Age-adjusted d-dimer cut-off levels to rule out pulmonary embolism: a prospective outcome study: the ADJUST study
Exter, P.L. den, Es, J. van, Righini, M., Roy, P.M., Verschuren, F., Ghuysen, A., Rutschmann, O., Sanchez, O., Jaffrelot, M., Trinh-Duc, A., Le Gall, C., Schmidt, J., Principe, A., Houten, A.A. van, Wolde, M. ten, Douma, R.A., Hazelaar, G., Erkens, P.M.G., Kralingen, K.W. van, Grootenboers, M.J., Durian, M., Cheung, Y.W., Meyer, G., Bounemeaux, H., Huisman, M.V., Kamphuisen, P.W., Le Gal, G.
Voorzitter(s): dr. R. Heijligberg, Ede & dr. A.F. Mulder, Utrecht
Locatie(s): Zaal 0.2/0.3
Categorie(ën):
Introduction: 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.
Aim of the study: To prospectively validate whether an age-adjusted D-Dimer cut-off, defined as age x 10 in patients aged 50 years or more, can safely increase the diagnostic yield of D-Dimer in elderly patients with suspected PE.
Materials and methods: We performed a multicentre multinational prospective management outcome study in 19 centers in The Netherlands, Belgium, France, and Switzerland between January 1, 2010 and February 28, 2013. All consecutive outpatients with clinically suspected PE were assessed by a sequential diagnostic strategy based on the assessment of clinical probability, higly sensitive D-Dimer measurement and computed tomography pulmonary angiography (CTPA). Patients with a D-Dimer value between the conventional cut-off of 500 µg/L and their age-adjusted cut-off did not undergo CTPA and were left untreated and formally followed for a three-month period.
Results: 3,346 patients with suspected PE were included. The prevalence of PE was 19%. Among the 2,898 patients with a non-high or an unlikely clinical probability, 817 (28.2%) had a D-Dimer < 500 µg/L, and 337 additional patients (11.6%) had a D-Dimer comprised between 500 µg/L and their age-adjusted cut-off. The three-month failure rate in patients with a D-Dimer > 500 µg/L but below the age-adjusted cut-off was 1/331: 0.3%, (95% CI 0.1 to 1.7%). Among the 766 patients aged 75 years or older, of whom 673 had a non-high clinical probability, using the age-adjusted cut-off instead of the 500 µg/L cut-off increased the proportion of patients in whom PE could be excluded on the basis of D-Dimer from 43/673 (6.4%) to 200/673 (29.7%), without any additional false-negative test.
Conclusions: Combined with pretest clinical probability assessment, the age-adjusted D-Dimer cut-off increased the number of patients in whom PE can be safely excluded without additional imaging. This was particulary true in elderly patients in whom the adjusted cut-off increased the diagnostic yield of D-Dimer five-fold without compromising safety.
- Over Exter, P.L. den
- Over Es, J. van
- Over Righini, M.
- Over Roy, P.M.
- Over Verschuren, F.
- Over Ghuysen, A.
- Over Rutschmann, O.
- Over Sanchez, O.
- Over Jaffrelot, M.
- Over Trinh-Duc, A.
- Over Le Gall, C.
- Over Schmidt, J.
- Over Principe, A.
- Over Houten, A.A. van
- Over Wolde, M. ten
- Over Douma, R.A.
- Over Hazelaar, G.
- Over Erkens, P.M.G.
- Over Kralingen, K.W. van
- Over Grootenboers, M.J.
- Over Durian, M.
- Over Cheung, Y.W.
- Over Meyer, G.
- Over Bounemeaux, H.
- Over Huisman, M.V.
- Over Kamphuisen, P.W.
- Over Le Gal, G.