D-dimer can help differentiate suspected pulmonary embolism patients that require anti-coagulation

Autor: Jatin Narang, Philip R. Wang, Spencer S. Seballos, Amy S. Nowacki, Sharon E. Mace
Rok vydání: 2021
Předmět:
Male
medicine.medical_specialty
Decision Making
VTE
venous thromboembolism
Suspected pulmonary embolism
Anti coagulation
PE
Pulmonary embolism
CTPA
computed pulmonary tomography angiography
Article
Fibrin Fibrinogen Degradation Products
03 medical and health sciences
0302 clinical medicine
Internal medicine
D-dimer
Humans
Medicine
Retrospective Studies
Receiver operating characteristic
DVT
deep vein thrombosis
DOAC
direct oral anti-coagulant
business.industry
Age Factors
Curve analysis
Area under the curve
Anticoagulants
030208 emergency & critical care medicine
Anti-coagulation
General Medicine
Middle Aged
ACCP
American College of Chest Physicians
medicine.disease
LMWH
low molecular weight heparin
Pulmonary embolism
medicine.anatomical_structure
V/Q scan
perfusion ventilation scan
Emergency Medicine
Cardiology
Female
Emergency Service
Hospital
Pulmonary Embolism
business
Biomarkers
Venous thromboembolism
Artery
Zdroj: The American Journal of Emergency Medicine
ISSN: 0735-6757
DOI: 10.1016/j.ajem.2020.08.086
Popis: Objectives Determine whether D-dimer concentration in the absence of imaging can differentiate patients that require anti-coagulation from patients who do not require anti-coagulation. Methods Data was obtained retrospectively from 366 hemodynamically stable adult ED patients with suspected pulmonary embolism (PE). Patients were categorized by largest occluded artery and aggregated into: ‘Require anti-coagulation’ (main, lobar, and segmental PE), ‘Does not require anti-coagulation’ (sub-segmental and No PE), ‘High risk of deterioration’ (main and lobar PE), and ‘Not high risk of deterioration’ (segmental, sub-segmental, and No PE) groups. Wilcoxon rank-sum test was used for 2 sample comparisons of median D-dimer concentrations. Receiver operating characteristic (ROC) curve analysis was utilized to determine a D-dimer cut-off that could differentiate ‘Require anti-coagulation’ from ‘Does not require anti-coagulation’ and ‘High risk of deterioration’ from ‘Low risk of deterioration’ groups. Results The ‘Require anti-coagulation’ group had a maximum area under the curve (AUC) of 0.92 at an age-adjusted D-dimer cut-off of 1540 with a specificity of 86% (95% CI, 81–91%), and sensitivity of 84% (79–90%). The ‘High risk of deterioration’ group had a maximum AUC of 0.93 at an age-adjusted D-dimer cut-off of 2500 with a specificity of 90% (85–93%) and sensitivity of 83% (77–90%). Conclusions An age-adjusted D-dimer cut-off of 1540 ng/mL differentiates suspected PE patients requiring anti-coagulation from those not requiring anti-coagulation. A cut-off of 2500 differentiates those with high risk of clinical deterioration from those not at high risk of deterioration. When correlated with clinical outcomes, these cut-offs can provide an objective method for clinical decision making when imaging is unavailable.
Highlights • ED providers are faced with risks and benefits when empirically administering anti-coagulation for suspected PE patients. • We show that D-dimer concentration can be used as a clinical decision making tool to minimize these risks. • A D-dimer cut-off of 1540 ng/mL can be used to minimize unnecessary anti-coagulation exposure in patients who do not need it. • A D-dimer cut-off of 2500 ng/mL can be used to minimize risk of withholding treatment for patients at risk of clinical deterioration. • Together these cut-offs provide an objective measure that can be combined with clinical gestalt to weight the risks and benefits of empiric anti-coagulation.
Databáze: OpenAIRE
Externí odkaz: