D-dimer threshold increase with pretest probability unlikely for pulmonary embolism to decrease unnecessary computerized tomographic pulmonary angiography

Abstract

Background: Increasing the threshold to define a positive D-dimer could reduce unnecessary computed tomographic pulmonary angiography (CTPA) for a suspected pulmonary embolism (PE) but might increase rates of a missed PE and missed pneumonia, the most common non-thromboembolic diagnosis seen on CTPA.

Objective: Measure the effect of doubling the standard D-dimer threshold for 'PE unlikely' Revised Geneva (RGS) or Wells' scores on the exclusion rate, frequency and size of a missed PE and missed pneumonia.

Methods: Patients evaluated for a suspected PE with 64-channel CTPA were prospectively enrolled from emergency departments (EDs) and inpatient units of four hospitals. Pretest probability data were collected in real time and the D-dimer was measured in a central laboratory. Criterion standard was CPTA interpretation by two independent radiologists combined with clinical outcome at 30 days.

Results: Of 678 patients enrolled, 126 (19%) were PE+ and 93 (14%) had pneumonia. Use of either Wells' ≤ 4 or RGS ≤ 6 produced similar results. For example, with RGS ≤ 6 and standard threshold (< 500 ng mL(-1)), D-dimer was negative in 110/678 (16%), and 4/110 were PE+ (posterior probability 3.8%) and 9/110 (8.2%) had pneumonia. With RGS ≤ 6 and a threshold < 1000 ng mL(-1) , D-dimer was negative in 208/678 (31%) and 11/208 (5.3%) were PE+, but 10/11 missed PEs were subsegmental and none had concomitant DVT. Pneumonia was found in 12/208 (5.4%) with RGS ≤ 6 and D-dimer < 1000 ng mL(-1).

Conclusions: Doubling the threshold for a positive D-dimer with a PE unlikely pretest probability could reduce CTPA scanning with a slightly increased risk of missed isolated subsegmental PE, and no increase in rate of missed pneumonia.

Trial registration: ClinicalTrials.gov NCT00368836.

© 2012 International Society on Thrombosis and Haemostasis.

Figures

Figure 1

Flow diagram showing the number of patients screened, enrolled and reasons for exclusions.

Figure 2

Scatter plot of the plasma D-dimer concentration versus patient age for patients. Red circles represent PE+ patients and open blue circles represent PE− patients. The curved lines are best fit quadratic equations (PE+: D-dimer = 3096 - 58*age +1.13*age2; PE-: D-dimer = 3052 – 66*age +0.63*age2)

Figure 3

A and B. (A) Scatter plot of the D-dimer versus the percentage of pulmonary vasculature obstructed on CTPA for all patients with PE and (B) shows data for the rectangle at the lower left corner; all red circles to the left of the vertical dotted line represent subsegmental PE.

Figure 3

A and B. (A) Scatter plot of the D-dimer versus the percentage of pulmonary vasculature obstructed on CTPA for all patients with PE and (B) shows data for the rectangle at the lower left corner; all red circles to the left of the vertical dotted line represent subsegmental PE.