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

Josien van Es; Inge Mos; Renée Douma; Petra Erkens; Marc Durian; Tessa Nizet; Anja van Houten; Herman Hofstee; Hugo ten Cate; Eric Ullmann; Harry Büller; Menno Huisman; P. W. Kamphuisen

doi:10.1160/TH11-08-0587

Thrombosis and Haemostasis, Inhaltsverzeichnis

Thromb Haemost 2012; 107(01): 167-171
DOI: 10.1160/TH11-08-0587

New Technologies, Diagnostic Tools and Drugs

Schattauer GmbH

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

Josien van Es

¹Academic Medical Center – Vascular Medicine, Amsterdam, Netherlands

,

Inge Mos

²Leiden University Medical Center – General Internal Medicine – Endocrinology, Leiden, Netherlands

,

Renée Douma

¹Academic Medical Center – Vascular Medicine, Amsterdam, Netherlands

,

Petra Erkens

³Maastricht University Medical Center – Lab Clinical Thrombosis and Haemostasis, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands

⁴Maastricht University Medical Center – Internal Medicine, Maastricht, Netherlands

,

Marc Durian

⁵Erasmus University Medical Center – Hematology, Rotterdam, Netherlands

,

Tessa Nizet

⁶Rijnstate Hospital – Pulmonary Medicine, Arnhem, Netherlands

,

Anja van Houten

⁷Maasstad Hospital – Internal and Pulmonal Medicine, Rotterdam, Netherlands

,

Herman Hofstee

⁸VU University Medical Center – Internal Medicine, Amsterdam, Netherlands

,

Hugo ten Cate

⁴Maastricht University Medical Center – Internal Medicine, Maastricht, Netherlands

,

Eric Ullmann

⁶Rijnstate Hospital – Pulmonary Medicine, Arnhem, Netherlands

,

Harry Büller

¹Academic Medical Center – Vascular Medicine, Amsterdam, Netherlands

,

Menno Huisman

²Leiden University Medical Center – General Internal Medicine – Endocrinology, Leiden, Netherlands

,

P. W. Kamphuisen

¹Academic Medical Center – Vascular Medicine, Amsterdam, Netherlands

› Institutsangaben

Abstract

Summary

Four 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.

Keywords

Clinical studies - pulmonary embolism - epidemiological studies - aging

Volltext

Referenzen

References
1 Anderson Jr. FA, Wheeler HB, Goldberg RJ. et al. A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism. The Worcester DVT Study. Arch Intern Med 1991; 151: 933-938.
2 Naess IA, Christiansen SC, Romundstad P. et al. Incidence and mortality of venous thrombosis: a population-based study. J Thromb Haemost 2007; 05: 692-699.
3 Silverstein MD, Heit JA, Mohr DN. et al. Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based study. Arch Intern Med 1998; 158: 585-593.
4 Heit JA, Silverstein MD, Mohr DN. et al. The epidemiology of venous thromboembolism in the community. Thromb Haemost 2001; 86: 452-463.
5 Le Gal G, Righini M, Roy PM. et al. Differential value of risk factors and clinical signs for diagnosing pulmonary embolism according to age. J Thromb Haemost 2005; 03: 2457-2464.
6 Perrier A, Desmarais S, Goehring C. et al. D-dimer testing for suspected pulmonary embolism in outpatients. Am J Respir Crit Care Med 1997; 156: 492-496.
7 Gibson NS, Douma RA, Squizzato A. et al. Application of a decision rule and a D-dimer assay in the diagnosis of pulmonary embolism. Thromb Haemost 2010; 103: 849-854.
8 The Christopher study investigators. van Belle A, Buller HR, Huisman MV, Huisman PM, Kaasjager K. et al. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. J Am Med Assoc 2006; 295: 172-179.
9 Rosendaal FR, Van Hylckama V, Doggen CJ. Venous thrombosis in the elderly. J Thromb Haemost 2007; 05 (01) 310-317.
10 Engbers MJ, Van Hylckama VA, Rosendaal FR. Venous thrombosis in the elderly: incidence, risk factors and risk groups. J Thromb Haemost 2010; 08: 2105-2112.
11 Righini M, Nendaz L, Le Gal G. et al. Influence of age on the cost-effectiveness of diagnostic strategies for suspected pulmonary embolism. J Thromb Haemost 2007; 05: 1869-1877.
12 Dentali F, Crowther M. Venous thromboembolism, age and hospitalisation: A potentially deadly combination. Thromb Haemost 2010; 104: 655-656.
13 Hager K, Platt D. Fibrin degeneration product concentrations (D-dimers) in the course of ageing. Gerontology 1995; 41: 159-165.
14 Masotti L, Ceccarelli E, Cappelli R. et al. Plasma D-dimer levels in elderly patients with suspected pulmonary embolism. Thromb Res 2000; 98: 577-579.
15 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.
16 Tardy B, Tardy-Poncet B, Viallon A. et al. Evaluation of D-dimer ELISA test in elderly patients with suspected pulmonary embolism. Thromb Haemost 1998; 79: 38-41.
17 Douma RA, Le GG, Sohne M, Righini 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. Br Med J 2010; 340: c1475.
18 Gibson NS, Sohne M, Kruip MJ. et al. Further validation and simplification of the Wells clinical decision rule in pulmonary embolism. Thromb Haemost 2008; 99: 229-234.
19 Klok FA, Mos IC, Nijkeuter M. et al. Simplification of the revised Geneva score for assessing clinical probability of pulmonary embolism. Arch Intern Med 2008; 168: 2131-2136.
20 Le Gal G, Righini M, Roy PM. et al. Prediction of pulmonary embolism in the emergency department: the revised Geneva score. Ann Intern Med 2006; 144: 165-171.
21 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.
22 Wells PS, Ginsberg JS, Anderson DR. et al. Use of a clinical model for safe management of patients with suspected pulmonary embolism. Ann Intern Med 1998; 129: 997-1005.
23 Klok FA, Kruisman E, Spaan J. et al. Comparison of the revised Geneva score with the Wells rule for assessing clinical probability of pulmonary embolism. J Thromb Haemost 2008; 06: 40-44.
24 Douma RA, Mos IC, Erkens PM. et al. Performance of 4 Clinical Decision Rules in the Diagnostic Management of Acute Pulmonary Embolism: A Prospective Cohort Study. Ann Intern Med 2011; 154: 709-718.