scholarly journals P113: Comparison of age-adjusted and clinical probability-adjusted D-dimer for diagnosing pulmonary embolism

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S116
Author(s):  
S. Sharif ◽  
C. Kearon ◽  
M. Li ◽  
M. Eventov ◽  
R. Jiang ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
False Negative ◽  
False Negative Rate ◽  
Retrospective Chart Review ◽  
Ct Scanning ◽  
Clinical Probability ◽  
Negative Rate ◽  
Wells Score ◽  
Acute Pe ◽  
D Dimer

Introduction: Diagnosing pulmonary embolism (PE) in the emergency department can be challenging due to non-specific signs and symptoms; this often results in the over-utilization of CT pulmonary angiography (CT-PA). In 2013, the American College of Chest Physicians identified CT-PA as one of the top five avoidable tests. Age-adjusted D-dimer has been shown to decrease CT utilization rates. Recently, clinical-probability adjusted D-dimer has been promoted as an alternative strategy to reduce CT scanning. The aim of this study is to compare the safety and efficacy of the age-adjusted D-dimer rule and the clinical probability-adjusted D-dimer rule in Canadian ED patients tested for PE. Methods: This was a retrospective chart review of ED patients investigated for PE at two hospitals from April 2013 to March 2015 (24 months). Inclusion criteria were the ED physician ordered CT-PA, Ventilation-Perfusion (VQ) scan or D-dimer for investigation of PE. Patients under the age of 18 were excluded. PE was defined as CT/VQ diagnosis of acute PE or acute PE/DVT in 30-day follow-up. Trained researchers extracted anonymized data. The age-adjusted D-dimer and the clinical probability-adjusted D-dimer rules were applied retrospectively. The rate of CT/VQ imaging and the false negative rates were calculated. Results: In total, 1,189 patients were tested for PE. 1,129 patients had a D-dimer test and a Wells score less than 4.0. 364/1,129 (32.3%, 95%CI 29.6-35.0%) would have undergone imaging for PE if the age-adjusted D-dimer rule was used. 1,120 patients had a D-dimer test and a Wells score less than 6.0. 217/1,120 patients (19.4%, 95%CI 17.2-21.2%) would have undergone imaging for PE if the clinical probability-adjusted D-dimer rule was used. The false-negative rate for the age-adjusted D-dimer rule was 0.3% (95%CI 0.1-0.9%). The false-negative rate of the clinical probability-adjusted D-dimer was 1.0% (95%CI 0.5-1.9%). Conclusion: The false-negative rates for both the age-adjusted D-dimer and clinical probability-adjusted D-dimer are low. The clinical probability-adjusted D-dimer results in a 13% absolute reduction in CT scanning compared to age-adjusted D-dimer.

scholarly journals LO81: Optimizing the use of CT scanning for pulmonary embolism in the emergency department

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S56
Author(s):  
S. Sharif ◽  
C. Kearon ◽  
M. Li ◽  
M. Eventov ◽  
P.E. Sneath ◽  
...  
Keyword(s):  
Emergency Department ◽  
Pulmonary Embolism ◽  
False Negative ◽  
False Negative Rate ◽  
Ct Scanning ◽  
Negative Rate ◽  
Wells Score ◽  
Wells Rule ◽  
Acute Pe ◽  
D Dimer

Introduction: Diagnosing pulmonary embolism (PE) can be challenging because the signs and symptoms are often non-specific. Studies have shown that evidence-based diagnostic algorithms are not always adhered to in the Emergency Department (ED), which leads to unnecessary CT scanning. In 2013, the American College of Chest Physicians identified CT pulmonary angiography as one of the top five avoidable tests. One solution is to use a clinical prediction rule combined with the D-dimer, which safely reduces the use of CT scanning. The objective of this study was to compare the proportion of patients tested for PE in two emergency departments, who 1) had a CT-PE and 2) whose diagnosis of PE was missed. We compared these rates to those if the Wells rule and D-dimer had been applied as standard. Methods: This was a retrospective chart review of ED patients investigated for PE at two hospitals from April 2013 to March 2015 (24 months). Inclusion criteria were the ED physician ordered CT-PE, Ventilation-Perfusion (VQ) scan or D-dimer for investigation of PE. Patients under the age of 18 were excluded. PE was defined as CT/VQ diagnosis of acute PE or acute PE/DVT in 30-day follow-up. Trained researchers extracted anonymized data. The rate of CT/VQ imaging and the false-negative rates were calculated. The false-negative rate was calculated as the number of patients diagnosed with PE within 30 days as a proportion of those patients who did not have a CT/VQ scan at initial presentation. Results: There were 1,189 patients included in this study. 55/1,189 patients (4.6%; 95%CI 3.6-6.0%) were ultimately diagnosed with PE within 30 days. 397/1,189 patients (33.4%; 95%CI 30.8-36.1%) had CT/VQ scans for PE. 3 out of 792 who were not scanned had a missed PE resulting in a false-negative rate of 0.4% (95% CI 0.1-1.1%). 80 patients had an elevated D-dimer or high Wells score but were not imaged. Furthermore, 75 patients who did not have an elevated D-dimer nor a high Wells score were imaged. Had Wells rule/D-dimer been adhered to, 402/1,189 patients (33.8%; 95%CI 31.9-36.6%) would have undergone imaging and the false negative rate would be 0/727, 0% (95%CI 0.0-0.5%). Conclusion: If the Wells rule and D-dimer was used in all patients tested for PE, a similar proportion would have a CT scan but fewer PEs would be missed.

scholarly journals LO55: Comparison of the age-adjusted D-dimer, clinical probability-adjusted D-dimer, and Wells rule with D-dimer for diagnosing deep vein thrombosis in the emergency department.

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S27-S27
Author(s):  
S. Sharif ◽  
C. Kearon ◽  
M. Eventov ◽  
P. Sneath ◽  
M. Li ◽  
...  
Keyword(s):  
False Negative ◽  
False Negative Rate ◽  
Duplex Ultrasonography ◽  
Vein Thrombosis ◽  
Clinical Probability ◽  
Negative Rate ◽  
Wells Score ◽  
Wells Rule ◽  
Deep Vein ◽  
D Dimer

Introduction: Diagnosing deep vein thrombosis (DVT) is of critical importance because of its associated morbidity and mortality. Diagnosing DVT can be challenging in the Emergency Department (ED) due to inconsistent adherence to, and utilization of the Wells rule. Both the age-adjusted and clinical probability adjusted D-dimer have been shown to decrease ultrasound (US) utilization rates. We aimed to compare the safety and efficacy of the Wells score with D-dimer to the age-adjusted and clinical probability-adjusted D-dimer in Canadian ED patients tested for DVT. Methods: This was a health records review of ED patients investigated for DVT at two EDs over a two-year period. Inclusion criteria were ED physician ordered duplex ultrasonography or D-dimer for investigation of lower limb DVT. Patients under the age of 18 were excluded. DVT was considered to be present during the ED visit if DVT was diagnosed on duplex ultrasonography and was treated for acute DVT, or if the patient was subsequently diagnosed with pulmonary embolism (PE) or DVT during the next 30 days. Trained researchers extracted anonymized data. The Wells D-dimer, age-adjusted D-dimer, and the clinical probability-adjusted D-dimer rules were applied retrospectively. The rate of duplex ultrasonography imaging and the false negative rate was calculated for each rule. Results: Between April 1st 2013 and March 31st 2015, there were 1,198 patients tested for DVT. Of the low and moderate clinical pretest probability patients (Wells score ≤ 2), only 436 had a D-Dimer test and were eligible for our analysis. The average age of the patients was 59, 56% were female, and 4% had a malignancy. 207/436 patients (47.4%, 95%CI 42.8-52.2%) would have had US imaging for DVT if the age-adjusted D-dimer rule was used. 214/436 patients (49.1%, 95%CI 44.4-53.8%) would have had imaging for DVT if the clinical probability-adjusted D-dimer was used. If the Wells rule was used with the standard D-dimer cutoff of 500, 241/436 patients (55.2%, 95%CI 50.6-59.9%) would have had imaging for DVT. The false-negative rate for the Wells rule was 1.5% (95%CI 0.5-4.4%). The false-negative rate for the age-adjusted D-dimer rule was 1.3% (95%CI 0.4-3.8%). The false-negative rate for the clinical-probability adjusted D-Dimer was 1.8% (95%CI 0.7-4.5%). Conclusion: In comparison with the approach of the Wells score and D-dimer, both the age-adjusted and clinical probability-adjusted D-dimer diagnostic strategies could reduce the proportion of patients who require US imaging.

scholarly journals P104: Evaluating the use of the pulmonary embolism rule-out criteria in the emergency department

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S93-S94
Author(s):  
S. Sharif ◽  
C. Kearon ◽  
M. Eventov ◽  
M. Li ◽  
P. Sneath ◽  
...  
Keyword(s):  
Emergency Department ◽  
Pulmonary Embolism ◽  
False Negative ◽  
False Negative Rate ◽  
Signs And Symptoms ◽  
Ct Scanning ◽  
Pulmonary Angiogram ◽  
Ct Angiogram ◽  
D Dimer ◽  
Rule Out

Introduction: Diagnosing pulmonary embolism (PE) can be challenging because the signs and symptoms are often non-specific. Studies have shown that evidence-based algorithms are not always adhered to in the Emergency Department (ED), which leads to unnecessary CT scanning. The pulmonary embolism rule-out criteria (PERC) can identify patients who can be safely discharged from the ED without further investigation for PE. The purpose of this study is to evaluate the use of the PERC rule in the ED and to compare the rates of testing for PE if the PERC rule was used. Methods: This was a health records review of ED patients investigated for PE at two emergency departments over a two-year period (April 2013-March 2015). Inclusion criteria were ED physician ordered CT pulmonary angiogram, ventilation-perfusion scan, or D-dimer for investigation of PE. Patients under the age of 18 were excluded. PE was considered to be present during the emergency department visit if PE was diagnosed on CT or VQ (subsegmental level or above), or if the patient was subsequently found to have PE or deep vein thrombosis during the next 30 days. Trained researchers extracted anonymized data. The rate of CT/VQ imaging and the negative predictive value was calculated. Results: There were 1,163 patients that were tested for PE and 1,097 patients were eligible for our analysis. Of the total, 330/1,097 (30.1%; 95%CI 27.4-32.3%) had CT/VQ imaging for PE, and 48/1,097 (4.4%; 95%CI 3.3-5.8%) patients were diagnosed with PE. 806/1,097 (73.5%; 95%CI 70.8-76.0%) were PERC positive, and of these, 44 patients had a PE (5.5%; 95%CI 4.1-7.3%). Conversely, 291/1,097 (26.5%; 95%CI 24.0-29.2%) patients were PERC negative, and of these, 4 patients had a PE (1.4%; 95%CI 0.5-3.5%). Of the PERC negative patients, 291/291 (100.0%; 95%CI 98.7-100.0%) had a D-dimer test done, and 33/291 (11.3%; 95%CI 8.2-15.5%) had a CT angiogram. If PERC was used, CT/VQ imaging would have been avoided in 33/1,097 (3%; 95%CI 2.2-4.2%) patients and the D-dimer would have been avoided in 291/1,097 (26.5%; 95%CI 24.0-29.2%) patients. Conclusion: If the PERC rule was used in all patients with suspected PE, fewer patients would have further testing. The false negative rate for the PERC rule was low.

scholarly journals P136: Evaluating the use of the YEARS clinical decision rule for diagnosing pulmonary embolism in the Emergency Department

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S105-S105 ◽  
Author(s):  
S. Sharif ◽  
C. Kearon ◽  
M. Eventov ◽  
M. Li ◽  
R. Jiang ◽  
...  
Keyword(s):  
Emergency Department ◽  
Pulmonary Embolism ◽  
Deep Vein Thrombosis ◽  
False Negative ◽  
False Negative Rate ◽  
Clinical Signs ◽  
Vein Thrombosis ◽  
Negative Rate ◽  
Deep Vein ◽  
D Dimer

Introduction: Diagnosing pulmonary embolism (PE) can be challenging because the signs and symptoms are often non-specific. Studies have shown that evidence-based algorithms are not always adhered to in the Emergency Department (ED) and are often not used correctly, which leads to unnecessary CT scanning. The YEARS diagnostic algorithm, consisting of three items (clinical signs of deep vein thrombosis, hemoptysis, and whether pulmonary embolism is the most likely diagnosis) and D-dimer, is a novel and simplified way to approach suspected acute PE. The purpose of this study was to 1) evaluate the use of the YEARS algorithm in the ED and 2) to compare the rates of testing for PE if the YEARS algorithm was used. Methods: This was a health records review of ED patients investigated for PE at two emergency departments over a two-year period (April 2013-March 2015). Inclusion criteria were ED physician ordered CT pulmonary angiogram, ventilation-perfusion scan, or D-dimer for investigation of PE. Patients under the age of 18 and those without a D-dimer test were excluded. PE was considered to be present during the emergency department visit if PE was diagnosed on CT or VQ (subsegmental level or above), or if the patient was subsequently found to have PE or deep vein thrombosis during the next 30 days. Trained researchers extracted anonymized data. The rate of CT/VQ imaging and the false negative rate was calculated. Results: There were 1,163 patients that were tested for PE and 1,083 patients were eligible for our analysis. Of the total, 317/1,083 (29.3%; 95%CI 26.6-32.1%) had CT/VQ imaging for PE, and 41/1,083 (3.8%; 95%CI 2.8-5.1%) patients were diagnosed with PE at baseline. Three patients had a missed PE, resulting in a false negative rate of 0.4% (95%CI 0.1-1.2%). If the YEARS algorithm was used, 211/1,083 (19.5%; 95%CI 17.2-22.0%) would have required imaging for PE. Of the patients who would not have required imaging according to the YEARS algorithm, 8/872 (0.9%; 95%CI 0.5-1.8%) would have had a missed PE. Conclusion: If the YEARS algorithm was used in all patients with suspected PE, fewer patients would have required imaging with a small increase in the false negative rate.

scholarly journals Wells’ Score in Diagnosis of Pulmonary Embolism in Patient with Thrombocytopenia: A Case Report

2019 ◽  
Vol 20 (3) ◽  
pp. 281-285
Author(s):  
Dragan Panic ◽  
Andreja Todorovic ◽  
Milica Stanojevic ◽  
Violeta Iric Cupic
Keyword(s):  
Pulmonary Embolism ◽  
Chest Pain ◽  
Acute Pulmonary Embolism ◽  
Pretest Probability ◽  
Clinical Prediction ◽  
Clinical Prediction Rules ◽  
Prediction Rules ◽  
Clinical Probability ◽  
Wells Score ◽  
D Dimer

Abstract Current diagnostic workup of patients with suspected acute pulmonary embolism (PE) usually starts with the assessment of clinical pretest probability, using clinical prediction rules and plasma D-dimer measurement. Although an accurate diagnosis of acute pulmonary embolism (PE) in patients is thus of crucial importance, the diagnostic management of suspected PE is still challenging. A 60-year-old man with chest pain and expectoration of blood was admitted to the Department of Cardiology, General Hospital in Cuprija, Serbia. After physical examination and laboratory analyses, the diagnosis of Right side pleuropne monia and acute pulmonary embolism was established. Clinically, patient was hemodynamically stable, auscultative slightly weaker respiratory sound right basal, without pretibial edema. Laboratory: C-reactive protein (CRP) 132.9 mg/L, Leukocytes (Le) 18.9x109/L, Erythrocytes (Er) 3.23x1012/L, Haemoglobin (Hgb) 113 g/L, Platelets (Plt) 79x109/L, D-dimer 35.2. On the third day after admission, D-dimer was increased and platelet count was decreased (Plt up to 62x109/L). According to Wells’ rules, score was 2.5 (without symptoms on admission), a normal clinical finding with clinical manifestation of hemoptysis and chest pain, which represents the intermediate level of clinical probability of PE. After the recidive of PE, Wells’ score was 6.5. In summary, this study suggests that Wells’ score, based on a patient’s risk for pulmonary embolism, is a valuable guidance for decision-making in combination with knowledge and experience of clinicians. Clinicians should use validated clinical prediction rules to estimate pretest probability in patients in whom acute PE is being consiered.

scholarly journals Performance of the Quantitative Latex Immunoturbidimetric D-dimer Assay for the Diagnosis of Acute Pulmonary Embolism at Rafik Hariri University Hospital

2020 ◽  
Vol 7 (3) ◽  
pp. 125-128
Author(s):  
Rida Salman ◽  
Mira Alsheikh ◽  
Rim Ismail
Keyword(s):  
Pulmonary Embolism ◽  
Negative Predictive Value ◽  
Ct Angiography ◽  
Sensitivity And Specificity ◽  
Predictive Value ◽  
Retrospective Chart Review ◽  
Latex Agglutination ◽  
University Hospital ◽  
Acute Pe ◽  
D Dimer

Background and aims: The diagnostic workup for pulmonary embolism (PE) includes D-dimer assay and computed tomographic angiography. Several D-dimer assays have been approved for PE diagnosis with different sensitivity and specificity. We aimed to study the sensitivity and specificity of the quantitative latex agglutination D-dimer assay used in a referral teaching hospital in Lebanon for the diagnosis of acute PE. Methods: Using a retrospective chart review, we studied 300 patients who had D-dimer test at Rafik Hariri University Hospital in the period between January 1, 2012 and December 31, 2013. Accordingly, 93 patients had a CT angiography after being suspected to have acute PE. A statistical table 2*2 was used to compare the results of CT angiography and D-dimer test. Results: Thirteen patients (13.97%) had PE and 60 patients (64.51%) had positive D-dimer test. Quantitative latex agglutination D-dimer assay had a sensitivity of 69%, specificity of 36%, and negative predictive value of 88%. False positive ratio was also 64%. Moreover, the receiver operating characteristic (ROC) curve was obtained with an area under the curve measuring 0.527. Conclusion: Quantitative latex agglutination D-dimer assay has a high negative predictive value; thus, it can exclude a PE diagnosis if it is associated with low clinical pretest probability.

Age-adjusted D-dimer for the diagnosis of deep vein thrombosis

2017 ◽  
Vol 33 (7) ◽  
pp. 458-463 ◽  
Author(s):  
Efrem Gómez-Jabalera ◽  
Sergio Bellmunt Montoya ◽  
Eva Fuentes-Camps ◽  
José Román Escudero Rodríguez
Keyword(s):  
Deep Vein Thrombosis ◽  
False Negative ◽  
Intermediate Risk ◽  
Vein Thrombosis ◽  
Clinical Probability ◽  
Specificity And Sensitivity ◽  
Wells Score ◽  
Risk Patients ◽  
Deep Vein ◽  
D Dimer

Objective In the diagnosis of deep vein thrombosis, new D-dimer cut-off values were defined by multiplying 10 µg/L × age. The objective of the present study is to define a more specific age-adjusted value, including the pre-test Wells score, without worsening sensitivity. Methods We designed a case–control study in patients attended in the emergency department with clinically suspected deep vein thrombosis. Demographics, Wells score, D-dimer and ultrasound data were collected. In low and intermediate clinical probability cases for deep vein thrombosis, we determined the specificity and sensitivity (false-negative rates) for the following cut-off values of D-dimer: age × 10 µg/L, age × 15 µg/L, age × 20 µg/L, age × 25 µg/L and age × 30 µg/L. The cut-off value with maximum specificity without any false-negative result (sensitivity 100%) was identified. Results We included 138 consecutive patients, 39.9% were men and the mean age was 71.6 years. Deep vein thrombosis was diagnosed in 16.7% of patients and the Wells score was low in 69.6%, intermediate in 21% and high in 9.4% of patients. Applying the conventional cut-off value of 500 µg/L, the specificity was 21.1% with a sensitivity of 100%. Maintaining 100% sensitivity, the highest specificity was reached with a cut-off value for D-dimer equivalent to the age × 25 µg/L in low-risk patients (67.1% specificity) and the age × 10 µg/L (50% specificity) in intermediate-risk patients. Conclusions In patients with low Wells score, the cut-off value can be raised to age × 25 µg/L in order to rule out deep vein thrombosis without jeopardizing safety. In intermediate-risk patients, the D-dimer cut-off value could be raised to age × 10 µg/L as previously suggested.

scholarly journals THE RELIABILITY OF CLINICAL PROBABILITY SCORE IN (WELLS SCORE) THE DIAGNOSIS OF PULMONARY EMBOLISM (PE) IN COVID-19 PATIENTS

2021 ◽  
Vol 9 (09) ◽  
pp. 345-349
Author(s):  
Saleh Alkhubaizi ◽  
◽  
Ahmad Al. ALalwi ◽  
Mamdoh Mahboob ◽  
Mohammed Al. Thubity ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Medical Records ◽  
Healthcare Professionals ◽  
Medical Center ◽  
Pulmonary Angiography ◽  
Clinical Probability ◽  
Study Results ◽  
Significant Difference ◽  
Wells Score ◽  
D Dimer

Background: The risk of developing pulmonary embolism (PE) is high in patients infected with COVID-19, and its diagnosis is a severe challenge for healthcare professionals duringthe COVID-19 pandemic. Physicians are frequently usingcomputed tomography pulmonary angiography(CTPA), d-dimer, and well score for the diagnosis of PE. Methods: A retrospective study was used in which we investigated the reliability of clinical well scores by collecting data, such as medical records in registered form (serum D-dimer level and Wells scores) of every patient for whom physicians have requested whose CTPA with suspicion of PE at King Faisal Medical Center (KFMC) from the period from 1st of April to the 1st of October. Results: The study results showed significantly higher values of d-dimer in patients with positive PEcompared to those with negative values. In addition wells score is not a reliable preclinical score in diagnosis PE in COVID 19 patient. Conclusions: As per the results of the well score, there is no significant difference between vulnerable people with PE +ve and -ve.

scholarly journals Physician and Patient Beliefs and Preferences in Pulmonary Embolism and Deep Vein Thrombosis Testing in People with Cancer

Blood ◽  
2021 ◽  
Vol 138 (Supplement 1) ◽  
pp. 4265-4265
Author(s):  
Anna Tran ◽  
Kerstin De Wit ◽  
Darshana Seeburruth
Keyword(s):  
Pulmonary Embolism ◽  
Diagnostic Imaging ◽  
Cancer Patients ◽  
Evidence Based ◽  
Vein Thrombosis ◽  
Clinical Probability ◽  
Wells Score ◽  
Low Threshold ◽  
Deep Vein ◽  
D Dimer

Abstract Introduction It is unclear whether evidence-based diagnostic protocols are followed when cancer patients are tested for venous thromboembolism (VTE). Evidence-based protocols reduce unnecessary diagnostic imaging, offer a patient-centered approach, and have the potential to standardize practice across medical specialties and settings. However, anecdote suggests that specialists who test people with cancer for VTE may prefer diagnostic imaging over clinical probability scoring and D-dimer testing. The aim of this study was to identify physician and patient knowledge, beliefs, values and preferences for VTE testing in cancer. This study was part of a program of research to set International Society of Thrombosis and Haemostasis standards for VTE testing in people with cancer. Methods This was an international qualitative interview study following COREQ guidelines. Semi-structured interviews with physicians and cancer patients were conducted via Zoom. We used purposive sampling to ensure inclusion of physicians from all specialties who test people with cancer for VTE, practicing across all continents. We invited people treated for cancer who had and did not have experience of VTE testing. We used grounded theory to create a conceptual framework which explains physician and patient values and preferences for VTE testing. Transcripts were coded by three researchers independently, who met to discuss their findings and agree on common codes. Researchers were a Thrombosis physician and two undergraduate students who ensured reflexivity was incorporated into their analysis. Results A total of 32 physicians and 6 cancer patients were invited to interview. Of those invited, 23 physicians and 6 patients across 6 continents completed an interview. Interviews lasted between 21 and 86 minutes. Our derived conceptual model can be seen in the attached Figure. Physicians reported a low threshold to test for VTE in people with cancer compared to those without cancer, because VTE was considered a fatal disease and highly prevalent in this patient population. Imaging was generally the only test used for VTE testing in cancer patients. Many participants relied on their Gestalt estimation of VTE probability when deciding whether to order imaging for pulmonary embolism or deep vein thrombosis. Most thought that low Wells score in combination with a negative D-dimer was not sufficiently sensitive to exclude VTE and anticipated the Wells score and D-dimer to be elevated. The Wells scores had poor face validity because they do not include cancer-specific variables and participants hoped to see a more nuanced formal score for VTE testing in cancer patients. Participants believed that their colleagues would support their diagnostic approach. Patients reported they were used to having tests and CT scans. Patients felt it was important for their physicians to prioritize testing for VTE. Patients had full trust and confidence in their physicians' testing decisions, particularly in decisions made by their oncologists. Conclusion Physicians have a low threshold to test people with cancer for VTE and tend not to use clinical probability assessment and D-dimer. Patients are comfortable having diagnostic imaging, feel VTE testing is important and have full trust in their physicians. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

scholarly journals Safety and Efficiency of the YEARS Diagnostic Algorithm for Pregnant Patients with Clinically Suspected Acute Pulmonary Embolism —the Artemis Study

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 419-419
Author(s):  
Liselotte M. Van Der Pol ◽  
Cecile Tromeur ◽  
Ingrid Bistervels ◽  
Thomas van Bemmel ◽  
Francis Couturaud ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Pregnant Women ◽  
Failure Rate ◽  
Acute Pulmonary Embolism ◽  
Diagnostic Algorithm ◽  
Ct Scanning ◽  
Ct Scans ◽  
Acute Pe ◽  
D Dimer

Abstract Background Acute pulmonary embolism (PE) is the leading cause of maternal mortality in Western countries, accounting for 20 to 30% of all maternal deaths. Therefore, the threshold to test for PE during pregnancy is low. Because evidence regarding the safety of ruling out PE with clinical decision rules and D-dimer tests in pregnant women is unavailable, all women with a suspected PE need to undergo an imaging test, with potential harm to patient and fetus by exposure to ionizing radiation. In the present international, multicenter, prospective management study, we evaluated the safety and efficiency of the YEARS diagnostic algorithm for ruling out PE in pregnant patients with clinically suspected PE (Netherlands Trial Registry number 5913). YEARS is a simple diagnostic algorithm designed to reduce the number of required computed tomography (CT) scans in the diagnostic work-up of PE in non-pregnant patients, and was recently shown to be as safe as conventional algorithms but associated with a significant absolute 14% reduction in the number of CT scans (van der Hulle et al., Lancet 2017). Methods The Artemis study was performed in 11 Dutch hospitals, 8 French hospitals and 1 Irish hospital. Consecutive pregnant patients with suspected acute PE were included. Exclusion criteria were treatment with therapeutically dosed anticoagulants >24 hours or contraindications for CT. The YEARS algorithm was slightly adjusted for application during pregnancy (figure 1): in patients with signs of deep vein thrombosis (DVT), compression ultrasonography was obligatory before CT scanning was considered. In patients with proven DVT, anticoagulant treatment was initiated and no further diagnostic tests were undertaken. In patients with no YEARS items (Figure 1), a D-dimer threshold of <1.0 µg/ml was sufficient to rule out PE. In the remaining patients D-dimer threshold was <0.5 µg/mL. CT scanning was only performed in patients with a D-dimer level above the threshold. Anticoagulant therapy was withheld if PE was excluded. The primary safety endpoint was the occurrence of symptomatic venous thromboembolism during 3 months of follow-up, the primary efficiency endpoint was the proportion of patients in whom CTPA could be avoided. All safety endpoints were adjudicated by an independent committee. Assuming a 1.0% diagnostic failure rate and defining a maximum acceptable failure rate of 2.7%, a total study population of 472 patients was required (one-sided alpha 0.05, beta 80%). Results and conclusion: The last patient was included in May 2018. At baseline, 48% of pregnant women with suspected acute PE had no YEARS item and a D-dimer threshold of 1.0 µg/mL was applied. A total of 42% had a D-dimer level below the relevant threshold and were managed without CT scanning. Follow-up and endpoint adjudication was not completed at the abstract submission deadline; full study results will be presented at the ASH meeting. Disclosures Couturaud: Pfizer: Research Funding; Bayer: Honoraria, Other: Travel Support; AstraZeneca: Honoraria; Actelion: Other: Travel Support; Intermune: Other: Travel Support; Leo Pharma: Other: Travel Support; Daiichi Sankyo: Other: Travel Support.

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