scholarly journals A 10-fold and greater increase in D-dimer at admission in COVID-19 patients is highly predictive of pulmonary embolism in a retrospective cohort study

2021 ◽  
Vol 12 ◽  
pp. 204062072110483
Author(s):  
Adrian Perera ◽  
Pratima Chowdary ◽  
James Johnson ◽  
Lucy Lamb ◽  
Anja Drebes ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
White Cell Count ◽  
Area Under The Curve ◽  
Pulmonary Vasculature ◽  
Reactive Protein ◽  
Pulmonary Angiogram ◽  
Right Ventricular Strain ◽  
Receiver Operator Curve Analysis ◽  
D Dimer ◽  
Operator Curve

Background: COVID-19 patients present with both elevated D-dimer and a higher incidence of pulmonary embolism (PE). This single-centre retrospective observational study investigated the prevalence of early PE in COVID-19 patients and its relation to D-dimer at presentation. Methods: The study included 1038 COVID-19-positive patients, with 1222 emergency department (ED) attendances over 11 weeks (16 March to 31 May 2020). Computed tomography pulmonary angiogram (CTPA) for PE was performed in 123 patients within 48 h of ED presentation, of whom 118 had D-dimer results. The remaining 875 attendances had D-dimer performed. Results: CTPA performed in 11.8% of patients within 48 h of ED presentation confirmed PE in 37.4% (46/123). Thrombosis was observed at all levels of pulmonary vasculature with and without right ventricular strain. In the CTPA cohort, patients with PE had significantly higher D-dimer, prothrombin time, C-reactive protein, troponin, total bilirubin, neutrophils, white cell count and lower albumin compared with non-PE patients. However, there was no difference in the median duration of inpatient stay or mortality. A receiver operator curve analysis demonstrated that D-dimer could discriminate between PE and non-PE COVID-19 patients (area under the curve of 0.79, p < 0.0001). Furthermore, 43% ( n = 62/145) of patients with D-dimer >5000 ng/ml had CTPA with PE confirmed in 61% ( n = 38/62), that is, 26% of >5000 ng/ml cohort. The sensitivity and specificity were related to D-dimer level; cutoffs of 2000, 3000, 4000, and 5000 ng/ml, respectively, had a sensitivity of 93%, 90%, 90% and 86%, and a specificity of 38%, 54%, 59% and 68%, and if implemented, an additional 229, 141, 106 and 83 CTPAs would be required. Conclusion: Our data suggested an increased PE prevalence in COVID-19 patients attending ED with an elevated D-dimer, and patients with levels >5000 ng/ml might benefit from CTPA to exclude concomitant PE.

Pulmonary Embolism

2019 ◽  
Author(s):  
Nadav Granat ◽  
Evan Avraham Alpert
Keyword(s):  
Computed Tomography ◽  
Pulmonary Embolism ◽  
Blood Clot ◽  
Pretest Probability ◽  
Treatment Modalities ◽  
Pulmonary Vasculature ◽  
Pulmonary Angiogram ◽  
Catheter Directed Thrombolysis ◽  
D Dimer ◽  
Rule Out

Pulmonary embolism is caused by a blood clot that travels from the deep veins through the heart and then lodges in the pulmonary vasculature. Common symptoms include pleuritic chest pain, dyspnea, or palpitations. Clinical scores such as the Wells score and Revised Geneva score can be used to assess the pretest probability of pulmonary embolism (PE) and guide work-up such as deciding to order D-dimer testing or imaging. However, clinical gestalt can also accurately assess the pretest probability of PE. The Pulmonary Embolism Rule-out Criteria is a decision rule that can be used to rule out PE without further testing. Imaging modalities include computed tomography pulmonary angiogram or ventilation/perfusion scanning. Novel or new oral anticoagulants are becoming the mainstay of treatment for the hemodynamically stable patient with pulmonary embolism. For the patient who is hemodynamically unstable, treatment modalities include intravenous alteplase, catheter-directed thrombolysis, surgical embolectomy, and catheter-directed embolectomy. A subset of patients with PE can be treated as outpatients. This review contains 1 figure, 4 tables, and 55 references. Key Words: anticoagulants, antithrombins, D-dimer, low-molecular-weight heparin, mechanical thrombolysis, multidetector computed tomography, radionuclide imaging, unfractionated heparin, pulmonary embolism, tissue plasminogen activator, warfarin

The Value of D-Dimer in Patients with Increased C-Reactive Protein Suspected of Pulmonary Embolism.

Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 5056-5056
Author(s):  
Claire Siemes ◽  
Paul Berendes ◽  
Frans van der Straaten ◽  
Ton Cleophas ◽  
Mark-David Levin
Keyword(s):  
Pulmonary Embolism ◽  
Conflicts Of Interest ◽  
Area Under The Curve ◽  
Roc Curves ◽  
Serum Levels ◽  
C Reactive Protein ◽  
Reactive Protein ◽  
Interaction Term ◽  
Pulmonary Embolisms ◽  
D Dimer

Abstract Abstract 5056 OBJECTIVE To investigate the relation between elevated levels of C-reactive protein (CRP) and D-dimer, and to study whether D-dimer levels can be interpreted in relation to elevated levels of CRP in the prediction of a pulmonary embolism in order to increase its specificity without decline in sensitivity. METHODS Between august 2004 and april 2007 (33 months) serum levels of C-reactive protein (mmol/L) and D-dimer (mmol/L) were cross-sectionally collected and pulmonary embolisms on CT-angiograms were scored within 48 hours. The study was devided into three parts. First, characteristics of excluded persons were studied. Second, the correlation between CRP and D-dimer level was considered in those with a defined (i.e. values with < and > symbols excluded) biomarker level. Finally, the effect of CRP level on the sensitivity of D-dimer for pulmonary embolisms was examined. RESULTS CRP and D-dimer levels were positively correlated ( r = 0.37; p < 0.001), and both were increased in persons with a pulmonary embolism (CRP: p = 0.02; D-dimer: p < 0.001). 14 % of variability in D-dimer level was explained by CRP level. Median D-dimer levels were increased in the pulmonary embolism (PE) group, however, the increase in D-dimer level by CRP quartile as was found in the non-PE was not seen in de PE-group. Adding the interaction term of CRP and D-dimer to the statistical model showed some influence on the area under the curve (AUC). Nevertheless, this was not significantly different from the model with only D-dimer levels. However, when stratified for CRP quartile, ROC-curves of the predictive effect of D-dimer on pulmonary embolisms showed a decrease in AUC by increment of CRP quartile. CONCLUSION CRP and D-dimer are positively correlated, and both predictive of PE. The predictive value of D-dimer for PE declines by increment of CRP, although this seems to be safely for a broader range of accompanied CRP levels. Disclosures No relevant conflicts of interest to declare.

Twenty-three year-old with pleuritic chest pain

Heart ◽  
2018 ◽  
Vol 105 (6) ◽  
pp. 464-469
Author(s):  
Karina P Gopaul ◽  
Helen M Parry ◽  
Damien Cullington
Keyword(s):  
Chest Pain ◽  
Congenital Heart ◽  
White Cell Count ◽  
Coarctation Of The Aorta ◽  
List Type ◽  
Pleuritic Chest Pain ◽  
Reactive Protein ◽  
Pulmonary Angiogram ◽  
Night Sweats ◽  
Ct Pulmonary Angiogram

Clinical introductionA 23-year-old woman followed at another medical centre for congenital heart disease (CHD) presented to our emergency clinic with 3 weeks of bilateral pleuritic chest pain. She returned from holiday in Greece 6 weeks earlier where a tattoo and nasal piercing had been performed. There was no history of night sweats or fever.Her temperature was 37.5°C, heart rate 120 beats/min, oxygen saturations 94% on room air and blood pressure 110/74. Her chest was clear and there was systolic murmur on auscultation. The chest radiograph showed peripheral bilateral lower zone atelectasis. The ECG demonstrated sinus tachycardia. The haemoglobin was 11.2 g/dL, white cell count 10.18×109/L, C-reactive protein 67 mg/L (normal <5 mg/L) and D dimer=430 ng/mL (normal <230 ng/mL).A pulmonary embolus was suspected and a CT pulmonary angiogram was performed (figure 1).QuestionBased on the CT findings, what is the most likely underlying congenital heart lesion in this patient?Bicuspid aortic valveCoarctation of the aortaFontan circulationParachute mitral valveVentricular septal defectFigure 1CT pulmonary angiogram (coronal views).

scholarly journals Differentiating combined pulmonary fibrosis and emphysema from pure emphysema: utility of late gadolinium-enhanced MRI

2020 ◽  
Vol 4 (1) ◽  
Author(s):  
Hannah Fleming ◽  
Simon M. Clifford ◽  
Aoife Haughey ◽  
Roisin MacDermott ◽  
Niall McVeigh ◽  
...  
Keyword(s):  
Pulmonary Fibrosis ◽  
Area Under The Curve ◽  
Resonance Imaging ◽  
High Resolution Computed Tomography ◽  
Antifibrotic Therapy ◽  
Control Subjects ◽  
Receiver Operator Curve Analysis ◽  
Healthy Control ◽  
Traction Bronchiectasis ◽  
Operator Curve

Abstract Background Differentiating combined pulmonary fibrosis with emphysema (CPFE) from pure emphysema can be challenging on high-resolution computed tomography (HRCT). This has antifibrotic therapy implications. Methods Twenty patients with suspected CPFE underwent late gadolinium-enhanced (LGE) thoracic magnetic resonance imaging (LGE-MRI) and HRCT. Data from twelve healthy control subjects from a previous study who underwent thoracic LGE-MRI were included for comparison. Quantitative LGE signal intensity (SI) was retrospectively compared in regions of fibrosis and emphysema in CPFE patients to similar lung regions in controls. Qualitative comparisons for the presence/extent of reticulation, honeycombing, and traction bronchiectasis between LGE-MRI and HRCT were assessed by two readers in consensus. Results There were significant quantitative differences in fibrosis SI compared to emphysema SI in CPFE patients (25.8, IQR 18.4–31.0 versus 5.3, IQR 5.0–8.1, p < 0.001). Significant differences were found between LGE-MRI and HRCT in the extent of reticulation (12.5, IQR 5.0–20.0 versus 25.0, IQR 15.0–26.3, p = 0.038) and honeycombing (5.0, IQR 0.0–10.0 versus 20.0, IQR 10.6–20.0, p = 0.001) but not traction bronchiectasis (10.0, IQR 5–15 versus 15.0, IQR 5–15, p = 0.878). Receiver operator curve analysis of fibrosis SI compared to similarly located regions in control subjects showed an area under the curve of 0.82 (p = 0.002). A SI cutoff of 19 yielded a sensitivity of 75% and specificity of 86% in differentiating fibrosis from similarly located regions in control subjects. Conclusion LGE-MRI can differentiate CPFE from pure emphysema and may be a useful adjunct test to HRCT in patients with suspected CPFE.

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.

Exclusion of pulmonary embolism using C-reactive protein and D-dimer

2003 ◽  
Vol 90 (12) ◽  
pp. 1198-1203 ◽  
Author(s):  
Daniel Hayoz ◽  
Bertrand Yersin ◽  
Arnaud Perrier ◽  
Ghassan Barghouth ◽  
Pierre Schnyder ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Clinical Judgment ◽  
Prediction Rule ◽  
Pulmonary Angiography ◽  
Enzyme Linked Immunosorbent Assay ◽  
Probability Assessment ◽  
C Reactive Protein ◽  
Reactive Protein ◽  
Clinical Probability ◽  
D Dimer

SummaryOur goal was to evaluate the diagnostic utility of C-reactive protein (CRP) alone or combined with clinical probability assessment in patients with suspected pulmonary embolism (PE), and to compare its performance to a D-dimer assay. We conducted a prospective study in which we performed a common immuno-turbidimetric CRP test and a rapid enzyme-linked immunosorbent assay (ELISA) D-dimer test in 259 consecutive outpatients with suspected PE at the emergency department of a teaching hospital. We assessed clinical probability of PE by a validated prediction rule overridden by clinical judgment. Patients with D-dimer levels ≥ 500 µg/l underwent a work-up consisting of lower-limb venous ultrasound, spiral computer-ized tomography, ventilation-perfusion scan, or pulmonary angiography. Patients were followed up for three months. Seventy-seven (30%) of the patients had PE.The CRP alone had a sensitivity of 84% (95% confidence interval [CI).: 74 to 92%) and a negative predictive value (NPV) of 87% (95% CI: 78 to 93%) at a cutpoint of 5 mg/l. Overall, 61 (24%) patients with a low clinical probability of PE had a CRP < 5 mg/l. Due to the low prevalence of PE (9%) in this subgroup, the NPV increased to 97% (95% CI: 89 to 100%). The D-dimer (cutpoint 500 µg/l) showed a sensitivity of 100% (95% CI: 95 to 100%) and a NPV of 100% (95% CI: 94 to 100%) irrespective of clinical probability and accurately rule out PE in 56 (22%) patients. Standard CRP tests alone or combined with clinical probability assessment cannot safely exclude PE.

scholarly journals d-Dimer Assessment Improves the Simplified Pulmonary Embolism Severity Index for In-Hospital Risk Stratification in Acute Pulmonary Embolism

2018 ◽  
Vol 24 (8) ◽  
pp. 1340-1346 ◽  
Author(s):  
Marta Kozlowska ◽  
Magdalena Plywaczewska ◽  
Marcin Koc ◽  
Szymon Pacho ◽  
Anna Wyzgal ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Adverse Event ◽  
Risk Stratification ◽  
Prognostic Value ◽  
Acute Pulmonary Embolism ◽  
Clinical Course ◽  
Area Under The Curve ◽  
Severity Index ◽  
Net Reclassification Improvement ◽  
D Dimer

d-dimer (DD) levels are used in the diagnostic workup of suspected acute pulmonary embolism (APE), but data on DD for early risk stratification in APE are limited. In this post hoc analysis of a prospective observational study of 270 consecutive patients, we aimed to optimize the discriminant capacity of the simplified pulmonary embolism severity index (sPESI), an APE risk assessment score currently used, by combining it with DD for in-hospital adverse event prediction. We found that DD levels were higher in patients with complicated versus benign clinical course 7.2 mg/L (25th-75th percentile: 4.5-27.7 mg/L) versus 5.1 mg/L (25th-75th percentile: 2.1-11.2 mg/L), P = .004. The area under the curve of DD for serious adverse event (SAE) was 0.672, P = .003. d-dimer =1.35 mg/L showed 100% negative predictive value for SAE and identified 11 sPESI ≥1 patients with a benign clinical course, detecting the 1 patient with SAE from sPESI = 0. d-dimer >15 mg/L showed heart rate for SAE 3.04 (95% confidence interval [CI]: 1-9). A stratification model which with sPESI + DD >1.35 mg/L demonstrated improved prognostic value when compared to sPESI alone (net reclassification improvement: 0.085, P = .04). d-dimer have prognostic value, values <1.35 mg/L identify patients with a favorable outcome, improving the prognostic potential of sPESI, while DD >15 mg/L is an independent predictor of SAE.

scholarly journals Massive pulmonary embolism in a COVID-19 patient: a case report

2020 ◽  
Vol 4 (FI1) ◽  
pp. 1-5
Author(s):  
Charlie J Sang ◽  
Brittain Heindl ◽  
Gregory Von Mering ◽  
Indranee Rajapreyar
Keyword(s):  
Pulmonary Embolism ◽  
Right Ventricular ◽  
Cardiovascular System ◽  
Massive Pulmonary Embolism ◽  
Coronary Syndrome ◽  
Pulmonary Angiogram ◽  
Catheter Directed Thrombolysis ◽  
Right Ventricular Strain ◽  
Prolonged Hospital ◽  
The Impact

Abstract Background Myocardial injury is associated with excess mortality in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections, and the mechanisms of injury are diverse. Coagulopathy associated with this infection may have unique cardiovascular implications. Case summary We present a case of 62-year-old male who presented after experiencing syncope and cardiac arrest. Given the clinical presentation and electrocardiographic findings, there was concern for acute coronary syndrome. However, coronary angiogram did not reveal significant coronary obstruction. Due to the unclear nature of his presentation, a bedside echocardiogram was rapidly performed and was indicative of right ventricular strain. Due to these findings, a pulmonary angiogram was performed that revealed massive pulmonary embolism. He successfully underwent catheter-directed thrombolysis and, after a prolonged hospital stay, was discharged home on lifelong anticoagulation. Discussion The impact of coronavirus disease-2019 (COVID-19) on the cardiovascular system has been prominent and multifaceted. COVID-19 can have wide-ranging effects on the cardiovascular system due to coagulopathy with resultant venous and arterial thrombo-embolism. Due to the critical condition of many patients affected by COVID-19, imaging for thrombo-embolic events is often delayed. With the use of bedside echocardiogram, observation of right ventricular strain may be critical in raising suspicion for pulmonary embolism, especially when atypical features are noted on electrocardiogram.

scholarly journals Is there a diagnostic value for the platelet indices patients in pulmonary embolism?

2017 ◽  
Vol 25 (2) ◽  
pp. 91-94
Author(s):  
İbrahim Çevik ◽  
Hüseyin Narcı ◽  
Güllü Akbaydoğan Dündar ◽  
Cüneyt Ayrık ◽  
Seyran B Babuş
Keyword(s):  
Pulmonary Embolism ◽  
Mean Platelet Volume ◽  
Area Under The Curve ◽  
Control Group ◽  
Platelet Distribution Width ◽  
Platelet Volume ◽  
Distribution Width ◽  
Platelet Indices ◽  
Platelet Number ◽  
D Dimer

Background: Pulmonary embolism is a common disease with a high mortality risk. It has recently been reported that platelet indices may be diagnostic in pulmonary embolism. Objective: In this study, we aimed to determine the diagnostic value of platelet indices in acute pulmonary embolism. Methods: The study group was composed of 61 patients diagnosed with pulmonary embolism and a control group of 67 subjects without pulmonary embolism. Patient age, sex, leukocyte and platelet number, hemoglobin concentration (Hb), mean platelet volume, platelet distribution width, red blood cell distribution width, C-reactive protein, D-Dimer, and troponin I levels were retrospectively analyzed and compared between the two groups. Results: There was no significant difference between age and platelet number of pulmonary embolism and control group. In pulmonary embolism group, platelet distribution width level was significantly high (p = 0.002), whereas mean platelet volume level was significantly lower (p = 0.038). Receiver operating characteristic curve analysis revealed that a mean platelet volume cut-off of 9 fL had a sensitivity of 35%, a specificity of 89.55%, and area under the curve of 0.589 for pulmonary embolism, while a platelet distribution width cut-off of 12.8 fL had a sensitivity of 61%, a specificity of 71.64%, and area under the curve of 0.661. Platelet distribution width and D-dimer levels had a significant positive correlation with each other, whereas there was no significant correlation between mean platelet volume and D-dimer. Conclusion: Platelet distribution width values of the pulmonary embolism group were higher than those of control group. Although the area under the curve of platelet distribution width is slightly better than for platelet number or mean platelet volume, it does not seem that this parameter has better diagnostic accuracy than the other two.

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