Download PDF
Thromb Haemost 2024; 124(01): 049-057
DOI: 10.1055/s-0043-57018
Stroke, Systemic or Venous Thromboembolism

Obesity as a Predictor for Pulmonary Embolism and Performance of the Age-Adjusted D-Dimer Strategy in Obese Patients with Suspected Pulmonary Embolism

Jan O. Gaugler 
1   Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
,
Marc Righini
2   Division of Angiology and Hemostasis, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
,
Helia Robert-Ebadi
2   Division of Angiology and Hemostasis, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
,
Olivier Sanchez
3   Université Paris Cité, Paris, France
4   Service de Pneumologie et Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
5   INSERM UMR S 1140, Innovative Therapies in Hemostasis, Paris, France
,
Pierre-Marie Roy
6   Department of Emergency Medicine, University Hospital of Angers, Angers, France
7   UMR MitoVasc CNRS 6015 - INSERM 1083, Health Faculty, Angers, France
,
Franck Verschuren
8   Emergency Department, Saint-Luc University Hospital, IREC Institute, Université Catholique de Louvain, Brussels, Belgium
,
Sebastien Miranda
9   Department of Internal Medicine, Rouen University Hospital, Normandie University, UNIROUEN, INSERM U1096, Rouen, France.
,
Aurélien Delluc 
10   Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada.
,
Grégoire Le Gal  ‡   *
10   Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada.
,
Tobias Tritschler  ‡   *
1   Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
10   Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada.
› Author Affiliations Funding The ADJUST-PE study was funded by grant 32003B-130863 from the Swiss National Science Foundation, the 2007 presidential fund from the International Society on Thrombosis and Haemostasis, grant 2010-5 from the Dutch Thrombosis Foundation, and grant PHRC 2011 08-01 from the Projets Hospitaliers de Recherche Clinique, French Ministry of Health. Aurélien Delluc, Grégoire Le Gal, and Tobias Tritschler are members of the Canadian Venous Thromboembolism Research Network (CanVECTOR); the network received grant funding from the Canadian Institutes of Health Research (CDT-142654). Aurélien Delluc is recipient of a University of Ottawa Department of Medicine Research Salary Award. Grégoire Le Gal holds a mid-career clinician scientist award from the Heart and Stroke Foundation of Ontario, and the Chair on the Diagnosis of Venous Thromboembolism, Department of Medicine, University of Ottawa. The funders had no role in the study design, in the collection, analysis, and interpretation of data, in the writing of the manuscript, and in the decision to submit the article for publication.
› Further Information
Also available at
    Permissions and Reprints


Abstract

Introduction Obesity is a risk factor for venous thromboembolism, but studies evaluating its association with pulmonary embolism (PE) in patients with suspected PE are lacking.

Objectives To evaluate whether body mass index (BMI) and obesity (i.e., BMI ≥30 kg/m2) are associated with confirmed PE in patients with suspected PE and to assess the efficiency and safety of the age-adjusted D-dimer strategy in obese patients.

Methods We conducted a secondary analysis of a multinational, prospective study, in which patients with suspected PE were managed according to the age-adjusted D-dimer strategy and followed for 3 months. Outcomes were objectively confirmed PE at initial presentation, and efficiency and failure rate of the diagnostic strategy. Associations between BMI and obesity, and PE were examined using a log-binomial model that was adjusted for clinical probability and hypoxia.

Results We included 1,593 patients (median age: 59 years; 56% women; 22% obese). BMI and obesity were not associated with confirmed PE. The use of the age-adjusted instead of the conventional D-dimer cut-off increased the proportion of obese patients in whom PE was considered ruled out without imaging from 28 to 38%. The 3-month failure rate in obese patients who were left untreated based on a negative age-adjusted D-dimer cut-off test was 0.0% (95% confidence interval: 0.0–2.9%).

Conclusion BMI on a continuous linear scale and obesity were not predictors of confirmed PE among patients presenting with a clinical suspicion of PE. The age-adjusted D-dimer strategy appeared safe in ruling out PE in obese patients with suspected PE.

Keywords

clinical prediction - D-dimer - diagnosis - obesity - pulmonary embolism

Authors' Contribution

Study concept and design: J. O. G., M. R., and G. L. G., T. T.. Provision of study materials or patients: M. R., O. S., P.-M. R., F. V., and G. L. G.. Data analysis: Tobias Tritschler. Drafting of the manuscript: J. O. G., G. L. G., and T. T.. Critical revision of the manuscript for important intellectual content: all authors. Final approval of the manuscript: all authors.


* Contributed equally.


Supplementary Material



Publication History

Received: 22 January 2023

Accepted: 09 March 2023

Article published online:
12 June 2023

© 2023. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

Comment to this article:

Obesity and Pulmonary Embolism: Can We Dismantle the “Obesity Paradox”Thromb Haemost 2024; 124(01): 058-060
DOI: 10.1055/a-2187-0966

 

  • References

  • 1 Swinburn BA, Sacks G, Hall KD. et al. The global obesity pandemic: shaped by global drivers and local environments. Lancet 2011; 378 (9793): 804-814
    CrossrefPubMedSearch in Google Scholar
  • 2 Ng M, Fleming T, Robinson M. et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014; 384 (9945): 766-781
    CrossrefPubMedSearch in Google Scholar
  • 3 NCD Risk Factor Collaboration (NCD-RisC). Trends in adult body-mass index in 200 countries from 1975 to 2014: a pooled analysis of 1698 population-based measurement studies with 19·2 million participants. Lancet 2016; 387 (10026): 1377-1396
    CrossrefPubMedSearch in Google Scholar
  • 4 Goldhaber SZ, Grodstein F, Stampfer MJ. et al. A prospective study of risk factors for pulmonary embolism in women. JAMA 1997; 277 (08) 642-645
    CrossrefPubMedSearch in Google Scholar
  • 5 Stein PD, Beemath A, Olson RE. Obesity as a risk factor in venous thromboembolism. Am J Med 2005; 118 (09) 978-980
    CrossrefPubMedSearch in Google Scholar
  • 6 Pomp ER, le Cessie S, Rosendaal FR, Doggen CJ. Risk of venous thrombosis: obesity and its joint effect with oral contraceptive use and prothrombotic mutations. Br J Haematol 2007; 139 (02) 289-296
    CrossrefPubMedSearch in Google Scholar
  • 7 Severinsen MT, Kristensen SR, Johnsen SP, Dethlefsen C, Tjønneland A, Overvad K. Anthropometry, body fat, and venous thromboembolism: a Danish follow-up study. Circulation 2009; 120 (19) 1850-1857
    CrossrefPubMedSearch in Google Scholar
  • 8 Huisman MV, Barco S, Cannegieter SC. et al. Pulmonary embolism. Nat Rev Dis Primers 2018; 4: 18028
    CrossrefPubMedSearch in Google Scholar
  • 9 Braekkan SK, Siegerink B, Lijfering WM, Hansen JB, Cannegieter SC, Rosendaal FR. Role of obesity in the etiology of deep vein thrombosis and pulmonary embolism: current epidemiological insights. Semin Thromb Hemost 2013; 39 (05) 533-540
    Thieme ConnectPubMedSearch in Google Scholar
  • 10 Lim W, Le Gal G, Bates SM. et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: diagnosis of venous thromboembolism. Blood Adv 2018; 2 (22) 3226-3256
    CrossrefPubMedSearch in Google Scholar
  • 11 Konstantinides SV, Meyer G, Becattini C. et al; ESC Scientific Document Group. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 2020; 41 (04) 543-603
    CrossrefPubMedSearch in Google Scholar
  • 12 Righini M, Nendaz M, Le Gal G, Bounameaux H, Perrier A. Influence of age on the cost-effectiveness of diagnostic strategies for suspected pulmonary embolism. J Thromb Haemost 2007; 5 (09) 1869-1877
    CrossrefPubMedSearch in Google Scholar
  • 13 Rodger MA, Kahn SR, Wells PS. et al. Identifying unprovoked thromboembolism patients at low risk for recurrence who can discontinue anticoagulant therapy. CMAJ 2008; 179 (05) 417-426
    CrossrefPubMedSearch in Google Scholar
  • 14 Hawley PC, Hawley MP. Difficulties in diagnosing pulmonary embolism in the obese patient: a literature review. Vasc Med 2011; 16 (06) 444-451
    CrossrefPubMedSearch in Google Scholar
  • 15 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 (11) 1117-1124
    CrossrefPubMedSearch in Google Scholar
  • 16 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 (19) 2131-2136
    CrossrefPubMedSearch in Google Scholar
  • 17 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 (03) 416-420
    Thieme ConnectPubMedSearch in Google Scholar
  • 18 McNutt LA, Wu C, Xue X, Hafner JP. Estimating the relative risk in cohort studies and clinical trials of common outcomes. Am J Epidemiol 2003; 157 (10) 940-943
    CrossrefPubMedSearch in Google Scholar
  • 19 Newcombe RG. Two-sided confidence intervals for the single proportion: comparison of seven methods. Stat Med 1998; 17 (08) 857-872
    CrossrefPubMedSearch in Google Scholar
  • 20 R Core Team. R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. 2022 . Accessed March 28, 2023 at: https://www.R-project.org/
    PubMedSearch in Google Scholar
  • 21 Rahmani J, Haghighian Roudsari A, Bawadi H. et al. Relationship between body mass index, risk of venous thromboembolism and pulmonary embolism: a systematic review and dose-response meta-analysis of cohort studies among four million participants. Thromb Res 2020; 192: 64-72
    CrossrefPubMedSearch in Google Scholar
  • 22 van Beek EJ, Brouwerst EM, Song B, Stein PD, Oudkerk M. Clinical validity of a normal pulmonary angiogram in patients with suspected pulmonary embolism–a critical review. Clin Radiol 2001; 56 (10) 838-842
    CrossrefPubMedSearch in Google Scholar
  • 23 Dronkers CEA, van der Hulle T, Le Gal G. et al; Subcommittee on Predictive and Diagnostic Variables in Thrombotic Disease. Towards a tailored diagnostic standard for future diagnostic studies in pulmonary embolism: communication from the SSC of the ISTH. J Thromb Haemost 2017; 15 (05) 1040-1043
    CrossrefPubMedSearch in Google Scholar