Pulmonary embolism D-dimer: Difference between revisions
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*[[Pulmonary embolism CT#Multi-Detector CT|Multidetector CT]] is indicated in hemodynamically stable with high clinical probability and/or patients with elevated plasma d-dimer levels.<ref name="pmid16403929">{{cite journal| author=van Belle A, Büller HR, Huisman MV, Huisman PM, Kaasjager K, Kamphuisen PW et al.| title=Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. | journal=JAMA | year= 2006 | volume= 295 | issue= 2 | pages= 172-9 | pmid=16403929 | doi=10.1001/jama.295.2.172 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16403929 }} </ref> | *[[Pulmonary embolism CT#Multi-Detector CT|Multidetector CT]] is indicated in hemodynamically stable patients with a '''''high clinical probability of PE''''' and/or patients with elevated plasma [[d-dimer]] levels secondary to the lack of specificity.<ref name="pmid16403929">{{cite journal| author=van Belle A, Büller HR, Huisman MV, Huisman PM, Kaasjager K, Kamphuisen PW et al.| title=Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. | journal=JAMA | year= 2006 | volume= 295 | issue= 2 | pages= 172-9 | pmid=16403929 | doi=10.1001/jama.295.2.172 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16403929 }} </ref><ref name="pmid19620439">{{cite journal| author=Gupta RT, Kakarla RK, Kirshenbaum KJ, Tapson VF| title=D-dimers and efficacy of clinical risk estimation algorithms: sensitivity in evaluation of acute pulmonary embolism. |journal=AJR Am J Roentgenol | year= 2009 | volume= 193 | issue= 2 | pages= 425-30 | pmid=19620439 |doi=10.2214/AJR.08.2186 | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19620439 }} </ref> | ||
*In '''low-to-moderate''' | *In patients with '''''low-to-moderate suspicion of PE''''', a normal [[D-dimer]] level is considered to be sufficient to exclude the possibility of pulmonary embolism.<ref name="pmid8165626">{{cite journal |author=Bounameaux H, de Moerloose P, Perrier A, Reber G|title=Plasma measurement of D-dimer as diagnostic aid in suspected venous thromboembolism: an overview |journal=Thromb. Haemost.|volume=71 |issue=1 |pages=1-6 |year=1994 |pmid=8165626 |doi=}}</ref> | ||
==Flowchart summarizing the role of D-dimer in the diagnosis of PE== | ==Flowchart summarizing the role of D-dimer in the diagnosis of PE== | ||
Revision as of 03:52, 8 May 2012
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Pulmonary embolism D-dimer On the Web |
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Risk calculators and risk factors for Pulmonary embolism D-dimer |
Editor(s)-In-Chief: The APEX Trial Investigators, C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]
Overview
D-dimer is a fibrin degradation product, that is elevated in the plasma after an acute blood clot. Majority of the patients with pulmonary embolism have some degree of endogenous fibrinolysis with subsequent elevation of D-dimer. Therefore, the negative predictive value of D-dimer for the diagnosis of pulmonary embolism is very high. Despite this high sensitivity and negative predictive value, a wide range of diseases associated with mild degree of fibrinolysis falsely elevate D-dimer levels and contribute towards reduced specificity and positive predictive value. Such disease states include pneumonia, congestive heart failure (CHF), myocardial infarction (MI) and malignancy. Additionally, in patients with prolong symptoms of venous thromboembolism (≥14 days), patients on therapeutic heparin therapy and patients with suspected deep venous thrombosis on oral anticoagulation, the plasma d-dimer levels are considerable lower, resulting in high false-negative values.[1][2]
Abnormal Levels
Plasma d-dimer levels of higher than 500 ng/mL is considered abnormal.[3]
Sensitivity and Specificity
Sensitivity[3]
ELISA (p=0.020), quantitative rapid ELISA (p=0.016) and semi-quantitative ELISA (p=0.047) are shown to be statistically superior to whole-blood agglutination.
Specificity[3]
Qualitative rapid ELISA has shown to be statistically superior to ELISA (p=0.004), quatitative rapid ELISA (p=0.002), semi-quantitative rapid ELISA (p=0.001), quantitative (p=0.005) and semi-quantitative latex agglutination assays (p=0.019).
| Method | Sensitivity (95% CI) | Specificity (95% CI) | Positive Likelihood Ratio (95% CI) | Negative Likelihood Ratio (95% CI) | Time to obtain Results |
|---|---|---|---|---|---|
| Enzyme-linked immunosorbent assay (ELISA) | 0.95 (0.85 to 1.00) | NS | NS | 0.13 (0.03 to 0.58) | ≥ 8 hours |
| Quantitative rapid ELISA | 0.95 (0.83 to 1.00) | NS | NS | 0.13 (0.02 to 0.84) | 30 mins |
| Semi-Quantitative rapid ELISA | 0.93 (0.79 to 1.00) | NS | NS | 0.20 (0.04 to 0.96) | 10 mins |
| Qualitative rapid ELISA | NS | 0.68 (0.50 to 0.87) | NS | 0.11 (0.01 to 0.93) | 10 mins |
| Quantitative Latex Agglutination | NS | NS | NS | NS | 10-15 mins |
| Semi-quantitative Latex Agglutination | NS | NS | NS | 0.17 (0.04 to 0.78) | 5 mins |
| Whole-Blood Agglutination | NS | 0.74 (0.60 to 0.88) | NS | NS | 2 mins |
Hemodynamically Stable Patients
Incidence of Thromboembolic Events in Hemodynamicaly Stable Patients
| Condition | Incidence of thromboembolic event (%) |
|---|---|
| Patients not receiving anticoagulation and with negative CT findings. | 1.5%[4][5] |
| Patients with High d-dimer level | 1.5% |
| Patients with Normal d-dimer level | 0.5%[4] |
- Multidetector CT is indicated in hemodynamically stable patients with a high clinical probability of PE and/or patients with elevated plasma d-dimer levels secondary to the lack of specificity.[5][6]
- In patients with low-to-moderate suspicion of PE, a normal D-dimer level is considered to be sufficient to exclude the possibility of pulmonary embolism.[7]
Flowchart summarizing the role of D-dimer in the diagnosis of PE
| Patients with suspection of Pulmonary embolism | |||||||||||||||||||||||
| Clinically Low or Moderate | Clinically High | ||||||||||||||||||||||
| D-Dimer Positive | |||||||||||||||||||||||
| D-Dimer Negative | |||||||||||||||||||||||
| No treatment | Further Tests | Further Tests | |||||||||||||||||||||
A new D-Dimer (DDMR) analyzer has shown to have higher accuracy in excluding patients with non-high clinical pre-test probability.[8]
ESC Guideline Recommendations [9]
Suspected Non High-risk PE Patients
| “ |
Class I1. Plasma D-dimer measurement is recommended in emergency department patients to reduce the need for unnecessary imaging and irradiation, preferably using a highly sensitive assay. (Level of Evidence: A) Low clinical probabilityClass I1. Normal D-dimer level using either a highly or moderately sensitive assay excludes pulmonary embolism. (Level of Evidence: A) Intermediate clinical probabilityClass I1. Normal D-dimer level using a highly sensitive assay excludes pulmonary embolism. (Level of Evidence: A) Class IIa1. Further testing should be considered if D-dimer level is normal when using a less sensitive assay. (Level of Evidence: B) High clinical probabilityClass III1. D-dimer measurement is not recommended in high clinical probability patients as a normal result does not safely exclude pulmonary embolism even when using a highly sensitive assay. (Level of Evidence: C) |
” |
Guideline Resources
Guidelines on the diagnosis and management of acute pulmonary embolism. The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology[9]
References
- ↑ Bruinstroop E, van de Ree MA, Huisman MV (2009). "The use of D-dimer in specific clinical conditions: a narrative review". Eur J Intern Med. 20 (5): 441–6. doi:10.1016/j.ejim.2008.12.004. PMID 19712840.
- ↑ Agnelli G, Becattini C (2010). "Acute pulmonary embolism". N Engl J Med. 363 (3): 266–74. doi:10.1056/NEJMra0907731. PMID 20592294.
- ↑ 3.0 3.1 3.2 Stein PD, Hull RD, Patel KC, Olson RE, Ghali WA, Brant R, Biel RK, Bharadia V, Kalra NK (2004). "D-dimer for the exclusion of acute venous thrombosis and pulmonary embolism: a systematic review". Annals of Internal Medicine. 140 (8): 589–602. PMID 15096330. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ 4.0 4.1 Perrier A, Roy PM, Sanchez O, Le Gal G, Meyer G, Gourdier AL; et al. (2005). "Multidetector-row computed tomography in suspected pulmonary embolism". N Engl J Med. 352 (17): 1760–8. doi:10.1056/NEJMoa042905. PMID 15858185. in: J Fam Pract. 2005 Aug;54(8):653, 657
- ↑ 5.0 5.1 van Belle A, Büller HR, Huisman MV, Huisman PM, Kaasjager K, Kamphuisen PW; et al. (2006). "Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography". JAMA. 295 (2): 172–9. doi:10.1001/jama.295.2.172. PMID 16403929.
- ↑ Gupta RT, Kakarla RK, Kirshenbaum KJ, Tapson VF (2009). "D-dimers and efficacy of clinical risk estimation algorithms: sensitivity in evaluation of acute pulmonary embolism". AJR Am J Roentgenol. 193 (2): 425–30. doi:10.2214/AJR.08.2186. PMID 19620439.
- ↑ Bounameaux H, de Moerloose P, Perrier A, Reber G (1994). "Plasma measurement of D-dimer as diagnostic aid in suspected venous thromboembolism: an overview". Thromb. Haemost. 71 (1): 1–6. PMID 8165626.
- ↑ Gosselin RC, Wu JR, Kottke-Marchant K, Peetz D, Christie DJ, Muth H; et al. (2012). "Evaluation of the Stratus® CS Acute Care™ D-dimer assay (DDMR) using the Stratus® CS STAT Fluorometric Analyzer: A prospective multisite study for exclusion of pulmonary embolism and deep vein thrombosis". Thromb Res. doi:10.1016/j.thromres.2011.12.015. PMID 22245223.
- ↑ 9.0 9.1 Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P, Bengel F, Brady AJ, Ferreira D, Janssens U, Klepetko W, Mayer E, Remy-Jardin M, Bassand JP (2008). "Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)". Eur. Heart J. 29 (18): 2276–315. doi:10.1093/eurheartj/ehn310. PMID 18757870. Retrieved 2011-12-07. Unknown parameter
|month=ignored (help)