A negative D-dimer identifies patients at low risk of death within 30 days: a prospective observational emergency department cohort study

Abstract Objective To determine the ability of a normal D-dimer level (<0.5 mg/l) to identify emergency department (ED) patients at low risk of 30-day all-cause mortality. Design In this prospective observational study, D-dimer levels of adult medical patients were assessed at arrival to the ED. Data on 30-day survival status were extracted from the Danish Civil Registration System with complete follow-up. Setting The Hospital of South West Jutland. Patients All patients aged 18 years or older who required any blood sample on a clinical indication on arrival to the ED. Participants were required to give written informed consent before enrollment. Main results The study population of 1 518 patients with median age 66 years of which 49.4% were female. Of the 791 (52.1%) patients with normal D-dimer levels, 3 (0.4%) died within 30 days; one death resulted from an unrelated traumatic accident. Of the 727 (47.9%) patients with abnormal D-dimer levels (≥0.50 mg/l), 32 (4.4%) died within 30 days. Patients with normal D-dimer levels had a significantly lower 30-day mortality compared to patients with abnormal D-dimer levels (odds ratio 0.08, 95% CI 0.02–0.28): of the 35 patients who died within 30 days, 19 (54.3%) had normal or near normal vital signs when first assessed. Conclusion Normal D-dimer levels identified patients at low risk of 30-day mortality. Since most patients who died within 30 days presented with normal or near normal vital signs, D-dimer levels appear to provide additional prognostic information.

Download Full-text

Normal gait, albumin and d-dimer levels identify low risk emergency department patients: a prospective observational cohort study with 365-day 100% follow-up

QJM ◽

10.1093/qjmed/hcz226 ◽

2019 ◽

Vol 113 (2) ◽

pp. 86-92

Author(s):

L Lyngholm ◽

C H Nickel ◽

J Kellett ◽

S Chang ◽

T Cooksley ◽

...

Keyword(s):

Emergency Department ◽

Laboratory Data ◽

Secondary Analysis ◽

Vital Signs ◽

Low Risk ◽

Ambulatory Care Setting ◽

Laboratory Findings ◽

Normal Gait ◽

Co Morbidity ◽

D Dimer

Abstract Background If survival could be reliably predicted many patients could be safely managed outside of hospital in an ambulatory care setting. Aim Comparison of common laboratory findings, co-morbidities, mobility and vital signs as predictors of mortality of acutely ill emergency department (ED) attendees. Design Prospective observational study. Methods Secondary analysis of 1334 consenting acutely ill patients attending a Danish ED. Results 67 (5%) out of 1334 patients died within 100 days. After logistic regression seven predictors of 100 days mortality remained significant: an albumin level ≤34 gm/l, D-dimer level >0.51 mg/l, an Asadollahi score (based on admission laboratory data and age) ≥12, a platelet count <159 X 1000/ml, impaired mobility on presentation, a respiratory rate ≥30 bpm and a Charlson co-morbidity index ≥3. Only 5 of the 442 without any of these variables died within 365 days. Only one of the 517 patients with a stable independent gait and normal d-dimer and albumin levels died within 100 days, none died within 30 days of assessment and 12 died within 365 days. Of the remaining 817 patients 66 (8%) died within 100 days. Conclusion These findings suggest that normal gait, albumin and d-dimer levels are the most parsimonious way of identifying low risk ED patients.

Download Full-text

Monotherapy Anticoagulation to Expedite Home Treatment of Patients Diagnosed With Venous Thromboembolism in the Emergency Department: A Pragmatic Effectiveness Trial

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.120.007600 ◽

2021 ◽

Author(s):

Jeffrey A. Kline ◽

David H. Adler ◽

Naomi Alanis ◽

Joseph R. Bledsoe ◽

Daniel M. Courtney ◽

...

Keyword(s):

Emergency Department ◽

Venous Thromboembolism ◽

Venous Thrombosis ◽

The United States ◽

Home Treatment ◽

Low Risk ◽

Severe Bleeding ◽

Effectiveness Trial ◽

Risk Of Death ◽

Recurrent Vte

BACKGROUND: The objective was to test if low-risk emergency department patients with vitamin K antagonist (venous thromboembolism [VTE]; including venous thrombosis and pulmonary embolism [PE]) can be safely and effectively treated at home with direct acting oral (monotherapy) anticoagulation in a large-scale, real-world pragmatic effectiveness trial. METHODS: This was a single-arm trial, conducted from 2016 to 2019 in accordance with the Standards for Reporting Implementation Studies guideline in 33 emergency departments in the United States. Participants had newly diagnosed VTE with low risk of death based upon either the modified Hestia criteria, or physician judgment plus the simplified PE severity index score of zero, together with nonhigh bleeding risk were eligible. Patients had to be discharged within 24 hours of triage and treated with either apixaban or rivaroxaban. Effectiveness was defined by the primary efficacy and safety outcomes, image-proven recurrent VTE and bleeding requiring hospitalization >24 hours, respectively, with an upper limit of the 95% CI for the 30-day frequency of VTE recurrence below 2.0% for both outcomes. RESULTS: We enrolled 1421 patients with complete outcomes data, including 903 with venous thrombosis and 518 with PE. The recurrent VTE requiring hospitalization occurred in 14/1421 (1.0% [95% CI, 0.5%–1.7%]), and bleeding requiring hospitalization occurred in 12/1421 (0.8% [0.4%–1.5%). The rate of severe bleeding using International Society for Thrombosis and Haemostasis criteria was 2/1421 (0.1% [0%–0.5%]). No patient died, and serious adverse events occurred in 2.5% of venous thrombosis patients and 2.3% of patients with PE. Medication nonadherence was reported by patients in 8.0% (6.6%–9.5%) and was associated with a risk ratio of 6.0 (2.3–15.2) for VTE recurrence. Among all patients diagnosed with VTE in the emergency department during the period of study, 18% of venous thrombosis patients and 10% of patients with PE were enrolled. CONCLUSIONS: Monotherapy treatment of low-risk patients with venous thrombosis or PE in the emergency department setting produced a low rate of bleeding and VTE recurrence, but may be underused. Patients with venous thrombosis and PE should undergo risk-stratification before home treatment. Improved patient adherence may reduce rate of recurrent VTE. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03404635

Download Full-text

Prognostic accuracy of qSOFA in predicting 28-day mortality among infected patients in an emergency department: a prospective validation study

Emergency Medicine Journal ◽

10.1136/emermed-2019-208456 ◽

2019 ◽

pp. emermed-2019-208456

Author(s):

S M Osama Bin Abdullah ◽

Rune Husås Sørensen ◽

Ram Benny Christian Dessau ◽

Saifullah Muhammed Rafid Us Sattar ◽

Lothar Wiese ◽

...

Keyword(s):

Emergency Department ◽

Predictive Value ◽

Characteristic Curve ◽

Likelihood Ratios ◽

Registration System ◽

Civil Registration ◽

Prognostic Accuracy ◽

Observational Cohort ◽

Sensitivity Specificity ◽

Sirs Criteria

BackgroundFew prospective studies have evaluated the quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA) criteria in emergency department (ED)settings. The aim of this study was to determine the prognostic accuracy of qSOFA compared with systemic inflammatory response syndrome (SIRS) in predicting the 28-day mortality of infected patients admitted to an ED.MethodsA prospective observational cohort study of all adult (≥18 years) infected patients admitted to the ED of Slagelse Hospital, Denmark, was conducted from 1 October 2017 to 31 March 2018. Patients were enrolled consecutively and data related to SIRS and qSOFA criteria were obtained from electronic triage record. Information regarding mortality was obtained from the Danish Civil Registration System. The original cut-off values of ≥2 was used to determine the prognostic accuracy of SIRS and qSOFA criteria for predicting 28-day mortality and was assessed by analyses of sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratios and area under the receiver operating characteristic curve (AUROC) with 95% confidence intervals (CI).ResultsA total of 2112 patients were included in this study. A total of 175 (8.3%) patients met at least two qSOFA criteria, while 1012 (47.9%) met at least two SIRS criteria on admission. A qSOFA criteria of at least two for predicting 28-day mortality had a sensitivity of 19.5% (95% CI 13.6% to 26.5%) and a specificity of 92.6% (95% CI 91.4% to 93.7%). A SIRS criteria of at least two for predicting 28-day mortality had a sensitivity of 52.8% (95% CI 44.8% to 60.8%) and a specificity of 52.5% (95% CI 50.2% to 54.7%). The AUROC values for qSOFA and SIRS were 0.63 (95% CI 0.59 to 0.67) and 0.52 (95% CI 0.48 to 0.57), respectively.ConclusionBoth SIRS and qSOFA had poor sensitivity for 28-day mortality. qSOFA improved the specificity at the expense of the sensitivity resulting in slightly higher prognostic accuracy overall.

Download Full-text

The utility of copeptin in the emergency department as a predictor of adverse outcomes in non-ST-elevation acute coronary syndrome: the COPED-PAO study

Emergency Medicine Journal ◽

10.1136/emermed-2012-201996 ◽

2013 ◽

Vol 31 (4) ◽

pp. 286-291 ◽

Cited By ~ 9

Author(s):

Miquel Sánchez ◽

Pere Llorens ◽

Pablo Herrero ◽

F Javier Martín-Sanchez ◽

Pascual Piñera ◽

...

Keyword(s):

Emergency Department ◽

Acute Coronary Syndrome ◽

Adverse Events ◽

Adverse Outcomes ◽

Troponin Level ◽

Prognostic Information ◽

Risk Of Death ◽

Coronary Syndrome ◽

St Elevation ◽

Elevation Acute Coronary Syndrome

AimsTo test the utility of a single copeptin determination at presentation to the emergency department (ED) as a short-term prognosis marker in patients with non-ST-elevation acute coronary syndrome (NSTEACS). To compare the results with those achieved with conventional troponin.MethodsA multicentric, prospective, observational, longitudinal, cohort study involving 15 Spanish EDs. Inclusion: consecutive patients with chest pain (<12 h) finally diagnosed of NSTEACS. Measurements: copeptin and troponin at arrival. Cut-off point for copeptin: 25.9 pmol/l. Follow-up: within 2 months after ED attendance to identify 30-day adverse events. Discriminatory capacity of copeptin and troponin was compared by receiver operating characteristic (ROC) curves.ResultsWe included 377 patients with NSTEACS. Adverse events: 11 (2.9%) patients died, 27 (7.2%) had an adverse coronary event, 14 (3.7%) had a stroke, and 48 (12.7%) a composite endpoint. The initial copeptine value was over 25.9 pmol/l in 114 patients, and they presented a higher mortality rate (OR: 4.2, (95% CI 1.2 to 14.8); p=0.03). This association disappeared after adjusting by clinical variables or troponin level. No significant differences were found for the remaining endpoints. The area under the curve of the ROC curve of 30-day mortality was 0.73 (95% CI 0.58 to 0.87) for copeptin, and 0.80 (95% CI 0.73 to 0.87) for troponin.ConclusionsIn patients with NSTEACS, determination of copeptin at presentation to the ED is associated with risk of death during the subsequent month. This association, however, disappears after adjusting by baseline features or troponin level, so copeptin does not add complementary prognostic information over that provided by troponin.

Download Full-text

Can D-Dimer in Low-Risk Patients Exclude Aortic Dissection in the Emergency Department?

Journal of Emergency Medicine ◽

10.1016/j.jemermed.2021.07.028 ◽

2021 ◽

Author(s):

Drew A. Long ◽

Samuel M. Keim ◽

Michael D. April ◽

Alex Koyfman ◽

Brit Long ◽

...

Keyword(s):

Emergency Department ◽

Aortic Dissection ◽

Low Risk ◽

Risk Patients ◽

D Dimer

Download Full-text

Perceived Physical Fatigability Predicts All-Cause Mortality in Older Adults

The Journals of Gerontology Series A ◽

10.1093/gerona/glab374 ◽

2021 ◽

Author(s):

Nancy W Glynn ◽

Theresa Gmelin ◽

Sharon W Renner ◽

Yujia Susanna QiaoScM ◽

Robert M Boudreau ◽

...

Keyword(s):

Older Adults ◽

Prognostic Indicator ◽

Underlying Disease ◽

Registration System ◽

Civil Registration ◽

Risk Of Death ◽

Validated Questionnaire ◽

Patient Reported ◽

Cox Proportional Hazard Models

Abstract Background Perceived physical fatigability is highly prevalent in older adults and associated with mobility decline and other health consequences. We examined the prognostic value of perceived physical fatigability as an independent predictor of risk of death among older adults. Methods Participants (N = 2,906), mean age 73.5 [SD, 10.4] years, 54.2% women, 99.7% white enrolled in the Long Life Family Study were assessed at Visit 2 (2014-2017) with 2.7 [SD, 1.0] years follow-up. The Pittsburgh Fatigability Scale (PFS), a 10-item, self-administered validated questionnaire (score range 0-50, higher=greater fatigability) measured perceived physical fatigability at Visit 2. Deaths post-Visit 2 through December 31, 2019 were identified by: family members notifying field centers, reporting during another family member’s annual phone follow-up, an obituary, or Civil Registration System (Denmark). We censored all other participants at their last contact. Cox proportional hazard models predicted mortality by fatigability severity, adjusted for family relatedness and other covariates. Results Age-adjusted PFS Physical scores were higher for those who died (19.1 [SE, 0.8]) compared to alive (12.2, [SE, 0.4]) overall, as well as across age strata (P<.001), except for those 60-69 years (P=.79). Participants with the most severe fatigability (PFS Physical scores ≥25) were over twice as likely to die (HR, 2.33 [95% CI, 1.65 to 3.28]) compared to those with less severe fatigability (PFS Physical scores <25) after adjustment. Conclusions This work underscores the utility of the PFS as a novel patient-reported prognostic indicator of phenotypic aging that captures both overt and underlying disease burden that predicts death.

Download Full-text

Prospective validation of quick Sequential Organ Failure Assessment (qSOFA) for mortality among patients with infection admitted to an emergency department

Dansk Tidsskrift for Akutmedicin ◽

10.7146/akut.v2i3.112933 ◽

2019 ◽

Vol 2 (3) ◽

pp. 26

Author(s):

Osama Bin Abdullah

Keyword(s):

Emergency Department ◽

Organ Failure ◽

Predictive Value ◽

Receiver Operating Curve ◽

Registration System ◽

Civil Registration ◽

Failure Assessment ◽

Qsofa Score ◽

Sensitivity Specificity ◽

Admission Variables

Background: Only few prospective studies have evaluated the new quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA) score in emergency department (ED) settings. The aim of this study was to determine the prognostic value of qSOFA compared to systemic inflammatory response syndrome (SIRS) in predicting 28-day mortality of infected patients admitted to an ED. Methods: A prospective observational cohort study of all adult (≥18 years) infected patients admitted to the ED of Slagelse Hospital during 01.10.2017 to 31.03.2018. All patients with suspected or documented infection on arrival to the ED, and treated with antibiotics, were included. Admission variables included in the SIRS- and qSOFA criteria were prospectively obtained from triage forms. Information regarding 28-day mortality was obtained from the Danish Civil Registration System. The diagnostic performance of qSOFA and SIRS score for predicting 28-day mortality was assessed by analyses of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the receiver operating curve (AUC) with 95% confidence intervals (CI). Results: A total of 2,168 patients (47.42% male) were included. A total of 181 (8.35%) met at least two qSOFA criteria, and 1,046 (48.25%) met at least two SIRS criteria on admission. The overall 28-day mortality was 7.47% (95% CI 6.40-8.66%). Unadjusted odds ratio of qSOFA and SIRS for 28-day mortality was 2.93 (95% CI 1.92-4.47) vs 1.27 (95% CI 0.92-1.74), respectively. A qSOFA score of at least two for predicting 28-day mortality had a sensitivity of 19.10% (95% CI 13.40-26.00%), a specificity of 92.50% (95% CI 91.30-93.60%), a PPV and NPV of 17.10% (95% CI 11.90-23.40%) and 93.40% (95% CI 92.20-94.50%), respectively. A SIRS score of at least two for predicting 28-day mortality had a sensitivity of 53.70 (95% CI 45.70-61.60%), a specificity of 52.20% (95% CI 50.00-54.40%), a PPV and NPV of 8.32% (95% CI 6.72-10.20%) and 93.30% (95% CI 91.70-94.70%), respectively. The AUC for qSOFA and SIRS was 0.56 (95% CI 0.53-0.59) vs 0.53 (95% CI 0.49-0.57). Conclusion: Use of qSOFA had improved specificity, but with poor sensitivity, in predicting in 28-day mortality. qSOFA and SIRS showed similar discrimination potential for mortality.

Download Full-text

Predicting mortality and readmission based on chief complaint in emergency department patients: a cohort study

Trauma Surgery & Acute Care Open ◽

10.1136/tsaco-2020-000604 ◽

2021 ◽

Vol 6 (1) ◽

pp. e000604

Author(s):

Søren Flink Sørensen ◽

Stig Holm Ovesen ◽

Marianne Lisby ◽

Mia Hansen Mandau ◽

Ida Katrine Thomsen ◽

...

Keyword(s):

Emergency Department ◽

Cohort Study ◽

Clinical Outcome ◽

Chief Complaint ◽

Level Of Evidence ◽

Altered Level ◽

Registration System ◽

Civil Registration ◽

Chief Complaints ◽

Minor Injuries

BackgroundEmergency department (ED) patients present with complaints and not diagnoses. Characterization and risk stratification based on chief complaint can therefore help clinicians improve ED workflow and clinical outcome. In this study we investigated the 30-day mortality and readmission among ED patients based on chief complaint.MethodsIn this cohort study we retrieved routinely collected data from electronic medical records and the Danish Civil Registration System of all ED contacts from July 1, 2016 through June 30, 2017. All patients triaged with one chief complaint using the Danish Emergency Process Triage system were included. Patients with minor injuries were excluded. The chief complaint assigned by the triaging nurse was used as exposure, and 30-day mortality and 30-day readmission were the primary outcomes. Logistic regression was used to determine crude and adjusted ORs with reference to the remaining study population.ResultsA total of 41 470 patients were eligible. After exclusion of minor injuries and patients not triaged, 19 325 patients were included. The 30-day mortality and 30-day readmission differed significantly among the chief complaints. The highest 30-day mortality was observed among patients presenting with altered level of conscousness (ALOC) (8.4%, OR=2.0, 95% CI 1.3 to 3.1) and dyspnea (8.0%, OR=2.1, 95% CI 1.6 to 2.6). 30-day readmission was highest among patients presenting with fever/infection (11.7%, OR=1.9, 95% CI 1.4 to 2.4) and dyspnea (11.2%, OR=1.7, 95% CI 1.4 to 2.0).DiscussionChief complaint is associated with 30-day mortality and readmission in a mixed ED population. ALOC and dyspnea had the highest mortality; fever/infection and dyspnea had the highest readmission rate. This knowledge may assist in improving and optimizing symptom-based initial diagnostic workup and treatment, and ultimately improve workflow and clinical outcome.Level of evidenceLevel III.

Download Full-text

Frailty and mortality: Braden Scale is associated with mortality among elderly, infected patients admitted to an emergency department

Dansk Tidsskrift for Akutmedicin ◽

10.7146/akut.v2i3.112993 ◽

2019 ◽

Vol 2 (3) ◽

pp. 51

Author(s):

Rune Husås Sørensen

Keyword(s):

Emergency Department ◽

High Risk ◽

Elderly Patients ◽

Odds Ratio ◽

Risk Group ◽

High Risk Group ◽

Low Risk ◽

Assessment Tools ◽

Registration System ◽

Braden Scale

Background: Infections can lead to serious clinical condition among the frail and elderly population and is associated with high mortality. Currently, no consistent use of frailty risk assessment tools is implemented outside geriatric departments. The Braden Scale (BS) for predicting pressure sore risk is used routinely in hospital settings and has also been associated with mortality in some studies. The aim of this study was to examine the association between BS and 28-day mortality among infected elderly patients admitted to an emergency department (ED). Methods: A prospective study conducted between 1st October 2017 and 31st March 2018 among elderly (≥65 years) patients admitted to the ED at Slagelse Hospital with an infection. Information on BS (low-risk: BS≥19; intermedium risk:13<BS<18; high-risk:BS≤12), and other relevant data was obtained from the patient records. Information on 28-day mortality was obtained from the Danish Civil Registration System. We have used logistic regression analysis to adjust for potential confounders of the association between BS and mortality. Changes in model fit were analyzed by the log-likelihood test. Results: A total of 1468 patients (52.0% female) aged ≥65 years with median age of 78.9 years (interquartile range 72.8-86.0) were included. BS was registered among 1072 (73.0%) patients. A total of 89 patients (8.3%) were in the high-risk group (BS≤12), 508 (47.4%) were in the intermedium-risk group and 475 patients (44.3%) in the low-risk group. The overall 28-day mortality was 10.0%. Unadjusted odds ratio (OR) for mortality, with low-risk group as reference, was 2.21 (95% confidence interval (CI)1.42-3.45) for intermedium risk and 7.66 (95% CI 4.34-13.51) for the high-risk group. Odds ratio for the patients with missing BS was 0.60 (95% CI 0.32-1.12). Adjusted OR was 2.02 (95% CI 1.29-3.17) and 7.46 (95% CI 4.16-13.35) for the intermedium and high-risk groups, respectively. Conclusion: The Braden Scale can be used as a prognostic marker among elderly patients admitted to an ED with infection.

Download Full-text

Association of Increased Fibrin Turnover and Defective Fibrinolytic Capacity with Leg Atherosclerosis

Thrombosis and Haemostasis ◽

10.1055/s-0038-1648855 ◽

1994 ◽

Vol 72 (02) ◽

pp. 292-296 ◽

Cited By ~ 24

Author(s):

M Cortellaro ◽

E Cofrancesco ◽

C Boschetti ◽

L Mussoni ◽

M B Donati ◽

...

Keyword(s):

Arterial Disease ◽

Venous Stasis ◽

Stepwise Discriminant Analysis ◽

Predisposing Factor ◽

Risk Of Death ◽

Peripheral Arterial ◽

Fibrinolytic Potential ◽

Fibrinolytic Capacity ◽

Control Study ◽

D Dimer

SummaryPatients with peripheral arterial disease have a high risk of death from cardiovascular events. As defective fibrinolysis associated with leg atherosclerosis has been suggested as a predisposing factor, we sought a relation among decreased fibrinolysis, the presence of leg atherosclerosis and the incidence of thrombotic events in a case control study nested in the PLAT.Fifty-eight patients with coronary and/or cerebral atherothrombotic disease, free of leg atherosclerosis at Doppler examination, were compared with 50 atherosclerotic patients with leg involvement. High D-dimer (153.0 vs 81.3 ng/ml, p <0.001) and tPA antigen before venous stasis (14.4 vs 11.8 ng/ml, p <0.03), and low tPA antigen (6.7 vs 15.6 ng/ml, p <0.01) and fibrinolytic activity released after venous stasis (fibrinolytic capacity: 113.2 vs 281.4 mm2, p <0.001) were found in patients with leg atherosclerosis. D-dimer and fibrinolytic capacity, in addition to age, were selected by stepwise discriminant analysis as characterizing patients with leg atherosclerosis. Moreover, higher D-dimer and tPA inhibitor characterized patients with leg atherosclerosis who subsequently experienced thrombotic events.These findings constitute evidence of high fibrin turnover and impaired fibrinolytic potential in patients with leg atherosclerosis. Thus impaired fibrinolysis may contribute to the prothrombotic state in these patients.

Download Full-text