of the latex assay used has been assessed properly.

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Faculty Opinions recommendation of Effect of the Pulmonary Embolism Rule-Out Criteria on Subsequent Thromboembolic Events Among Low-Risk Emergency Department Patients: The PROPER Randomized Clinical Trial.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.732660133.793569461 ◽

2020 ◽

Author(s):

Victor Tapson

Keyword(s):

Clinical Trial ◽

Emergency Department ◽

Pulmonary Embolism ◽

Randomized Clinical Trial ◽

Low Risk ◽

Thromboembolic Events ◽

Emergency Department Patients ◽

Rule Out

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Faculty Opinions recommendation of Effect of the Pulmonary Embolism Rule-Out Criteria on Subsequent Thromboembolic Events Among Low-Risk Emergency Department Patients: The PROPER Randomized Clinical Trial.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.732660133.793543059 ◽

2018 ◽

Author(s):

Jeffrey Kline

Keyword(s):

Clinical Trial ◽

Emergency Department ◽

Pulmonary Embolism ◽

Randomized Clinical Trial ◽

Low Risk ◽

Thromboembolic Events ◽

Emergency Department Patients ◽

Rule Out

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Faculty Opinions recommendation of Effect of the Pulmonary Embolism Rule-Out Criteria on Subsequent Thromboembolic Events Among Low-Risk Emergency Department Patients: The PROPER Randomized Clinical Trial.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.732660133.793542665 ◽

2018 ◽

Author(s):

Lars C Huber

Keyword(s):

Clinical Trial ◽

Emergency Department ◽

Pulmonary Embolism ◽

Randomized Clinical Trial ◽

Low Risk ◽

Thromboembolic Events ◽

Emergency Department Patients ◽

Rule Out

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Evidence for Age-Adjusted D-Dimer to Rule out Pulmonary Embolism: An Institutional Study

American Journal of Clinical Pathology ◽

10.1093/ajcp/aqaa137.007 ◽

2020 ◽

Vol 154 (Supplement_1) ◽

pp. S5-S5

Author(s):

Ridin Balakrishnan ◽

Daniel Casa ◽

Morayma Reyes Gil

Keyword(s):

Pulmonary Embolism ◽

False Positive ◽

False Positive Rate ◽

Moderate Risk ◽

Older Population ◽

Statistical Measures ◽

Positive Rate ◽

Risk Patients ◽

D Dimer ◽

Rule Out

Abstract The diagnostic approach for ruling out suspected acute pulmonary embolism (PE) in the ED setting includes several tests: ultrasound, plasma d-dimer assays, ventilation-perfusion scans and computed tomography pulmonary angiography (CTPA). Importantly, a pretest probability scoring algorithm is highly recommended to triage high risk cases while also preventing unnecessary testing and harm to low/moderate risk patients. The d-dimer assay (both ELISA and immunoturbidometric) has been shown to be extremely sensitive to rule out PE in conjunction with clinical probability. In particularly, d-dimer testing is recommended for low/moderate risk patients, in whom a negative d-dimer essentially rules out PE sparing these patients from CTPA radiation exposure, longer hospital stay and anticoagulation. However, an unspecific increase in fibrin-degradation related products has been seen with increase in age, resulting in higher false positive rate in the older population. This study analyzed patient visits to the ED of a large academic institution for five years and looked at the relationship between d-dimer values, age and CTPA results to better understand the value of age-adjusted d-dimer cut-offs in ruling out PE in the older population. A total of 7660 ED visits had a CTPA done to rule out PE; out of which 1875 cases had a d-dimer done in conjunction with the CT and 5875 had only CTPA done. Out of the 1875 cases, 1591 had positive d-dimer results (>0.50 µg/ml (FEU)), of which 910 (57%) were from patients older than or equal to fifty years of age. In these older patients, 779 (86%) had a negative CT result. The following were the statistical measures of the d-dimer test before adjusting for age: sensitivity (98%), specificity (12%); negative predictive value (98%) and false positive rate (88%). After adjusting for age in people older than 50 years (d-dimer cut off = age/100), 138 patients eventually turned out to be d-dimer negative and every case but four had a CT result that was also negative for a PE. The four cases included two non-diagnostic results and two with subacute/chronic/subsegmental PE on imaging. None of these four patients were prescribed anticoagulation. The statistical measures of the d-dimer test after adjusting for age showed: sensitivity (96%), specificity (20%); negative predictive value (98%) and a decrease in the false positive rate (80%). Therefore, imaging could have been potentially avoided in 138/779 (18%) of the patients who were part of this older population and had eventual negative or not clinically significant findings on CTPA if age-adjusted d-dimers were used. This data very strongly advocates for the clinical usefulness of an age-adjusted cut-off of d-dimer to rule out PE.

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