Age-Dependent D-dimer Cut-off to Avoid Unnecessary CT-Exams for Ruling-out Pulmonary Embolism

Abstract

Purpose: To evaluate the effect of an age-dependent D-Dimer cut-off in patients who underwent a computed tomography pulmonary angiogram (CTPA) for suspected pulmonary embolism (PE)

Material and Methods: Retrospective application of an age-dependent D-dimer cut-off (age/100 in patients aged over 50) in 530 consecutive patients, both in- and outpatients, aged over 18, who underwent CTPA for suspected PE according to the guidelines.

Results: The application of an age-dependent D-dimer cut-off showed a now negative test-result in 17 of 530 patients (3.2 %). The proportion was 4.1 % (17 of 418) in patients aged over 50. None of these 17 cases was diagnosed with PE in CTPA, the false-negative rate was 0 %. The effect could be seen in outpatients (14 of 377 [3.7 %]) as well as in inpatients(3 of 153 [2.0 %]) with no statistically significant difference (p > 0.05).

Conclusion: The application of an age-dependent D-dimer cut-off as part of the guidline-based algorithm for suspected PE reduced the number of necessary CTPA in outpatients as well as in inpatients.

Key points:

• The application of an age-dependent D-dimer cut-off reduces the number of CTPA as part of the diagnostic algorithm in patients suspected for PE

No reduction in diagnostic safety was found

• The age adjustement performed equally in outpatients and inpatients

Citation Format:

• Altmann MM, Wrede CE., Peetz D et al. Age-Dependent D-dimer Cut-off to Avoid Unnecessary CT-Exams for Ruling-out Pulmonary Embolism. Fortschr Röntgenstr 2015; 187: 795 – 800

Zusammenfassung

Ziel: Überprüfung des Effekts einer altersangepassten Anhebung des D-Dimer-Grenzwerts von Patienten, die bei Verdacht auf Lungenarterienembolie (LAE) eine Computertomografie-Untersuchung der Pulmonalgefäße (CTPA) erhielten.

Material und Methoden: Retrospektive Anwendung der altersangepassten Anhebung des D-Dimer-Grenzwerts ab einem Alter von 50 Jahren nach der Formel Lebensalter/100 in mg/l auf 530 Patienten über 18 Jahren, die im Notfallzentrum (n = 377) oder auf der Station (n = 153) behandelt wurden und bei klinischem Verdacht auf eine LAE eine CTPA-Untersuchung erhielten.

Ergebnisse: Die Anwendung des altersangepassten D-Dimer-Grenzwerts ergab bei 17 von 530 Patienten (3,2 %) ein neu negatives Testergebnis. Bezogen auf die über 50-jährigen Patienten lag der Anteil dieser Patienten bei 4,1 % (17 von 418). In keinem der 17 Fälle wurde in der CTPA-Untersuchung eine LAE nachgewiesen; somit lag die Rate der falsch-negativen Testergebnisse bei 0 %. Dabei zeigte sich dieser Effekt gleichermaßen bei Patienten des Notfallzentrums wie bei stationären Patienten (14 von 377 [3,7 %] vs. 3 von 153 [2,0 %], p > 0,05).

Schlussfolgerung: Die Anwendung eines altersangepassten D-Dimer-Grenzwerts im Rahmen des leitliniengerechten Algorithmus bei Verdacht auf LAE reduziert die Zahl an erforderlichen CTPA-Untersuchungen sowohl bei Patienten des Notfallzentrums als auch bei stationären Patienten.

Key words

embolism/thrombosis - thorax - CT-angiography - vascular

• References

• 1 Torbicki A, Perrier A, Konstantinides S et al. Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur. Heart J 2008; 29: 2276-2315
• 2 Laporte S, Mismetti P, Décousus H et al. Clinical predictors for fatal pulmonary embolism in 15520 patients with venous thromboembolism: findings from the Registro Informatizado de la Enfermedad TromboEmbolica venosa (RIETE) Registry. Circulation 2008; 117: 1711-1716
• 3 Tapson VF. Acute pulmonary embolism. N Engl J Med 2008; 358: 1037-1052
• 4 Squizzato A, Luciani D, Rubboli A et al. Differential diagnosis of pulmonary embolism in outpatients with non-specific cardiopulmonary symptoms. Intern Emerg Med 2013; 8: 695-702
• 5 Stein PD, Fowler SE, Goodman LR et al. Multidetector computed tomography for acute pulmonary embolism. N Engl J Med 2006; 354: 2317-2327
• 6 Perrier A, Roy PM, Sanchez O et al. Multidetector-row computed tomography in suspected pulmonary embolism. N Engl J Med 2005; 352: 1760-1768
• 7 Davies HE, Wathen CG, Gleeson FV. The risks of radiation exposure related to diagnostic imaging and how to minimise them. BMJ 2011; 342: d947
• 8 Hurwitz LM, Reiman RE, Yoshizumi TT et al. Radiation dose from contemporary cardiothoracic multidetector CT protocols with an anthropomorphic female phantom: implications for cancer induction. Radiology 2007; 245: 742-750
• 9 Singh J, Daftary A. Iodinated contrast media and their adverse reactions. J Nucl Med Technol 2008; 36: 69-74 ; quiz 76–77
• 10 Blättler W, Gerlach H, Hach-Wunderle V et al. Interdisziplinäre S2-Leitlinie Diagnostik und Therapie der Venenthrombose und der Lungenembolie. VASA 2010; 39: 1-39
• 11 Wells PS, Anderson DR, Rodger M et al. Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer. Thromb Haemost 2000; 83: 416-420
• 12 Budzynski AZ, Marder VJ, Parker ME et al. Antigenic markers on fragment DD, a unique plasmic derivative of human crosslinked fibrin. Blood 1979; 54: 794-804
• 13 Wilson DB, Gard KM. Evaluation of an automated, latex-enhanced turbidimetric D-dimer test (advanced D-dimer) and usefulness in the exclusion of acute thromboembolic disease. Am J Clin Pathol 2003; 120: 930-937
• 14 Adam SS, Key NS, Greenberg CS. D-dimer antigen: current concepts and future prospects. Blood 2009; 113: 2878-2887
• 15 Lindner G, Funk GC, Pfortmueller CA et al. D-dimer to rule out pulmonary embolism in renal insufficiency. Am J Med 2014; 127: 343-347
• 16 Harper PL, Theakston E, Ahmed J et al. D-dimer concentration increases with age reducing the clinical value of the D-dimer assay in the elderly. Intern Med J 2007; 37: 607-613
• 17 Righini M, Goehring C, Bounameaux H et al. Effects of age on the performance of common diagnostic tests for pulmonary embolism. Am J Med 2000; 109: 357-361
• 18 Douma RA, le Gal G, Sohne M et al. Potential of an age adjusted D-dimer cut-off value to improve the exclusion of pulmonary embolism in older patients: a retrospective analysis of three large cohorts. BMJ 2010; 340: c1475-c1475
• 19 Van Belle A, Büller HR, Huisman MV et al. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. JAMA 2006; 295: 172-179
• 20 Ghaye B, Remy J, Remy-Jardin M. Non-traumatic thoracic emergencies: CT diagnosis of acute pulmonary embolism: the first 10 years. Eur Radiol 2002; 12: 1886-1905
• 21 Biederer J, Wildberger JE, Reuter M et al. Protokollempfehlungen für die Computertomografie der Lunge. Fortschr Röntgenstr 2008; 180: 471-479
• 22 Pontana F, Henry S, Duhamel A et al. Impact of iterative reconstruction on the diagnosis of acute pulmonary embolism (PE) on reduced-dose chest CT angiograms. Eur Radiol 2015; 25: 1182-1189
• 23 Deak PD, Smal Y, Kalender WA. Multisection CT protocols: sex- and age-specific conversion factors used to determine effective dose from dose-length product. Radiology 2010; 257: 158-166
• 24 Chandra S, Sarkar PK, Chandra D et al. Finding an alternative diagnosis does not justify increased use of CT-pulmonary angiography. BMC Pulm Med 2013; 13: 9
• 25 Costa AF, Basseri H, Sheikh A et al. The yield of CT pulmonary angiograms to exclude acute pulmonary embolism. Emerg Radiol 2013; 21-23
• 26 Penaloza A, Roy PM, Kline J et al. Performance of age-adjusted D-dimer cut-off to rule out pulmonary embolism. J Thromb Haemost 2012; 10: 1291-1296
• 27 Van Es J, Mos I, Douma R et al. 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. Thromb Haemost 2012; 107: 167-171
• 28 Jaffrelot M, LeVen F, LeRoux PY et al. External validation of a D-dimer age-adjusted cut-off for the exclusion of pulmonary embolism. Thromb. Haemost 2012; 107: 1005-1007
• 29 Schouten HJ, Geersing GJ, Koek HL et al. Diagnostic accuracy of conventional or age adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism: systematic review and meta-analysis. BMJ 2013; 346: f2492
• 30 Righini M, Van Es J, Den Exter PL et al. Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study. JAMA 2014; 311: 1117-1124
• 31 Miron M, Perrier A, Bounameaux H et al. Contribution of noninvasive evaluation to the diagnosis of pulmonary embolism in hospitalized patients. Eur Respir J 1999; 13: 1365-1370
• 32 Raimondi P, Bongard O, de Moerloose P et al. D-Dimer plasma concentration in various clinical conditions: Implication for the use of this test in the diagnostic approach of venous thromboembolism. Thromb Res 1993; 69: 125-130
• 33 Moores LK, Jackson WL, Shorr AF et al. Meta-analysis: outcomes in patients with suspected pulmonary embolism managed with computed tomographic pulmonary angiography. Ann Intern Med 2004; 141: 866-874