Age-Adjusted D-Dimer Cut-off Levels to Rule out Pulmonary Embolism: A Prospective Outcome Study

Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. LBA-4-LBA-4
Author(s):  
Marc Righini ◽  
Paul den Exter ◽  
Josien van ES ◽  
Franck Verschuren ◽  
Alexandre Ghuisen ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Clinical Practice ◽  
Emergency Room ◽  
Pulmonary Angiography ◽  
Outcome Study ◽  
Clinical Probability ◽  
Imaging Test ◽  
D Dimer ◽  
Rule Out

Abstract Introduction D-dimer testing allows to safely rule out pulmonary embolism (PE) without imaging test in approximately one third of outpatients. However, D-Dimer test is less useful as age increases because of a lower specificity. We recently derived an age-adjusted D-dimer cut-off value (age-adjusted cut-off = patient’s age x 10 in patients aged > 50 years, in μg/L), which allowed to significantly increase the proportion of patients in whom PE could be non-invasively excluded, without compromising safety. However, before being implemented in clinical practice, the safety of the age-adjusted cut-off should be verified in a management outcome study. Methods We designed a multicentre multinational prospective management outcome study. All consecutive outpatients seen in the emergency room of 22 centres in 4 countries with clinically suspected PE were assessed by a sequential diagnostic strategy based on the assessment of clinical probability, D-dimer measurement and computed tomography pulmonary angiography (CTPA). Patients with a D-dimer value between the usual threshold of 500 μg/L and their age-adjusted cut-off did not undergo CTPA and were left untreated and formally followed for a three-month period. Results Between January 1, 2010 and February 28, 2013, we included 3,377 patients. Mean age was 62 years, and 57% were females. Overall, the proportion of confirmed PE was 18%.  Among the 2,927 patients with a non-high clinical probability, 832 (28.4%) had a D-Dimer < 500 μg/L, and 345 additional patients (11.8%) had a D-Dimer comprised between 500 μg/L and their age-adjusted cut-off. During the 3-month follow-up period, out of the 345 patients with a D-Dimer between 500 μg/L and their age-adjusted cut-off, 18 patients received anticoagulation for another indication than PE. Of the remaining 327 patients, 7 died, and 7 underwent testing for suspected venous thromboembolism (VTE), of which one was confirmed. Therefore, the failure rate of the age-adjusted cut-off was 1/327: 0.3%, (95% CI 0.1 to 1.7%). Overall, 789 patients were aged 75 years or more, of them 697 had a non-high clinical probability. The proportion of patients with D-Dimer < 500 μg/L was 50/697 (7.2%). Another 161 patients had a D-Dimer above 500 μg/L and under their age-adjusted cut-off. Therefore, the proportion of patients > 75 with a negative D-Dimer using the age-adjusted cut-off was 211/697 (30.3%), of them none had a confirmed VTE during follow-up: 0.0%, (95%CI: 0.0 to 1.9%). Conclusions Our study demonstrates that the age-adjusted D-Dimer cut-off may now be used in clinical practice in emergency room patients with suspected PE. Combined with clinical probability, it increases the number of patients in whom PE can be excluded without imaging test, and this is particularly true among elderly patients, with a four-fold increased yield of D-dimer. A D-Dimer above 500 μg/L but under the age-adjusted cut-off safely excludes the diagnosis of PE, with a 3-month risk of VTE in line with that observed in patients with a D-Dimer under 500 μg/L or after a negative pulmonary angiography, the gold-standard test for PE. Disclosures: No relevant conflicts of interest to declare.

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.

A Fast Track Strategy for Managing Suspected Pulmonary Embolism (PE) in Outpatients.

Blood ◽  
2004 ◽  
Vol 104 (11) ◽  
pp. 1766-1766
Author(s):  
Waleed Ghanima ◽  
Vibeke Almaas ◽  
Saad Aballi ◽  
Dorje Christina ◽  
Per Morten Sandset
Keyword(s):  
Management Strategy ◽  
Diagnostic Algorithm ◽  
Spiral Ct ◽  
Pulmonary Angiography ◽  
Step Test ◽  
Safety And Efficacy ◽  
Clinical Probability ◽  
D Dimer ◽  
Compression Ultrasonography

Abstract Background: Several strategies for managing patients with suspected PE have been validated. However, most of these strategies are complicated, involving multiple rounds of tests, and are thus, time consuming, costly and difficult to apply in clinical practice. Aiming to introduce a simple, fast and cost-effective strategy, we adopted a new diagnostic approach combining clinical probability assessment, D-Dimer and multi-slice spiral CT (MSSCT) scanning. Aims: The aim of this study was to assess the safety and efficacy of this management strategy by a prospective outcome study with 3-month follow-up. Methods: 495 consecutive patients referred to the Emergency Department at Østfold Hospital, Fredrikstad, Norway, for suspected PE, between Feb 2002 and Dec 2003, were considered for inclusion. 63 (12.7%) patients were excluded and the final cohort consisted of 432 patients. Patients were managed by serial non-invasive testing starting with D-Dimer test. Normal plasma D-Dimer (Liatest, latex agglutination assay, Stago-France, cut-off <0.4 mg/L) was deemed to rule out PE in patients with low-intermediate clinical probability (CP). CP for PE was assessed according to the categories proposed by Hyers. Patients with normal D-Dimer, but with high CP, and patients with elevated D-Dimer proceeded to MSSCT scan. A 4-row detector spiral CT scan was used in the study (scans were done with 2.5 mm collimation, pitch of 1.25). If MSSCT diagnosis was inconclusive, bilateral compression ultrasonography was recommended followed by a perfusion scan and eventually pulmonary angiography if further verification was necessary. Patients with verified PE received anticoagulation according to the hospitals guidelines. The entire cohort were followed-up for 3 months. Results: Normal D-Dimer and low-intermediate CP ruled out PE in 100 patients (23.1%). Twenty patients had normal D-Dimer but high CP and proceeded to MSSCT. All proved negative for PE. A total of 332 patients underwent MSSCT examination. PE was diagnosed in 95 patients (22%) and was ruled out by negative MSSCT in 221 patients. In 16 patients (4.8%), MSSCT was inconclusive due to suboptimal contrast filling (n=7), artefacts (n=2), or uncertain peripheral emboli (n=7). In ten, interpretation was inconclusive but decision to anticoagulate was made by the attending physician. Compression ultrasonography was performed in three of those; two had positive findings for DVT. In the remaining six, anticoagulation was withheld. Five had undergone further examination with ultrasound; none had DVT. Pulmonary angiography was carried out in one and perfusion lung scan in another patient; both examinations were negative. The diagnostic algorithm yielded a definite diagnosis in 96.3% of the patients. Follow-up was successfully completed in 321 (98.1%) of the patients in whom anticoagulation was withheld. Five of 321 patients (1.5%) in whom the diagnostic algorithm ruled out PE died during the follow-up period. The cause of death was adjudicated as not related to PE in three and possibly related to PE in two. No patient developed venous thromboembolism during the 3 month follow-up period, resulting in a 3-month thromboembolic rate of 0%, 95%CI (0–1.1%). Conclusions: Our results compare favorably to the results reported in previous outcome studies, and confirm the safety and efficacy of this management strategy combining D-Dimer as a first step test followed by MSSCT as a single imaging test in patients with elevated D-Dimer.

scholarly journals A comparative analysis of the diagnostic performances of four clinical probability models to rule out pulmonary embolism

2021 ◽  
Vol 10 (Supplement_1) ◽  
Author(s):  
BV Silva ◽  
C Mendonca ◽  
P Silverio Antonio ◽  
A Ferreira ◽  
N Cunha ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Pulmonary Angiography ◽  
Probability Models ◽  
Vein Thrombosis ◽  
Funding Sources ◽  
Clinical Probability ◽  
Low Probability ◽  
Deep Vein ◽  
Rule Out ◽  
Funding Acknowledgements

Abstract Funding Acknowledgements Type of funding sources: None. Background  Ruling out pulmonary embolism (PE) through a combination of clinical assessment and Ddimer is crucial to avoid excessive computed tomography pulmonary angiography (CTPA), and different algorithms should be considered as an alternative to the fixed cutoff to achieve that goal. Purpose  To compare diagnostic performance of 4 algorithms to rule out PE: fixed Ddimer cutoff, age-adjusted, YEARS and PEGeD. Methods  Retrospective study of consecutive outpatients who presented to the emergency department and underwent CTPA for PE suspicion from April 2019 to May 2020. In fixed and age-adjusted cut-off, high probability patients are directly selected for CTPA. Low to moderate probability patients perform CTPA if Ddimer ≥500µg/L in fixed cutoff, and in age-adjusted cutoff if Ddimer ≥500µg/L in patients who are ≤ 50 years of age, and if Ddimer level was more than 10 times the patient’s age in patients older than 50 years. YEARS includes 3 items (signs of deep vein thrombosis, haemoptysis and whether PE is the most likely diagnosis): patients without any YEARS items and Ddimer ≥1000ng/mL or with ≥1 items and Ddimer 500ng/mL perform CTPA. In the PEGeD, patients with high clinical probability or with intermediate and Ddimers &gt;500µg/L or low probability and Ddimer &gt;1000 µg/L are selected for CTPA. Results We enrolled 571 patients and PE was confirmed by CTPA in 172. Compared with a fixed Ddimer cutoff, age-adjusted was associated with a significant increase of specificity (p &lt; 0.001), correctly avoiding 38 CTPAs, without losing sensitivity. YEARS and PEGED resulted in a increase in specificity, compared to the fixed cutoff, but with an impairment of sensitivity (p &lt; 0.001). PEGeD had the worst sensitivity (13 more false negatives (FN) than the fixed cutoff). Despite the lack of difference between PEGed and YEARS strategies regarding sensitivity, PEGED had a significantly higher specificity (p &lt; 0.001) and allowed to correctly avoid a higher number of CTPA (95 vs 85), compared to the fixed cutoff. Conclusion  Compared to fixed d-dimer cutoff, all algorithms were associated with an increased specificity. Age-adjusted cutoff was the only that is not associated with a significant decrease in sensitivity when compared to fixed cutoff, allowing to safely reduce the need to perform CTPA. Sen(%)Spec(%)Correctly avoid CTPAs(n)FN(n)Fixed cutoff251017Age-adjusted933513912YEARS894718619PEGED884919620

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.

From dyspnea to pulmonary embolism

2009 ◽  
Vol 66 (9) ◽  
pp. 643-647 ◽  
Author(s):  
Arnaud Perrier
Keyword(s):  
Pulmonary Embolism ◽  
Large Body ◽  
Prediction Rule ◽  
Clinical Suspicion ◽  
First Episode ◽  
Left Heart Failure ◽  
Coronary Syndrome ◽  
Clinical Probability ◽  
D Dimer ◽  
Rule Out

Pulmonary embolism (PE) is often evoked in patients with new-onset or worsening dyspnea, especially when it is associated with pleuritic chest pain. However, the prevalence of PE in patients with a clinical suspicion ranges from 20 % to as low as 5 %. Unfortunately, what exactly constitutes a clinical suspicion of PE in a patient with dyspnea can not be accurately standardized. The presence of risk factors for venous thromboembolism should prompt the search for PE. However, their absence does not rule out PE as the cause of the patient’s symptoms, since around 30 % of patients with a first episode of PE have no risk or precipitating factors. Once PE is suspected, the diagnostic workup can be standardized and based on a large body of evidence, combining clinical assessment by a prediction rule, D-dimer measurement and CT angiography in patients with an elevated D-dimer level or a high clinical probability of PE. Patients with obvious alternative diagnoses such as acute left heart failure, pneumonia or acute coronary syndrome should not be investigated for PE.

Is a normal computed tomography pulmonary angiography safe to rule out acute pulmonary embolism in patients with a likely clinical probability?

2017 ◽  
Vol 117 (08) ◽  
pp. 1622-1629 ◽  
Author(s):  
Tom van der Hulle ◽  
Nick van Es ◽  
Paul den Exter ◽  
Josien van Es ◽  
Inge Mos ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Pulmonary Embolism ◽  
Acute Pulmonary Embolism ◽  
Meta Analysis ◽  
Pulmonary Angiography ◽  
Computed Tomography Pulmonary Angiography ◽  
Clinical Probability ◽  
Pulmonary Angiogram ◽  
Wells Rule ◽  
Rule Out

SummaryA normal computed tomography pulmonary angiography (CTPA) remains a controversial criterion for ruling out acute pulmonary embolism (PE) in patients with a likely clinical probability. We set out to determine the risk of VTE and fatal PE after a normal CTPA in this patient category and compare these risk to those after a normal pulmonary angiogram of 1.7% (95%CI 1.0–2.7%) and 0.3% (95%CI 0.02–0.7%). A patient-level meta-analysis from 4 prospective diagnostic management studies that sequentially applied the Wells rule, D-dimer tests and CTPA to consecutive patients with clinically suspected acute PE. The primary outcome was the 3-month VTE incidence after a normal CTPA. A total of 6,148 patients were included with an overall PE prevalence of 24%. The 3-month VTE incidence in all 4,421 patients in whom PE was excluded at baseline was 1.2% (95%CI 0.48–2.6) and the risk of fatal PE was 0.11% (95%CI 0.02–0.70). In patients with a likely clinical probability the 3-month incidences of VTE and fatal PE were 2.0% (95%CI 1.0–4.1%) and 0.48% (95%CI 0.20–1.1%) after a normal CTPA. The 3-month incidence of VTE was 6.3% (95%CI 3.0–12) in patients with a Wells rule >6 points. In conclusion, this study suggests that a normal CTPA may be considered as a valid diagnostic criterion to rule out PE in the majority of patients with a likely clinical probability, although the risk of VTE is higher in subgroups such as patients with a Wells rule >6 points for which a closer follow-up should be considered.Supplementary Material to this article is available online at www.thrombosis-online.com.

Computerized Tomographic Pulmonary Angiography Compared with Ventilation-Perfusion Lung Scanning as Inital Diagnostic Modality for Patients with Suspected Pulmonary Embolism: A Randomized Controlled Trial.

Blood ◽  
2005 ◽  
Vol 106 (11) ◽  
pp. 1619-1619 ◽  
Author(s):  
David R. Anderson ◽  
Philip S. Wells ◽  
Susan Kahn ◽  
Marc Rodger ◽  
Michael J. Kovacs ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Randomized Controlled Trial ◽  
Controlled Trial ◽  
Pulmonary Angiography ◽  
Suspected Pulmonary Embolism ◽  
Cancer Management ◽  
Randomized Controlled ◽  
Lung Scanning ◽  
D Dimer

Abstract Ventilation-perfusion (VQ) lung scanning and computerized tomographic pulmonary angiography (CTPA) have been validated as imaging procedures for the evaluation of patients with suspected pulmonary embolism and are used widely. To compare the safety and utility of VQ scanning and CTPA we performed a multi-centre randomized controlled trial in patients presenting with clinically suspected acute pulmonary embolism. All patients were evaluated using an explicit clinical model to determine pretest probability (Wells score) and with D-dimer. Patients considered at low likelihood of pulmonary embolism (score &lt; 4.5 and negative D-dimer) did not undergo further testing and were followed as a separate cohort. The remaining patients were randomized to undergo either VQ scanning or CTPA. Patients diagnosed with pulmonary embolism on the basis of a high probability VQ scan or a positive CTPA were treated. Other patients underwent bilateral venous ultrasound imaging of the proximal veins of lower extremities and those confirmed to have DVT were treated. Physicians were able to refer patients for traditional pulmonary angiography or serial ultrasonography after initial testing but switching of patients to have the alternative pulmonary imaging procedure was not permitted by the protocol. Patients in whom pulmonary embolism was considered excluded did not receive antithrombotic therapy and were followed for a three month period. The primary outcome was the development of symptomatic pulmonary embolism or proximal deep vein thrombosis in the follow-up period in patients in whom the diagnosis of pulmonary embolism had initially been excluded. 1577 patients were enrolled in the study of whom 172 entered the low risk cohort. 1405 patients were randomized, 694 to CTPA and 711 to VQ scanning. 19.2% (133) of patients in the CTPA versus 14.2% (101) were diagnosed with pulmonary embolism in the initial evaluation period (difference 5.0%, 95% CI 1.1% to 8.9%). Of those in whom pulmonary embolism was considered excluded 0.4% (2/561) patients undergoing CTPA versus 1.0% (6/610) patients undergoing VQ scanning developed venous thromboembolism in follow-up (difference −0.6%, 95% CI −1.6% to 0.3%) including one with fatal pulmonary embolism in the VQ group. All cause mortality was higher in the three month follow-up for patients undergoing VQ scanning (30/610, 4.9%) than for CTPA (17/694, 2.4%) in whom pulmonary embolism was considered excluded. Most of these deaths were from cancer. Management practices using bilateral ultrasonography with either VQ scanning or CTPA to exclude the diagnosis of pulmonary embolism resulted in low rates of venous thromboembolic complications. More patients were diagnosed intitally with pulmonary embolism using the CTPA approach and fewer patients died in this cohort in the three month follow-up period.

scholarly journals P039: Utilization of serum D-dimer assays and computed tomography pulmonary angiography (CTPA) scans in the diagnosis of pulmonary embolism among emergency department (ED) physicians

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S78-S78
Author(s):  
L. Salehi ◽  
P. Phalpher ◽  
H. Yu ◽  
M. Ossip ◽  
R. Valani ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Pulmonary Embolism ◽  
Decision Rules ◽  
Pulmonary Angiography ◽  
Low Risk ◽  
Urgent Care ◽  
Computed Tomography Pulmonary Angiography ◽  
Risk Patients ◽  
D Dimer ◽  
Rule Out

Introduction: As the availability of Computed Tomography Pulmonary Angiography (CTPA) to rule out pulmonary embolism (PE) increases, so too does its utilization, and consequent overutilization. A variety of evidence-based algorithms and decision rules using clinical criteria and D-Dimer testing have been proposed as instruments to allow physicians to safely rule out a PE in low-risk patients. However, studies have shown mixed results with respect to both physician uptake of these decision rules and their impact on improving ordering practices among physicians. The objective of this study is to describe the prevalence of D-Dimer utilization among ED physicians and its impact on positive yield rates of CTPAs in a community setting. Methods: Data was collected on all CTPA studies ordered by ED physicians at two very high-volume community hospitals and an affiliated urgent care centre during the 2-year period between January 1, 2016 and December 31, 2017. For each CTPA, we determined if 1) a D-Dimer had been ordered prior to CTPA, if 2) the D-Dimer was positive, and if 3) the CTPA was positive for a PE. Using a chi-square test, we compared the diagnostic yield for those patients who had a D-Dimer prior to their CTPA and those who did not. Results: A total of 2,811 CTPAs were included in the analysis. Of these, 964 CTPAs (34.3%) were ordered without a D-Dimer. Of those 1,847 patients who underwent D-Dimer testing prior to the CTPA, 343 (18.7%) underwent a CTPA despite a negative D-Dimer. When compared as a group, those CTPAs preceded by a D-Dimer showed no significant difference in positive yields when compared to those CTPAs ordered without a prior D-Dimer (9.9% versus 11.3%, p = 0.26). Conclusion: The findings of this study present a complicated picture of the impact of D-Dimer utilization on CTPA ordering patterns. There is evidence of suboptimal uptake of routine D-Dimer ordering, and adherence to guidelines in terms of forgoing CTPAs in low-risk patients with negative D-Dimers. While this study design leaves unanswered the question of how many CTPAs were avoided as a result of a negative D-Dimer, the finding of a similar positive yield among those patients who had a D-Dimer ordered versus those who did not is interesting, and illustrative of the issues arising from the high false-positive rates associated with D-Dimer screening.

scholarly journals Different D-dimer algorithms to rule out pulmonary embolism in patients with cancer: a comparative study

2021 ◽  
Vol 10 (Supplement_1) ◽  
Author(s):  
BV Silva ◽  
C Mendonca ◽  
N Cunha ◽  
P Silverio Antonio ◽  
T Rodrigues ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Cancer Patients ◽  
Clinical Decision ◽  
Pulmonary Angiography ◽  
Lower Sensitivity ◽  
Vein Thrombosis ◽  
Patients With Cancer ◽  
D Dimer ◽  
Active Cancer ◽  
Rule Out

Abstract Funding Acknowledgements Type of funding sources: None. Background Pulmonary embolism (PE) is more prevalent in patients with cancer. D-dimers are a less useful test in such patients due to less specificity. Several algorithms have been developed as an alternative to the fixed d-dimer cutoff,  aiming to avoid the excessive use of computed tomography pulmonary angiography (CTPA), but it is not clear which is the most accurate algorithm in PE patients with cancer. Objective To compare the efficacy of 4 algorithms to rule out pulmonary embolism (fixed Ddimer cutoff, age-adjusted, YEARS and PEGed) in patients with active cancer. Methods Retrospective study of consecutive outpatients who presented to the emergency department and underwent CTPA for PE suspicion from April 2019 to February 2020. The clinical-decision algorithms were retrospectively applied. In fixed and age-adjusted cutoffs, high probability patients are directly selected for CTPA and the others perform CTPA if DDimer ≥500µg/L or age x10 µg/L within patients over 50 years, respectively. YEARS includes 3 items (signs of deep vein thrombosis, haemoptysis and whether PE is the most likely diagnosis): patients without any YEARS items and Ddimer ≥1000ng/mL or with ≥1 items and Ddimer 500ng/mL perform CTPA. In the PEGeD, patients with high clinical probability or with intermediate and Ddimer &gt;500µg/L or low probability and Ddimer &gt;1000 µg/L are selected for CTPA. Results Of 409 patients with suspected PE, 87 patients (21,3%) had cancer. The prevalence of PE was 38% in cancer patients and 35% in patients without cancer (p &gt; 0.05). Age-adjusted cut-off, compared to the conventional cutoff, had an AUC significantly higher (0.68 vs 0.61, p = 0.005). Despite both having 100% sensitivity, age-adjusted cutoff had a significant higher specificity compared to conventional cut-off (44% vs 35%, p &lt; 0.05). Both YEARS and PEGED algorithms had significantly lower sensitivity (p = 0.003 and p = 0.002, respectively) and higher specificity (p &lt; 0.001, for both) compared to conventional cutoff in patients with active cancer. The AUC of these two algorithms was not significantly different compared to conventional cutoff (p = 0.08 and p = 0.78, respectively). Conclusion Considering our results, age-adjusted cut-off seems to be the most accurate algorithm to rule out pulmonary embolism in active cancer patients. Sen(%)Spec(%)Conventional10022Age-adjusted10035YEARS9144PEGED9130Abstract Figure. AUC of four algorithms

scholarly journals Validity and clinical utility of the simplified Wells rule for assessing clinical probability for the exclusion of pulmonary embolism

2009 ◽  
Vol 101 (01) ◽  
pp. 197-200 ◽  
Author(s):  
Nadine Gibson ◽  
Victor Gerdes ◽  
Harry Büller ◽  
Philip Wells ◽  
Arnaud Perrier ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Cohort Study ◽  
Venous Thromboembolism ◽  
Clinical Utility ◽  
Multicenter Cohort Study ◽  
Clinical Probability ◽  
Multicenter Cohort ◽  
Wells Rule ◽  
D Dimer

SummaryThe recently introduced simplified Wells rule for the exclusion of pulmonary embolism (PE) assigns only one point to the seven variables of the original Wells rule. This study was performed to independently validate the simplified Wells rule for the exclusion of PE. We retrospectively calculated the prevalence of PE in the “unlikely” probability categories of the original Wells (cut-off ≤4) and the simplified Wells rule (cut-off ≤1) in 922 consecutive patients with clinically suspected PE from a multicenter cohort study. We compared the three-month incidence of venous thromboembolism (VTE) in patients with an unlikely probability and a normal D-dimer test using both scores, and the proportion of patients with this combination (clinical utility). The proportion of patients categorized as PE “unlikely” was similar using the original (78%) and the simplified (70%) Wells rule. The prevalence of PE was 13% (95% confidence interval [CI], 11–16%) and 12% (95%CI, 9.7–15%) for the original Wells and simplified Wells “unlikely” categories, respectively. None of the patients with PE “unlikely” and a normal D-dimer test experienced VTE during three-month follow-up. The proportions of patients in whom further tests could safely be withheld based on PE “unlikely” and a normal D-dimer test was 28% (95%CI, 25–31%) using the original and 26% (95%CI, 24–29%) using the simplified Wells rule. In this external retrospective validation study, the simplified Wells rule appeared to be safe and clinically useful, although prospective validation remains necessary. Simplification of the Wells rule may enhance the applicability.

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