scholarly journals Clinical applicability of D-dimer assay in the diagnosis of pulmonary embolism reduces with aging

2007 ◽  
Vol 1 (4) ◽  
pp. 153-164
Author(s):  
Luca Masotti ◽  
Giancarlo Landini ◽  
Fabio Antonelli ◽  
Elio Venturini ◽  
Roberto Cappelli ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Elderly Patients ◽  
Case Reports ◽  
High Morbidity ◽  
Clinical Probability ◽  
Clinical Applicability ◽  
Diagnostic Management ◽  
Diagnostic Work ◽  
Work Up ◽  
D Dimer

Despite modern algorithms have been proposed for diagnosis of pulmonary embolism (PE), it remains understimed and often missed in clinical practice, especially in elderly patients, resulting in high morbidity and mortality when early and correctly untreated. One of the main controversial issue is represented by the role and applicability of D-dimer in the diagnostic work up of geriatric patients. Most recent guidelines in young-adult patients suggest to perform D-dimer assay by ELISA or immunoturbidimetric methods only in non high pre-test clinical probability (PTP) patients; in these patients negative D-dimer can safely rule out the diagnosis of PE. This strategy is safe also in elderly patients; however the percentage of patients with non high PTP and negative D-dimer reduces progressively with age, making difficult its clinical applicability. The Authors, starting from two case reports, up date the diagnostic management of PE underling the limitations of D-dimer assay in elderly patients.

Ruling out clinically suspected pulmonary embolism by assessment of clinical probability and D-dimer levels: a management study

2003 ◽  
Vol 89 (01) ◽  
pp. 97-103 ◽  
Author(s):  
Johan Lutisan ◽  
Marinus Marwijk Kooy ◽  
Bart Kuipers ◽  
Ad Oostdijk ◽  
Jef van der Leur ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Probability Assessment ◽  
Suspected Pulmonary Embolism ◽  
Thromboembolic Risk ◽  
Management Study ◽  
Entire Cohort ◽  
Clinical Probability ◽  
Diagnostic Work ◽  
Work Up ◽  
D Dimer

SummaryD-dimer test combined with clinical probability assessment has been proposed as the first step in the diagnostic work-up of patients with suspected pulmonary embolism (PE). In a prospective management study we investigated the safety and efficiency of excluding PE by a normal D-dimer combined with a low or moderate clinical probability. Of the 202 study patients this combination ruled out PE in 64 (32%) patients. The 3-month thromboembolic risk in these patients was 0% (95% CI, 0.0-5.6%).The prevalence of PE in the entire cohort was 29% (59 patients), whereas in the low, moderate and high clinical probability groups this was 25%, 26% and 50%, respectively. We conclude that ruling out suspected PE by a normal D-dimer combined with a low or moderate clinical probability appears to be a safe and efficient strategy. The accuracy of the clinical probability assessment is modest.

The role of fibrin monomers in optimizing the diagnostic work-up of deep vein thrombosis

2007 ◽  
Vol 97 (05) ◽  
pp. 807-813 ◽  
Author(s):  
Fred Haas ◽  
Mariette Agterof ◽  
Marike Vos ◽  
Douwe Biesma ◽  
Roger Schutgens
Keyword(s):  
Deep Vein Thrombosis ◽  
Clinical Score ◽  
Vein Thrombosis ◽  
Clinical Probability ◽  
Diagnostic Work ◽  
Additional Value ◽  
Deep Vein ◽  
Work Up ◽  
Fibrin Monomers ◽  
D Dimer

SummaryDespite the use of a clinical score and D-dimers to exclude deep vein thrombosis (DVT), the majority of patients still need repeated ultrasound (US).The aim of the study was to investigate whether fibrin monomers (FMs), as markers of thrombin generation, have additional value in the diagnosis of DVT. This is a posthoc analysis of 464 outpatients, participants in a management study using D-dimers (Tina-Quant® ) and a clinical score in the exclusion of DVT. Two new FM assays (Auto LIA-FM® and IATRO SF®, Japan) were performed. Overall sensitivity, negative predictive value (NPV) and specificity of the D-dimer test were 98%, 98% and 42%.The optimal cut-off point for the Auto LIAFM test was ≤ 3 µ g/ml with values of 88%, 88% and 59%, respectively. The IATRO SF test had an optimal cut-off point of ≤ 2 µ g/ ml with values of 92%, 81 and 22%, respectively.The NPV of a non-high clinical score and a normal D-dimer (n=97) was 100%. In patients with a high clinical score (n=160), the NPV of the D-dimer was 88%. In these patients, a single US combined with a normal D-dimer or FM test had an equal NPV as serial US (100 versus 98%, respectively) and lead to a reduction in the need for US by 36–53%, respectively. In patients with abnormal D-dimer concentrations (n=343), a normal US combined with a normal Auto LIA-FM test had a NPV of 97%,which was also true for serial US.This could lead to a reduction in the need for US by 45%. The present studied FMs are inferior to theTina-Quant D-dimer test when used as primary screening tool to exclude DVT.Adding these FMs to patients with a normal Tina-Quant D-dimer has no benefit. In patients with a high pretest clinical probability score, a single US in combination with a normal D-dimer or FM test might be as safe as serial US. In patients with abnormal D-dimer concentrations and a normal US, a normal FM test might be able to replace the second US.

scholarly journals THE MANAGEMENT OF VENOUS THROMBOEMBOLIC DISORDERS

2013 ◽  
Vol 3 (3) ◽  
Author(s):  
Diana S. Purwanto
Keyword(s):  
Venous Thromboembolism ◽  
Thrombotic Event ◽  
Venous Stasis ◽  
Initial Management ◽  
Clinical Probability ◽  
Venous Thromboembolic ◽  
Life Threatening ◽  
Diagnostic Work ◽  
Work Up ◽  
D Dimer

Abstrak: Tromboemboli vena (VTE) mengacu pada semua bentuk trombosis patologis yang terjadi di sirkulasi vena, yang paling umum adalah trombosis vena dalam (DVT) pada ekstremitas bawah, namun manifestasi VTE yang paling mengancam nyawa adalah embolisasi trombi vena dalam ke sirkulasi paru, yang disebut emboli paru (PE). Banyak faktor baik yang diturunkan atau didapat, bisa menyebabkan VTE karena faktor-faktor tersebut mempengaruhi stasis vena, kerusakan pembuluh dan hiperkoagulabilitas, sebagai pemicu peristiwa trombotik. Sebuah kombinasi dari tes D-dimer dan probabilitas klinis diperkenalkan oleh Wells sebagai langkah pertama dalam diagnosis. Agen antikoagulan biasanya UFH atau LMWH, harus diberikan untuk menghindari pembentukan bekuan lebih lanjut ketika gangguan VTE dikonfirmasi. Pada saat efek antitrombotik yang memadai dicapai dengan heparin, antikoagulan oral seperti warfarin digunakan untuk mengurangi kemungkinan VTE berulang. Kata kunci: Tromboemboli vena, DVT, PE, D-dimer, antikoagulan.     Abstract: Venous thromboembolism (VTE) refers to all forms of pathologic thrombosis occurring on the venous side of the circulation, the most common of which is deep venous thrombosis (DVT) of the lower extremities. The most life-threatening manifestation of VTE is embolization of venous thrombi to the pulmonary circulation, called pulmonary embolism (PE). Many factors, either inherited or acquired, can cause VTE, since these factors influence the venous stasis, vessel damage and hypercoagulability, as the trigger of thrombotic event.   A combination of a D-dimer assay and clinical probability as a first step in diagnostic work-up was introduced by Wells et al. An initial management of anticoagulant agents usually UFH or LMWH, should be administered to avoid further clot formation when VTE disorder is confirmed. At some point an adequate antithrombotic effect is achieved with heparin, oral anticoagulant such as warfarin is started to reduce the probability of recurrent VTE. Keywords: Venous thromboembolism, DVT, PE, D-dimer, anticoagulant.

D-dimer Assays for the Exclusion of Venous Thromboembolism: Which Test for which Diagnostic Strategy?

2000 ◽  
Vol 83 (02) ◽  
pp. 180-181 ◽  
Author(s):  
P. de Moerloose
Keyword(s):  
Venous Thromboembolism ◽  
Diagnostic Strategy ◽  
Vein Thrombosis ◽  
Clinical Probability ◽  
Lung Scan ◽  
Diagnostic Work ◽  
Work Up ◽  
Diagnostic Work Up ◽  
D Dimer

SummaryD-dimer measurement has proven to be very useful to rule out deep vein thrombosis (DVT) and pulmonary embolism (PE) in symptomatic outpatients (1). The problem faced by many physicians is the choice and the position of the D-Dimer tests in the diagnostic work-up of patients suspected of venous thromboembolism (VTE). In the last and present issues of Thrombosis and Haemostasis, two very interesting studies addressing these questions were published.In the first paper (2), de Groot and colleagues evaluated, in a management study, the clinical utility of incorporating the SimpliRED assay in the diagnostic work-up of patients with suspected PE. Of the 245 study subjects, 59 did not receive anticoagulant therapy on the basis of a nondiagnostic lung scan, a normal D-dimer and a non-high clinical probability of PE. In the follow-up, only one patient experienced a thromboembolic event (which can be compared with the 6% of subsequent rate of VTE in the follow-up of the 54 patients with a normal perfusion lung scan). However, if SimpliRED D-dimer would have been used alone as a first exclusion step, 6 of 61 patients with proven PE had been missed (9.8%, 95% CI 3.7-20.2).

Clinical usefulness of D-dimer testing in cancer patients with suspected pulmonary embolism

2006 ◽  
Vol 95 (04) ◽  
pp. 715-719 ◽  
Author(s):  
Grégoire Le Gal ◽  
Sylvain De Lucia ◽  
Pierre-Marie Roy ◽  
Guy Meyer ◽  
Drahomir Aujesky ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Cancer Patients ◽  
Diagnostic Value ◽  
Clinical Usefulness ◽  
Limited Data ◽  
Suspected Pulmonary Embolism ◽  
Diagnostic Work ◽  
Work Up ◽  
D Dimer ◽  
Rule Out

SummaryLimited data are available about the diagnostic value of D-dimer testing in cancer patients with clinically suspected pulmonary embolism (PE).Therefore, we evaluated i) the safety and clinical usefulness of an ELISA D-dimer test to rule out PE in cancer patients compared with non-cancer patients and ii) whether adopting a higher D-dimer cut-off value might increase the usefulness of D-dimer in cancer patients. We analysed data from two outcome studies which enrolled 1,721 consecutive patients presenting in the emergency department with clinically suspected PE. Presence of an active malignancy was abstracted from the database. All patients underwent a sequential diagnostic work-up including an ELISA D-dimer test and a 3-month followup. Sensitivity and predictive value (NPV) were 100% in both cancer and non-cancer patients. PE was ruled out by a negative D-dimer test in 494/1,554 (32%) patients without cancer, and in 18/164 (11%) patients witha malignancy. At cut-off values varying from 500 to 900 µg/l, the sensitivity was unchanged (100%, 95% CI: 93% to 100%) and the specificity increased from 16% (95% CI:11% to 24%) to 30% (95% CI:22% to 39%).The 3-month thromboembolic risk was 0% (95 % CI: 0% to 18%) in cancer patients witha negative D-dimer test. ELISA D-dimer appears safe to rule out pulmonary embolism in cancer patients but it is negative in only one of ten patients at the usual cut-off value. Increasing the cut-off value of D-dimer in cancer patients might increase the test’s clinical usefulness.

Rapid ELISA Assay for Plasma D-Dimer in the Diagnosis of Segmental and Subsegmental Pulmonary Embolism

2000 ◽  
Vol 84 (08) ◽  
pp. 156-159 ◽  
Author(s):  
Huub van Ingen ◽  
Edwin van Beek ◽  
Arie Berghout ◽  
Matthijs Oudkerk ◽  
Paul Sijens
Keyword(s):  
Pulmonary Embolism ◽  
Reference Method ◽  
Pulmonary Angiography ◽  
Diagnostic Strategy ◽  
Study Objective ◽  
Predictive Values ◽  
Angiographic Evidence ◽  
Diagnostic Work ◽  
Work Up ◽  
D Dimer

Summary Study objective To assess the accuracy of a rapid ELISA D-dimer assay for the exclusion of pulmonary embolism (PE) in patients suspected of PE, using pulmonary angiography alone as reference method rather than a diagnostic strategy including lung scintigraphy and leg vein ultrasonography. Methods In 342 patients who were examined by pulmonary angiography to diagnose or exclude PE, the accuracy of the quantitative rapid VIDAS D-dimer test for the exclusion of PE was evaluated retrospectively. D-dimer levels were assayed in frozen samples collected during the diagnostic work-up at the time of pulmonary angiography while on treatment with unfractionated heparin for 1-2 days. Results Mean plasma D-dimer concentrations were increased in patients with angiographic evidence of PE (P <0.0001). The sensitivity of D-dimer for segmental PE was 98%, its accuracy in excluding segmental PE was 99%, higher than the respective figures for subsegmental PE (76% and 94%; P <0.01, both). For both forms of PE combined the sensitivity was 90% and the negative predictive value 94%. Discussion The sensitivity and negative predictive values reported here, are low compared with previous studies using the same rapid ELISA D-dimer assay. This probably reflects an overlooking of mild cases of subsegmental PE in previous studies, although a reduction of D-dimer levels by the heparin pretreatment may have contributed to part of the discrepancy. Prospective studies are needed to clarify this issue.

scholarly journals General practitioner use of D-dimer in suspected venous thromboembolism: historical cohort study in one geographical region in the Netherlands

BMJ Open ◽  
2019 ◽  
Vol 9 (5) ◽  
pp. e026846 ◽  
Author(s):  
Angel M R Schols ◽  
Eline Meijs ◽  
Geert-Jan Dinant ◽  
Henri E J H Stoffers ◽  
Mariëlle M E Krekels ◽  
...  
Keyword(s):  
Cohort Study ◽  
General Practitioner ◽  
Clinical Assessment ◽  
Geographical Region ◽  
Historical Cohort ◽  
Diagnostic Work ◽  
Work Up ◽  
Diagnostic Work Up ◽  
D Dimer

ObjectivesTo investigate how many general practitioner (GP)-referred venous thromboembolic events (VTEs) are diagnosed during 1 year in one geographical region and to investigate the (urgent) referral pathway of VTE diagnoses, including the role of laboratory D-dimer testing.DesignHistorical cohort study.SettingGP patients of 47 general practices in a demarcated geographical region of 161 503 inhabitants in the Netherlands.ParticipantsWe analysed all 895 primary care patients in whom either the GP determined a D-dimer value or who had a diagnostic work-up for suspected VTE in a non-academic hospital during 2015.Primary and secondary outcome measuresThe primary outcomes of this study were the total number of VTEs per year and the diagnostic pathways—including the role of GP determined D-dimer testing—of patients urgently referred to secondary care for suspected VTE. Additionally, we explored the use of an age-adjusted D-dimer cut-off.ResultsThe annual VTE incidence was 0.9 per 1000 inhabitants. GPs annually ordered 5.1 D-dimer tests per 1000 inhabitants. Of 470 urgently GP-referred patients, 31.3% had a VTE. Of those urgently referred based on clinical assessment only (without D-dimer testing), 73.8% (96/130) had a VTE; based on clinical assessment and laboratory D-dimer testing yielded 15.0% (51/340) VTE. Applying age-adjusted D-dimer cut-offs to all patients aged 50 years or older resulted in a reduction of positive D-dimer results from 97.9% to 79.4%, without missing any VTE.ConclusionsAlthough D-dimer testing contributes to the diagnostic work-up of VTE, GPs have a high detection rate for VTE in patients who they urgently refer to secondary care based on clinical assessment only.

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