scholarly journals Diagnostic Accuracy of D-dimer Testing and the Revised Geneva Score in the Prediction of Pulmonary Embolism

2020 ◽  
Author(s):  
Mostafa A. Abolfotouh ◽  
Khaled Almadani ◽  
Mohammed A. Al Rowaily
Keyword(s):  
Pulmonary Embolism ◽  
Lower Limb ◽  
Predictive Accuracy ◽  
Previous History ◽  
High Sensitivity ◽  
Signs And Symptoms ◽  
Number Of Patients ◽  
Lower Limb Pain ◽  
Revised Geneva Score ◽  
D Dimer

Abstract Background. Pulmonary embolism (PE) diagnosis can sometimes be challenging due to the disease having nonspecific signs and symptoms at the time of presentation. The aim of the present study was to evaluate the validity of the D-dimer in combination with the revised Geneva score (RGS) in prediction of Pulmonary embolism.Methods. This is a retrospective study of 2010 patients with suspected PE who had undergone both D-dimer testing followed by chest CT angiography (CTPA). The predictive accuracy of D-dimer, adjusted D-dimer and the revised Geneva score were calculated. ROC curve was applied to allocate the optimum RGS cutoff for PE prediction.Results. Of all patients, the mean age was 52.2±20.2 years, two-thirds (65.1%) were females, with previous history of; DVT or PE (2%), surgery and/or fracture of lower limb (6.9%), active malignant conditions (14.4%), unilateral lower limb pain (0.6%), and hemoptysis (0.7%).The overall prevalence of PE was 16%. It was 0% in the low, 25.8% in intermediate and 88.9% in high clinical probability categories of RGS. Both conventional and age-adjusted D-dimer thresholds showed significant level of agreement (kappa=0.081, p<0.001), high sensitivity (94% & 92.8%), high NPV (91.2% & 91.4%), low specificity (12.3% & 15.3) and low PPV (17.5% & 17.8%), respectively. Combination of the age-adjusted D-dimer threshold and RGS at a cut-off of 5 points would provide 100% sensitivity and 61.7% specificity 34.1% PPV, 100% NPV and 0.87 AUC. At a RGS cutoff <5 points, PE could be have been excluded in 64.2% of patients with an abnormal age-adjusted D-dimer threshold without further imaging.Conclusion. Conventional and age-adjusted D-dimer tests showed high levels of agreement in prediction of PE, high sensitivity and low specificity. RGS has a good performance in PE prediction. Application of a clinical decision rule, using the revised Geneva score, and age adjusted D-dimer threshold could increase the number of patients in whom PE could be excluded without further imaging.

scholarly journals Acute Pulmonary Embolism in Coronavirus Disease 2019

2020 ◽  
Author(s):  
Yanan Guo ◽  
Wenwu Sun ◽  
Yanli Liu ◽  
Yanling Lv ◽  
Su Zhao ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Clinical Manifestations ◽  
Signs And Symptoms ◽  
Pulmonary Angiography ◽  
Severe Condition ◽  
Computed Tomographic ◽  
Number Of Patients ◽  
Wells Score ◽  
Computed Tomographic Pulmonary Angiography ◽  
D Dimer

Abstract Background Pulmonary embolism is a severe condition prone to misdiagnosis given its nonspecific signs and symptoms. Previous studies on the pneumonia outbreak caused by coronavirus disease 2019 (COVID-19) showed a number of patients with elevated d-dimer, whether those patients combined with pulmonary embolism got our attention. Methods Data on clinical manifestations, laboratory and radiological findings, treatment, and disease progression of 19 patients with laboratory-confirmed COVID-19 pneumonia,who completed computed tomographic pulmonary angiography (CTPA) during hospitalization in the Central Hospital of Wuhan from January 2 to March 26, 2020, were reviewed. Results Of the 19 suspected pulmonary embolism and subjected to CTPA patients, six were diagnosed with pulmonary embolism. The Wells’ score of the six patients with pulmonary embolism was 0–1, which suggested a low risk of pulmonary embolism. The median level of d-dimers collected at the day before or on the day of CTPA completion in the patients with pulmonary embolism was 18.36 (interquartile range [IQR]: 6.69–61.46) µg/mL, which was much higher than that in the patients without pulmonary embolism (median 9.47 [IQR: 4.22–28.02] µg/mL). Of the 6 patients diagnosed with pulmonary embolism, all patients received anticoagulant therapy, 5 of which survived and were discharged and 1 died. Conclusion A potential causal relationship exists between COVID-19 infection and pulmonary embolism, but whether this phenomenon is common remains uncertain. The clinical manifestations of COVID-19 patients who developed pulmonary embolism are similar to those of patients with increased d-dimer alone, prompting a significant challenge on differential diagnoses.

VIDAS D-Dimer in Combination with Clinical Pre-Test Probability to Rule out Pulmonary Embolism. A Systematic Review of the Management Outcome Studies.

Blood ◽  
2008 ◽  
Vol 112 (11) ◽  
pp. 1811-1811
Author(s):  
Marc Carrier ◽  
Marc Righini ◽  
Reza Karami Djurabi ◽  
Menno Huisman ◽  
Arnaud Perrier ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Data Extraction ◽  
Controlled Trial ◽  
Outcome Studies ◽  
Study Selection ◽  
Number Of Patients ◽  
Wells Score ◽  
Revised Geneva Score ◽  
Test Probability ◽  
D Dimer

Abstract Background: Clinical outcome studies have shown that it is safe to withhold anticoagulant therapy in patients with suspected pulmonary embolism (PE) who have a negative D-dimer result and a low pre-test probability (PTP) either using a PTP model or clinical gestalt. Purpose: To assess the safety of the combination of a non-high PTP using the Wells or Geneva models with a negative VIDAS© D-dimer result to exclude PE. Data Source: A systematic literature search strategy was conducted using MEDLINE, EMBASE, the Cochrane Register of Controlled Trials and all EBM Reviews. Study Selection: Seven studies (6 prospective management studies and 1 randomized controlled trial) reporting failure rates at three months were included in the analysis. Non-high PTP was defined has “unlikely” or “low/intermediate” PTP using either, the Wells’ score, the Geneva, Revised Geneva Score, or gestalt estimation. Data extraction: Two reviewers independently extracted data onto standardized forms. Data Synthesis: A total of 5,622 patients with non-high PTP were assessed using the VIDAS© D-dimer. PE was ruled out by a negative VIDAS© D-dimer test in 40% (95% confidence intervals (CI) 38.7 to 41.2%) of patients. The three-month thromboembolic risk in patients left untreated was 0.14% (95% CI 0.05 to 0.4%). Table 1. Accuracy Indices Total non-high PTP and negative VIDAS© D-Dimer Wells’ “unlikely” PTP and negative VIDAS© D-dimer Geneva* “low/intermediate” and negative VIDAS© D-dimer Number of patients 5,622 2,017 3,208 Sensitivity (%, 95% CI) 99.7 (99.0– 99.9) 98.7 (96.2– 99.6) 100.0 (99.4–100) Specificity (%, 95% CI) 47.4 (46.0– 48.9) 57.3 (55.0– 59.6) 40.8 (38.9– 42.7) NPV (%, 95% CI) 99.9 (99.6– 100) 99.7 (99.1– 99.9) 100.0 (99.6– 100) Conclusion: The combination of a non-high PTP with a negative VIDAS© D-dimer result, effectively and safely exclude PE in an important proportion of outpatients with suspected PE.

The combination of four different clinical decision rules and an age-adjusted D-dimer cut-off increases the number of patients in whom acute pulmonary embolism can safely be excluded

2012 ◽  
Vol 107 (01) ◽  
pp. 167-171 ◽  
Author(s):  
Inge Mos ◽  
Renée Douma ◽  
Petra Erkens ◽  
Marc Durian ◽  
Tessa Nizet ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Decision Rules ◽  
Clinical Decision ◽  
Clinical Decision Rules ◽  
Clinical Probability ◽  
Number Of Patients ◽  
Wells Score ◽  
Revised Geneva Score ◽  
D Dimer

SummaryFour clinical decision rules (CDRs) (Wells score, Revised Geneva Score (RGS), simplified Wells score and simplified RGS) safely exclude pulmonary embolism (PE), when combined with a normal D-dimer test. Recently, an age-adjusted cut-off of the D-dimer (patient’s age x 10 μg/l) safely increased the number of patients above 50 years in whom PE could safely be excluded. We validated the age-adjusted D-dimer test and assessed its performance in combination with the four CDRs in patients with suspected PE. A total of 414 consecutive patients with suspected PE who were older than 50 years were included. The proportion of patients in whom PE could be excluded with an ‘unlikely’ clinical probability combined with a normal age-adjusted D-dimer test was calculated and compared with the proportion using the conventional D-dimer cut-off. We assessed venous thromboembolism (VTE) failure rates during three months follow-up. In patients above 50 years, a normal age-adjusted D-dimer level in combination with an ‘unlikely’ CDR substantially increased the number of patients in whom PE could be safely excluded: from 13–14% to 19–22% in all CDRs similarly. In patients over 70 years, the number of exclusions was nearly four-fold higher, and the original Wells score excluded most patients, with an increase from 6% to 21% combined with the conventional and age-adjusted D-dimer cut-off, respectively. The number of VTE failures was also comparable in all CDRs. In conclusion, irrespective of which CDR is used, the age-adjusted D-dimer substantially increases the number of patients above 50 years in whom PE can be safely excluded.

Infra-popliteal deep venous thrombi and the risk of symptomatic pulmonary embolism in hospitalized patients

Vascular ◽  
2011 ◽  
Vol 19 (1) ◽  
pp. 29-33 ◽  
Author(s):  
Saadi Alhalbouni ◽  
Anil Hingorani ◽  
Alexander Shiferson ◽  
Natalie Marks ◽  
Enrico Ascher
Keyword(s):  
Pulmonary Embolism ◽  
Lower Extremity ◽  
Retrospective Review ◽  
Lower Limb ◽  
Hospitalized Patients ◽  
Symptomatic Pulmonary Embolism ◽  
Number Of Patients ◽  
Significant Difference ◽  
Hospital Patients ◽  
Made In

Infra-popliteal veins include the tibial and peroneal veins, as well as the soleal and gastrocnemial veins collectively known as the calf muscle veins (CMVs). Acute infra-popliteal deep venous thrombi (DVTs) are often considered insignificant with regard to the risk of pulmonary embolism (PE). A retrospective review of 4035 consecutive lower extremity venous duplex scans were made in 3146 hospital patients at our Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL)-accredited vascular lab. Seven hundred sixteen (17.7%) duplex scans were positive for acute DVTs, and 112 (2.8%) were associated with PEs. The breakdown of positive duplexes for acute DVTs was as follows: 202 (28.2%) isolated femoral-popliteal DVTs with PE in 23 (11.4%), 304 (42.5%) isolated infra-popliteal DVTs with PE in 24 (7.9%) and 210 (29.3%) multilevel DVTs involving both vein segments (femoral-popliteal and infra-popliteal) with PE in 38 (18.1%). Of the 304 isolated acute infra-popliteal DVTs, 207 (68.1%) were isolated CMV DVTs with evidence of PE in 12 (5.8%). No statistically significant difference ( P = 0.27) in the risk of PE between isolated femoral-popliteal and isolated infra-popliteal DVTs was noted. A significant number of patients (5.8%) with isolated CMV DVTs developed PE. Lower limb venous scans for DVTs should evaluate the infra-popliteal veins. Hospitalized patients with infra-popliteal DVTs should receive anticoagulation.

scholarly journals An oral combined contraceptive user with elevated D-dimer post COVID-19: a case report

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Nada A. Alyousefi
Keyword(s):  
Emergency Room ◽  
Lower Limb ◽  
Varicose Veins ◽  
Hormonal Contraception ◽  
Oral Contraception ◽  
Contraceptive User ◽  
Lower Limb Pain ◽  
The Right ◽  
D Dimer ◽  
Ethinyl Oestradiol

Abstract Background This case discusses the challenges created by COVID-19 (coronavirus disease 2019) in the area of hormonal contraception, highlighting the contraception knowledge gap for women in their post COVID-19 period, especially if they had high D-dimer levels. Case presentation This case involves a thirty-eight-year-old woman taking combined oral contraception (desogestrel/ethinyl oestradiol tablets) with a history of varicose veins. She recovered from a COVID-19 infection in November 2020. She presented to the emergency room with right lower-limb pain below the knee and progressive swelling for five days in February 2021. Physical examination of the lower limb showed mild swelling and tenderness of the right leg compared to the left leg. D-Dimer was elevated (1.06 mcg/mL FEU). COVID-19 screening was negative. A Doppler scan to exclude DVT was performed considering the clinical picture and high D-dimer level. There was no evidence of DVT in the right limb. She was reassured and discharged with instructions on when to visit the emergency room. The D-dimer had decreased to 0.53 mcg/mL FEU in March 2021. She booked an appointment with family medicine clinics because she was concerned about the continuation of combined oral contraception (desogestrel/ethinyl oestradiol tablets) with high D-dimer and risk of thrombosis. The follow-up D-dimer level in May 2021 was normal (0.4 mcg/mL FEU). The patient preferred to continue taking oral contraception. Conclusion An evidence-based consensus is needed to guide clinicians in providing contraception counselling for such patients.

scholarly journals Diagnostic Accuracy of D-Dimer Testing and the Revised Geneva Score in the Prediction of Pulmonary Embolism

2020 ◽  
Vol Volume 13 ◽  
pp. 1537-1543
Author(s):  
Mostafa A Abolfotouh ◽  
Khaled Almadani ◽  
Mohammed A Al Rowaily
Keyword(s):  
Pulmonary Embolism ◽  
Diagnostic Accuracy ◽  
Revised Geneva Score ◽  
D Dimer

Diagnostic management of pulmonary embolism using clinical assessment, plasma D-dimer assay, complete lower limb venous ultrasound and helical computed tomography of pulmonary arteries

2005 ◽  
Vol 93 (05) ◽  
pp. 982-988 ◽  
Author(s):  
Alain Cazanave ◽  
Marie Elias ◽  
Valérie Chabbert ◽  
Henri Juchet ◽  
Hélène Paradis ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Pulmonary Embolism ◽  
Clinical Assessment ◽  
Lower Limb ◽  
Pulmonary Arteries ◽  
Ct Scans ◽  
Helical Computed Tomography ◽  
Diagnostic Strategy ◽  
Clinical Probability ◽  
D Dimer

SummaryThe objective of the study was to assess the clinical validity of a non-invasive diagnostic strategy for acute pulmonary embolism using clinical assessment combined with both ELISA D-dimer and complete lower limb ultrasound (US) examination of proximal and distal veins, before single-detector helical computed tomography (CT) of pulmonary arteries. We expected the strategy to have a high diagnostic exclusion power and to safely decrease the number of CT scans. This prospective, multicenter outcome study included 274 consecutive outpatients. All underwent a priori clinical probability, D-dimer and bilateral complete lower limb US assessments. Only patients with a high clinical probability and both tests negative, or positive D-dimer and negative US assessments, underwent CT. This was deemed necessary in 114 patients (42%). At baseline, venous thromboembolism (VTE) was detected in 110 patients (40%), either by US showing proximal (n=65) or distal (n=36) thrombosis, or by CT (n=9). Anticoagulant was withheld in the remaining patients with negative results in both D-dimer and US but a non-high clinical probability (n=59), or in both US and CT (n=90), or with negative US (n=6) and inadequate CT (n=9). All patients underwent a three-month clinical follow-up. VTE occurred in one patient with inadequate CT, yielding an incidence of 0.6% [95% confidence interval: 0.1–3.4]. No patient died from VTE or had major bleeding. Using clinical probability, ELISA D-dimer and complete US before helical CT is a safe strategy resulting in a substantial reduction in CT scans.

Safety and Clinical Utility of Four Clinical Decision Rules In the Diagnostic Management of Acute Pulmonary Embolism – the Prometheus Diagnosis Study

Blood ◽  
2010 ◽  
Vol 116 (21) ◽  
pp. 3186-3186
Author(s):  
Inge CM Mos ◽  
Renée A Douma ◽  
Petra MG Erkens ◽  
Tessa AC Nizet ◽  
Marc F Durian ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Clinical Utility ◽  
Acute Pulmonary Embolism ◽  
Decision Rules ◽  
Clinical Decision ◽  
Clinical Decision Rules ◽  
Wells Rule ◽  
Revised Geneva Score ◽  
Acute Pe ◽  
D Dimer

Abstract Abstract 3186 Background Several clinical decision rules (CDRs) are available for the exclusion of acute pulmonary embolism (PE). This prospective multi-center study compared the safety and clinical utility of four CDRs (Wells rule, revised Geneva score, simplified Wells rule and simplified revised Geneva score) in excluding PE in combination with D-dimer testing. Methods Clinical probability of patients with suspected acute PE was assessed using a computerized based “black box”, which calculated all CDRs and indicated the next diagnostic step. A “PE unlikely” result according to all CDRs in combination with a normal D-dimer result excluded PE, while patients with “PE likely” according to at least one of the CDRs or an abnormal D-dimer result underwent CT-scanning. Patients in whom PE was excluded were followed for three months. Results 807 consecutive patients were included and PE prevalence was 23%. The number of patients categorized as “PE unlikely” ranged from 62% (simplified Wells rule) to 72% (Wells rule). Combined with a normal D-dimer level, the CDRs excluded PE in 22–24% of patients. The total failure rates of the CDR-D-dimer combinations were similar (1 failure, 0.5– 0.6%, upper 95% CI 2.9– 3.1%). Despite 30% of the patients had discordant CDR outcomes, PE was missed in none of the patients with discordant CDRs and a normal D-dimer result. Conclusions All four CDRs show similar safety and clinical utility for exclusion of acute PE in combination with a normal D-dimer level. With this prospective validation, the more straightforward simplified scores are ready for use in clinical practice. Disclosures: No relevant conflicts of interest to declare.

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.

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