D-dimer: role in ruling out pulmonary embolism in emergency care department
Keywords:
D-dimer, Emergency Care Department, Pulmonary embolism, Revised Geneva Score
Abstract
Introduction. Pulmonary embolism (PE) is a diagnostic challenge, particularly in prehospital care. The aim of this study was to determine to what extent evaluation of D-dimer value helps physicians with differentiation of PE, and whether D-dimer values are in correlation with values of Revised Geneva Score.
Methods. Data have been collected for the patients whose D-dimer has been evaluated at the Emergency Care Department of the City of Banja Luka in 2018. Gender, age, symptoms, working diagnosis and D-dimer value have all been recorded and also the fact whether the patient was referred to hospital treatment or not. For each patient the Revised Geneva Score was determined.
Results. Sixty-eight tests have been done in 2018. Out of 68 tests, 41 were negative (60.3%). D-dimer results helped in making a decisions about referring patients to the hospital or not (χ2=36.32, p<0.001). Patients with elevated D-dimer levels, especially where the values were four times higher that the refence ones, typically were referred to hospital treatmant, whereas 67.5% patients with negative D-dimer results were sent home after giving treatment and advice. In the elderly patients D-dimer was statistically more positive (F=10.82, p<0.001). Values of D-dimer were not significantly different regarding gender (χ2=2.19, p=0.33). According to the results of the Revised Geneva Score, 5.1% of patients had high risk of PTE, while moderate and low risk had 47.5% each. Although it has been found that the values of D-dimer were slightly more elevated at higher values of the Revised Geneva Score, that difference was not statistically significant (χ2=7.71, p=0.10).
Conclusion. Values of D-dimer considerably helped in diferentation of PE in the Emergency Care Department Banja Luka. D-dimer has a high negative predictive value and should be used to exclude PE diagnosis for patients with low clinical possibility of PE.
References
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2. Parakh RS, Sabath DE. Venous Thromboembolism: Role of the Clinical Laboratory in Diagnosis and Management. J Appl Lab Med 2019 Mar;3(5):870-82.
3. Benjamin EJ, Blaha MJ, Chiuve SE, Cushman M, Das SR, Deo R, de Ferranti SD, Floyd J, Fornage M, Gillespie C, Isasi CR, Jimenez MC, Jordan LC, Judd SE, Lackland D, Lichtman JH, Lisabeth L, Liu S, Longenecker CT, Mackey RH, Matsushita K, Mozaffarian D, Mussolino ME, Nasir K, Neumar RW, Palaniappan L, Pandey DK, Thiagarajan RR, Reeves MJ, Ritchey M, Rodriguez CJ, Roth GA, Rosamond WD, Sasson C, Towfighi A, Tsao CW, Turner MB, Virani SS, Voeks JH, Willey JZ, Wilkins JT, Wu JH, Alger HM, Wong SS, Muntner P; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart Disease and Stroke Statistics-2017 Update: A Report From the American Heart Association. Circulation 2017 Mar 7;135(10):e146-e603. doi: 10.1161/CIR.0000000000000485.
4. Konstantinides SV, Torbicki A, Agnelli G, Danchin N, Fitzmaurice D, Galiè N, Gibbs JS, Huisman MV, Humbert M, Kucher N, Lang I, Lankeit M, Lekakis J, Maack C, Mayer E, Meneveau N, Perrier A, Pruszczyk P, Rasmussen LH, Schindler TH, Svitil P, Vonk Noordegraaf A, Zamorano JL, Zompatori M; Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J (2014) 35, 3033-80.
5. Cohen AT, Agnelli G, Anderson FA, Arcelus JI, Bergqvist D, Brecht JG, Greer IA, Heit JA, Hutchinson JL, Kakkar AK, Mottier D, Oger E, Samama MM, Spannagl M. Venous thromboembolism (VTE) in Europe. The number of VTE events and associated morbidity and mortality. Thromb Haemost 2007;98(4):756–64.
6. Rubini G, Ferrari C, Cimino A, Fanelli M, Altini C, Gaudiano A, Nappi AG, Lavelli V, Niccoli Asabella A. How often suspected pulmonary embolism is diagnosed and its main diagnostic characteristics, in an emergency nuclear medicine service? Four years experience. Hell J Nucl Med 2019 Sep-Dec;22(3):187-93.
7. Kausar S, Khan HS, Nazir MTB, Adeel-Ur-Rehman, Kayani AM. Acute pulmonary embolism: presentation, diagnosis, management and factors impacting clinical outcome in a tertiary cardiac centre in Pakistan. J Coll Physicians Surg Pak 2019 Aug;29(8):749-52.
8. Alotaibi GS, Wu C, Senthilselvan A, McMurtry MS. Secular trends in incidence and mortality of acute venous thromboembolism: The AB-VTE population-based study. Am J Med 2016 Aug;129(8):879.e19-25. doi: 10.1016/j.amjmed.2016.01.041.
9. Bozorgmehr R, Pishgahi M, Mohaghegh P, Bayat M, Khodadadi P, Ghafori A. Relationship between thrombosis risk factors, clinical symptoms, and laboratory findings with pulmonary embolism diagnosis; a cross-sectional study. Arch Acad Emerg Med 2019 Jul 23;7(1):41. eCollection 2019.
10. Pollack CV, Schreiber D, Goldhaber SZ, Slattery D, Fanikos J, O’Neil BJ, et al. Clinical characteristics, management, and outcomes of patients diagnosed with acute pulmonary embolism in the emergency department: initial report of EMPEROR (Multicenter Emergency Medicine Pulmonary Embolism in the RealWorld Registry). J Am Coll Cardiol 2011;57(6):700–6.
11. Badertscher P et all; BASEL IX Investigators. Prevalence of pulmonary embolism in patients with syncope. J Am Coll Cardiol 2019 Aug 13;74(6):744-54.
12. Gibson NS, Sohne M, Kruip MJ, Tick LW, Gerdes V, Bossuyt PM, et al. Further validation and simplification of the Wells clinical decision rule in pulmonary embolism. Thromb Haemost 2008;99:229–34.
13. Le Gal G, Righini M, Roy P-M, Sanchez O, Aujesky D, Bounameaux H, et al. Prediction of pulmonary embolism in the emergency department: the revised Geneva score. Ann Intern Med 2006; 144:165–71.
14. Klok FA, Mos ICM, Nijkeuter M, Righini M, Perrier A, Le Gal G, et al. Simplification of the revised Geneva score for assessing clinical probability of pulmonary embolism. Arch Intern Med 2008;168:2131–36.
15. van Maanen R, Rutten FH, Klok FA, Huisman MV, Blom JW, Moons KGM, et al. Validation and impact of a simplified clinical decision rule for diagnosing pulmonary embolism in primary care: design of the PECAN prospective diagnostic cohort management study. BMJ Open 2019 Oct 10;9(10):e031639. doi: 10.1136/bmjopen-2019-031639.
16. Tak T, Karturi S, Sharma U, Eckstein L, Poterucha JT, Sandoval Y. Acute Pulmonary Embolism: Contemporary Approach to Diagnosis, Risk-Stratification, and Management. Int J Angiol 2019 Jun;28(2):100-11.
17. Kosuge M, Kimura K, Ishikawa T, Ebina T, Hibi K, Kusama I, et al. Electrocardiographic differentiation between acute pulmonary embolism and acute coronary syndromes on the basis of negative T waves. Am J Cardiol 2007 Mar 15;99(6):817-21.
18. Ed Burns. EKG changes in pulmonary embolism. Life in the fastline. [Cited 2019 November 19] Available from: https://litfl.com/ecg-changes-in-pulmonary-embolism/
19. Ozdemir M, Sonmez BM, Yilmaz F, Yilmaz A, Duyan M, Komut S. Is bedside end-tidal CO2 measurement a screening tool to exclude pulmonary embolism in emergency department? J Clin Med Res 2019 Oct;11(10):696-702.
20. van der Pol LM, Tromeur C, Faber LM, van der Hulle T, Kroft LJM, Mairuhu ATA, et al. Chest X-ray not routinely indicated prior to the YEARS algorithm in the diagnostic management of suspected pulmonary embolism. TH Open 2019 Jan 8;3(1):e22-e27. doi: 10.1055/s-0038-1676812. eCollection 2019 Jan.
21. Beenen LFM, Bossuyt PMM, Stoker J, Middeldorp S. Prognostic value of cardiovascular parameters in computed tomography pulmonary angiography in patients with acute pulmonary embolism. Eur Respir J 2018;52(1) pii: 1702611. doi: 10.1183/13993003.02611-2017.
22. Kruger PC, Eikelboom JW, Douketis JD, Hankey GJ. Pulmonary embolism: update on diagnosis and management. Med J Aust 2019 Jul;211(2):82-7.
23. Oi M, Yamashita Y, Toyofuku M, Morimoto T, Motohashi Y, Tamura T et al; COMMAND VTE Registry Investigators. D-dimer levels at diagnosis and long-term clinical outcomes in venous thromboembolism: from the COMMAND VTE Registry. J Thromb Thrombolysis 2019 Sep 30. doi: 10.1007/s11239-019-01964-0. [Epub ahead of print]
24. Lucassen W, Geersing GJ, Erkens PMG, et al. Clinical decision rules for excluding pulmonary embolism: a meta-analysis. Ann Intern Med 2011; 155: 448–60.
25. Geersing GJ, Zuithoff NPA, Kearon C, et al. Exclusion of deep vein thrombosis using the Wells rule in clinically important subgroups: individual patient data meta-analysis. BMJ 2014; 348: g1340.
26. Tasić N, Paixão TRLC, Gonçalves LM. Biosensing of D-dimer, making the transition from the central hospital laboratory to bedside determination. Talanta 2020 Jan 15;207:120270. doi: 10.1016/j.talanta.2019.120270. Epub 2019 Aug 16.
27. Rotzinger DC, Dunet V, Ilic V, Hugli OW, Meuli RA, Schmidt S. Pulmonary embolism during pregnancy: a 17-year single-center retrospective MDCT pulmonary angiography study. Eur Radiol 2019 Nov 14. doi: 10.1007/s00330-019-06501-4.
28. Guo J, Deng QF, Xiong W, Pudasaini B, Yuan P, Liu JM, Zhou CC. Comparison among different presentations of venous thromboembolism because of lung cancer. Clin Respir J 2019 Sep;13(9):574-582.
29. Polo Friz H, Pezzetti V, Orenti A, Caleffi A, Corno V, Crivellari C, Petri F, Polo Friz M, Punzi V, Teruzzi D, d'Oro LC, Giannattasio C, Vighi G, Cimminiello C, Boracchi P. Comorbidity burden conditions the prognostic performance of D-dimer in elderly patients with acute pulmonary embolism. Am J Emerg Med 2019 May;37(5):799-804.
30. Vögeli A, Ghasemi M, Gregoriano C, Hammerer A, Haubitz S, Koch D, Kutz A, Mueller B, Schuetz P. Diagnostic and prognostic value of the D-dimer test in emergency department patients: secondary analysis of an observational study. Clin Chem Lab Med 2019 Oct 25;57(11):1730-1736.
31. Rawat N, Mathur N, Rawat K, Mathur M, Tinna R, Kakkar R, Didel L. Correlation of D-Dimer Level with the Presence and Severity of Pulmonary Embolism on Computed Tomography Pulmonary Angiography. J Assoc Physicians India 2018 Oct;66(10):40-41.
32. Tran HA, Gibbs H, Merriman E, Curnow JL, Young L, Bennett A, Tan, Chunilal SD, Ward CM, Baker R, Nandurkar H. New guidelines from the Thrombosis and Haemostasis Society of Australia and New Zealand for the diagnosis and management of venous thromboembolism. Med J Aust 2019 Mar;210(5):227-235.
33. Wells PS, Anderson DR, Rodger M, et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer. Ann Intern Med 2001; 135: 98–107.
34. Reardon PM, Patrick S, Taljaard M, Thavorn K, Nemnom MJ, Mukarram M, Kim SM, Le Gal G, Huang L, Thiruganasambandamoorthy V. Diagnostic Accuracy and Financial Implications of Age-Adjusted D-Dimer Strategies for the Diagnosis of Deep Venous Thrombosis in the Emergency Department. J Emerg Med 2019 May;56(5):469-477.
35. Dutton J, Dachsel M, Crane R. Can the use of an age adjusted D-dimer cut-off value help in our diagnosis of suspected pulmonary embolism? Clin Med 2018;18:293–6.
36. Barth BE, Waligora G, Gaddis GM. Rapid Systematic Review: Age-Adjusted D-Dimer for Ruling Out Pulmonary Embolism. J Emerg Med 2018 Oct;55(4):586-592.
37. Jacob Ortiz, Rabia Saeed, Christopher Little, and Saul Schaefer. Age-Adjusted D-Dimer in the Prediction of Pulmonary Embolism: Does a Normal Age-Adjusted D-Dimer Rule Out PE? Biomed Res Int 2017; 2017: 4867060. Epub 2017 Oct 19.
38. Righini M, Van Es J, Den Exter PL, Roy PM, Verschuren F, Ghuysen A, Rutschmann OT, Sanchez O, Jaffrelot M, Trinh-Duc A, Le Gall C, Moustafa F, Principe A, Van Houten AA, Ten Wolde M, Douma RA, Hazelaar G, Erkens PM, Van Kralingen KW, Grootenboers MJ, Durian MF, Cheung YW, Meyer G, Bounameaux H, Huisman MV, Kamphuisen PW, Le Gal G. Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study. JAMA 2014 Mar 19;311(11):1117-24.
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2020/03/27
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