Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study
| Autor: | Morgan Jaffrelot, Marije Ten Wolde, Renée A. Douma, Menno V. Huisman, Paul L. den Exter, Olivier Thierry Rutschmann, Farès Moustafa, Pierre-Marie Roy, Josien van Es, Alessandra Principe, Pieter Willem Kamphuisen, A Trinh-Duc, Marc Philip Righini, Olivier Sanchez, Marco J. J. H. Grootenboers, Marc Durian, Y. Whitney Cheung, Guy Meyer, Catherine Le Gall, Franck Verschuren, Grégoire Le Gal, Klaas W Van Kralingen, Petra M. G. Erkens, Henri Bounameaux, Anja A. van Houten, Alexandre Ghuysen, Germa Hazelaar |
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| Přispěvatelé: | Service d'angiologie et d'hémostase (MR), Hôpital Universitaire de Genève, Department of Vascular Medicine (AMSTERDAM - DVM), Academic Medical Center - Academisch Medisch Centrum [Amsterdam] (AMC), University of Amsterdam [Amsterdam] (UvA)-University of Amsterdam [Amsterdam] (UvA), Department of Thrombosis and Hemostasis (LEIDEN - DTH), Leiden University Medical Center (LUMC), Service des Urgences (PMR), CHRU - ANGERS, Emergency Department (FV - ED), Saint Luc University Hospital, Hôpital Européen Georges Pompidou [APHP] (HEGP), Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Hôpitaux Universitaires Paris Ouest - Hôpitaux Universitaires Île de France Ouest (HUPO), Service des Urgences (MG), Centre Hospitalier Régional Universitaire de Brest (CHRU Brest), Service d'Accueil des Urgences (AGEN - SAU), Centre Hospitalier d'Agen, Service d'Accueil des Urgences (ARGENTEUIL - SAU), CH Argenteuil, Département des Urgences, CHU Clermont-Ferrand, Service des Urgences (CHPM - SU), CH Morlaix, Department of Internal Medicine (ROTTERDAM - Med Int), Maasstad Hospital, Department of Vascular Medicine (DVM - AMC), Department of General Practice (CAPHRI), Maastricht University [Maastricht], Department of Vascular Medicine (DVM - Groningen), University Medical Center Groningen [Groningen] (UMCG), Groupe d'Etude de la Thrombose de Bretagne Occidentale (GETBO), Institut Brestois Santé Agro Matière (IBSAM), Université de Brest (UBO)-Université de Brest (UBO)-Université de Brest (UBO), Centre d'Investigation Clinique (CIC - Brest), Université de Brest (UBO)-Institut National de la Santé et de la Recherche Médicale (INSERM), Cardiovascular Centre (CVC), Vascular Ageing Programme (VAP), Vascular Medicine, Other departments, 01 Internal and external specialisms, Family Medicine, RS: CAPHRI School for Public Health and Primary Care, Biochemie, RS: CAPHRI - Clinical epidemiology, Hematology |
| Rok vydání: | 2014 |
| Předmět: |
Male
MESH: Pulmonary Embolism REVISED GENEVA SCORE [SDV]Life Sciences [q-bio] 030204 cardiovascular system & hematology Gastroenterology MESH: Venous Thromboembolism 0302 clinical medicine Reference Values Outpatients EXCLUSION Prevalence Cutoff Prospective Studies 030212 general & internal medicine Geneva score Prospective cohort study ELDERLY-PATIENTS ddc:616 MESH: Aged MESH: Angiography MESH: Risk Respiratory disease Age Factors Angiography MESH: Reference Values General Medicine EMERGENCY Thrombosis 3. Good health Pulmonary embolism Europe MESH: Emergency Service Hospital Acute Disease MESH: Diagnostic Errors MESH: Acute Disease Female Emergency Service Hospital Risk medicine.medical_specialty MESH: Probability Age adjustment Sensitivity and Specificity Fibrin Fibrinogen Degradation Products 03 medical and health sciences Internal medicine D-dimer medicine MANAGEMENT MESH: Fibrin Fibrinogen Degradation Products Humans COMPUTED-TOMOGRAPHY Diagnostic Errors MESH: Prevalence Aged Probability MESH: Age Factors VENOUS THROMBOEMBOLISM MESH: Humans business.industry DIAGNOSTIC STRATEGIES medicine.disease MESH: Male MESH: Prospective Studies MESH: Sensitivity and Specificity Surgery CLINICAL PROBABILITY MESH: Outpatients THROMBOSIS MESH: Europe Pulmonary Embolism business MESH: Female |
| Zdroj: | JAMA : the journal of the American Medical Association Journal of the American Medical Association Journal of the American Medical Association, American Medical Association (AMA), 2014, 311 (11), pp.1117-24. ⟨10.1001/jama.2014.2135⟩ JAMA (Journal of the American Medical Association), Vol. 311, No 11 (2014) pp. 1117-1124 Journal of the American Medical Association, 311(11), 1117-1124 JAMA-Journal of the American Medical Association, 311(11), 1117-1124. AMER MEDICAL ASSOC JAMA, 311(11), 1117-1124. American Medical Association JAMA-Journal of the American Medical Association, 311(11), 1117-1124. American Medical Association |
| ISSN: | 0098-7484 1538-3598 |
| DOI: | 10.1001/jama.2014.2135 |
| Popis: | International audience; IMPORTANCE: D-dimer measurement is an important step in the diagnostic strategy of clinically suspected acute pulmonary embolism (PE), but its clinical usefulness is limited in elderly patients. OBJECTIVE: To prospectively validate whether an age-adjusted D-dimer cutoff, defined as age × 10 in patients 50 years or older, is associated with an increased diagnostic yield of D-dimer in elderly patients with suspected PE. DESIGN, SETTINGS, AND PATIENTS: A multicenter, multinational, prospective management outcome study in 19 centers in Belgium, France, the Netherlands, and Switzerland between January 1, 2010, and February 28, 2013. INTERVENTIONS: All consecutive outpatients who presented to the emergency department with clinically suspected PE were assessed by a sequential diagnostic strategy based on the clinical probability assessed using either the simplified, revised Geneva score or the 2-level Wells score for PE; highly sensitive D-dimer measurement; and computed tomography pulmonary angiography (CTPA). Patients with a D-dimer value between the conventional cutoff of 500 µg/L and their age-adjusted cutoff did not undergo CTPA and were left untreated and formally followed-up for a 3-month period. MAIN OUTCOMES AND MEASURES: The primary outcome was the failure rate of the diagnostic strategy, defined as adjudicated thromboembolic events during the 3-month follow-up period among patients not treated with anticoagulants on the basis of a negative age-adjusted D-dimer cutoff result. RESULTS: Of the 3346 patients with suspected PE included, the prevalence of PE was 19%. Among the 2898 patients with a nonhigh or an unlikely clinical probability, 817 patients (28.2%) had a D-dimer level lower than 500 µg/L (95% CI, 26.6%-29.9%) and 337 patients (11.6%) had a D-dimer between 500 µg/L and their age-adjusted cutoff (95% CI, 10.5%-12.9%). The 3-month failure rate in patients with a D-dimer level higher than 500 µg/L but below the age-adjusted cutoff was 1 of 331 patients (0.3% [95% CI, 0.1%-1.7%]). Among the 766 patients 75 years or older, of whom 673 had a nonhigh clinical probability, using the age-adjusted cutoff instead of the 500 µg/L cutoff increased the proportion of patients in whom PE could be excluded on the basis of D-dimer from 43 of 673 patients (6.4% [95% CI, 4.8%-8.5%) to 200 of 673 patients (29.7% [95% CI, 26.4%-33.3%), without any additional false-negative findings. CONCLUSIONS AND RELEVANCE: Compared with a fixed D-dimer cutoff of 500 µg/L, the combination of pretest clinical probability assessment with age-adjusted D-dimer cutoff was associated with a larger number of patients in whom PE could be considered ruled out with a low likelihood of subsequent clinical venous thromboembolism. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01134068. |
| Databáze: | OpenAIRE |
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