Impact of a Clinical Decision Rule and a D-dimer plus Alveolar Deadspace Measurement to Rule Out Pulmonary Embolism in an Urban Emergency Department

SummaryA safe and effective management strategy is pivotal in excluding pulmonary embolism (PE). The combination of Wells’ simplified dichotomous clinical decision rule and D-dimer test is non-invasive and could be highly efficient, though its safety has not been widely studied. We evaluated safety and efficiency of this combination in excluding PE. Wells clinical decision rule was performed in 941 consecutive patients with suspected PE and, if patients had a score ≤ 4.0 points, a VIDAS D-dimer test followed. Patients with a normal D-dimer concentration had no further tests, PE was considered excluded, and patients did not receive anticoagulant treatment. Patients, in whom PE was excluded, were followed up for three months. Four hundred fifty patients (51.2%) had a clinical decision score ≤ 4.0 points and a normal D-dimer concentration. In 45 of these patients, during the initial diagnostic period additional objective testing, although not indicated, was performed, and PE was established in two patients. During three months of follow up no venous thromboembolic events (VTE) occurred. Therefore, the overall VTE failure rate was two of 450 (0.4% [95%CI 0–1.1]); the overall prevalence of PE was 12.3%. The diagnostic protocol could be completed and allowed a decision to be made in 90% of the study patients. This study has prospectively established the safety of a combination of a dichotomized clinical decision rule and D-dimer test in ruling out PE. The strategy proved highly efficient, since more than 50% of patients could be managed without the need for more invasive and expensive tests.

Download Full-text

A clinical decision rule and D-dimer testing to rule out upper extremity deep vein thrombosis in high-risk patients

Thrombosis Research ◽

10.1016/j.thromres.2016.10.019 ◽

2016 ◽

Vol 148 ◽

pp. 59-62 ◽

Cited By ~ 9

Author(s):

Nick van Es ◽

Suzanne M Bleker ◽

Marcello Di Nisio ◽

Ankie Kleinjan ◽

Jan Beyer-Westendorf ◽

...

Keyword(s):

Deep Vein Thrombosis ◽

High Risk ◽

Decision Rule ◽

Clinical Decision ◽

Clinical Decision Rule ◽

Vein Thrombosis ◽

Risk Patients ◽

Deep Vein ◽

D Dimer ◽

Rule Out

Download Full-text

Clinical decision rule and D-dimer have lower clinical utility to exclude pulmonary embolism in cancer patients

Thrombosis and Haemostasis ◽

10.1160/th10-02-0093 ◽

2010 ◽

Vol 104 (10) ◽

pp. 831-836 ◽

Cited By ~ 18

Author(s):

Geerte van Sluis ◽

Pieter Kamphuisen ◽

Maaike Söhne ◽

Frank Leebeek ◽

Patrick Bossuyt ◽

...

Keyword(s):

Pulmonary Embolism ◽

Cancer Patients ◽

Decision Rule ◽

Clinical Utility ◽

Clinical Decision ◽

Clinical Decision Rule ◽

Modest Improvement ◽

Age Dependent ◽

Wells Rule ◽

D Dimer

SummaryPatients with malignancy frequently present with clinically suspected pulmonary embolism (PE). However, the safe and efficient combination of a clinical decision rule (CDR) and D-dimer test to rule out PE performs less well in patients with malignancy. We examined potential explanations and analysed whether elevating the D-dimer cut-off could improve the clinical utility. We used data on consecutive patients with suspected PE included in a multicenter management study. The performance of the Wells CDR and the D-dimer test was compared between patients with and without malignancy and multivariable analysis was used to compare the weights of the CDR variables. Furthermore, we combined the CDR (cut-off ≤4) with different D-dimer cut-off levels for the exclusion of PE. Of 3,306 patients with suspected PE, 475 (14%) had cancer. The Wells rule variables were less diagnostic in cancer patients. Increasing the D-dimer cut-off level to 700 μg/l for all ages or using an age-dependent cut-off resulted in an increase in the proportion of patients in whom PE could be excluded from 8.4% to 13% and 12%, respectively. The corresponding false-negative rates were 1.6% (95% confidence interval 0.3–8.7%) and 0.0% (0.0–6.3%). The Wells CDR and D-dimer perform less well in patients with suspected PE if they have cancer. Individual variables in the Wells rule are less diagnostic in cancer patients than in non-cancer patients with suspected PE. A CDR combined with an age-dependent D-dimer cut-off shows a modest improvement of the strategy in cancer patients.

Download Full-text