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==Laboratory Findings==
==Laboratory Findings==
===D-dimer Test===
===D-dimer Test===
''Fore more information about D-dimer, click '''[[D-dimer|here]]'''.''
* The D-dimer cut-off values varies among tests; however, [[D-dimer|plasma D-dimer]] > 500 ng/mL is the most commonly used cut-off concentration.<ref name="pmid15096330">{{cite journal |author=Stein PD, Hull RD, Patel KC, Olson RE, Ghali WA, Brant R, Biel RK, Bharadia V, Kalra NK |title=D-dimer for the exclusion of acute venous thrombosis and pulmonary embolism: a systematic review |journal=[[Annals of Internal Medicine]] |volume=140 |issue=8 |pages=589–602 |year=2004 |month=April |pmid=15096330 |doi= |url= |accessdate=2012-05-07}}</ref>
* The D-dimer cut-off values varies among tests; however, [[D-dimer|plasma D-dimer]] > 500 ng/mL is the most commonly used cut-off concentration.<ref name="pmid15096330">{{cite journal |author=Stein PD, Hull RD, Patel KC, Olson RE, Ghali WA, Brant R, Biel RK, Bharadia V, Kalra NK |title=D-dimer for the exclusion of acute venous thrombosis and pulmonary embolism: a systematic review |journal=[[Annals of Internal Medicine]] |volume=140 |issue=8 |pages=589–602 |year=2004 |month=April |pmid=15096330 |doi= |url= |accessdate=2012-05-07}}</ref>
**Plasma D-dimer>500 ng/ml, PE present (sensitivity: 84.8%; specificity:68.4%)<ref name="pmid9867754">{{cite journal| author=Ginsberg JS, Wells PS, Kearon C, Anderson D, Crowther M, Weitz JI et al.| title=Sensitivity and specificity of a rapid whole-blood assay for D-dimer in the diagnosis of pulmonary embolism. | journal=Ann Intern Med | year= 1998 | volume= 129 | issue= 12 | pages= 1006-11 | pmid=9867754 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9867754  }} </ref>
**Plasma D-dimer>500 ng/ml, PE present (sensitivity: 84.8%; specificity:68.4%)<ref name="pmid9867754">{{cite journal| author=Ginsberg JS, Wells PS, Kearon C, Anderson D, Crowther M, Weitz JI et al.| title=Sensitivity and specificity of a rapid whole-blood assay for D-dimer in the diagnosis of pulmonary embolism. | journal=Ann Intern Med | year= 1998 | volume= 129 | issue= 12 | pages= 1006-11 | pmid=9867754 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9867754  }} </ref>
**Plasma D-dimer<500 excludes PE (high negative predictive value)
**Plasma D-dimer<500 excludes PE (high negative predictive value)


* However, the use of the cut off value 500 ng/mL for abnormal D-dimer limits the diagnostic role of D-dimer in the elderly, among whom D-dimer increases with age in the absence of any ongoing [[venous thromboembolism]] process.  In a metanalysis of 5 cohort studies of 2818 subjects with low clinical probability of [[DVT]], the use of an age adjusted cut-off value of D-dimer increases the number of subjects in whom [[DVT]] can be excluded.<ref name="pmid22511491">{{cite journal| author=Douma RA, Tan M, Schutgens RE, Bates SM, Perrier A, Legnani C et al.| title=Using an age-dependent D-dimer cut-off value increases the number of older patients in whom deep vein thrombosis can be safely excluded. | journal=Haematologica | year= 2012 | volume= 97 | issue= 10 | pages= 1507-13 | pmid=22511491 | doi=10.3324/haematol.2011.060657 | pmc=PMC3487551 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22511491  }} </ref>  A metaanalysis of 13 cohorts of 12,497 patients with a low probability of [[venous thromboembolism]] revealed that the use of an age adjusted cut point for the D-dimer concentration increases the specificity of this test without altering its sensitivity.<ref name="pmid23645857">{{cite journal| author=Schouten HJ, Geersing GJ, Koek HL, Zuithoff NP, Janssen KJ, Douma RA et al.| title=Diagnostic accuracy of conventional or age adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism: systematic review and meta-analysis. | journal=BMJ | year= 2013 | volume= 346 | issue=  | pages= f2492 | pmid=23645857 | doi=10.1136/bmj.f2492 | pmc=PMC3643284 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23645857  }} </ref>
* However, the use of the cut off value 500 ng/mL for abnormal D-dimer limits the diagnostic role of D-dimer in the elderly, among whom D-dimer increases with age in the absence of any ongoing [[venous thromboembolism]] process.  The age adjusted cut off value of D-dimer is the following:
 
* According to a multicenter, multinational prospective study of 3346 subjects presenting to the emergency department for suspicion of [[pulmonary embolism]], the use of a fixed D-dimer cut-off value is compared to an age adjusted D-dimer cut-off value. The use of the age adjusted cut-off value in patients with low clinical probability of [[pulmonary embolism]] is associated with an increased number of patients in whom [[pulmonary embolism]] is excluded with a decreased likelihood of the occurrence of subsequent [[venous thromboembolism]] episodes.<ref name="JAMA 2014"> 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. doi:10.1001/jama.2014.2135. </ref>
 
* The age adjusted cut off value of D-dimer is the following:
** If age <50 years, the cut off value for D-dimer is 500 ng/mL.
** If age <50 years, the cut off value for D-dimer is 500 ng/mL.
** If age >50 years, the cut off value for D-dimer is age multiplied by 10.<ref name="pmid22511491">{{cite journal| author=Douma RA, Tan M, Schutgens RE, Bates SM, Perrier A, Legnani C et al.| title=Using an age-dependent D-dimer cut-off value increases the number of older patients in whom deep vein thrombosis can be safely excluded. | journal=Haematologica | year= 2012 | volume= 97 | issue= 10 | pages= 1507-13 | pmid=22511491 | doi=10.3324/haematol.2011.060657 | pmc=PMC3487551 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22511491  }} </ref><ref name="pmid23645857">{{cite journal| author=Schouten HJ, Geersing GJ, Koek HL, Zuithoff NP, Janssen KJ, Douma RA et al.| title=Diagnostic accuracy of conventional or age adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism: systematic review and meta-analysis. | journal=BMJ | year= 2013 | volume= 346 | issue=  | pages= f2492 | pmid=23645857 | doi=10.1136/bmj.f2492 | pmc=PMC3643284 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23645857  }} </ref><ref name="JAMA 2014"> 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. doi:10.1001/jama.2014.2135. </ref>
** If age >50 years, the cut off value for D-dimer is age multiplied by 10.<ref name="pmid22511491">{{cite journal| author=Douma RA, Tan M, Schutgens RE, Bates SM, Perrier A, Legnani C et al.| title=Using an age-dependent D-dimer cut-off value increases the number of older patients in whom deep vein thrombosis can be safely excluded. | journal=Haematologica | year= 2012 | volume= 97 | issue= 10 | pages= 1507-13 | pmid=22511491 | doi=10.3324/haematol.2011.060657 | pmc=PMC3487551 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22511491  }} </ref><ref name="pmid23645857">{{cite journal| author=Schouten HJ, Geersing GJ, Koek HL, Zuithoff NP, Janssen KJ, Douma RA et al.| title=Diagnostic accuracy of conventional or age adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism: systematic review and meta-analysis. | journal=BMJ | year= 2013 | volume= 346 | issue=  | pages= f2492 | pmid=23645857 | doi=10.1136/bmj.f2492 | pmc=PMC3643284 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23645857  }} </ref><ref name="JAMA 2014"> 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. doi:10.1001/jama.2014.2135. </ref>

Revision as of 21:12, 18 June 2014

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Editor(s)-In-Chief: C. Michael Gibson, M.S., M.D. [1], The APEX Trial Investigators; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]

Overview

The results of routine laboratory tests including arterial blood gas analysis are non-specific in making the diagnosis of pulmonary embolism. These laboratory studies can be obtained to rule-out other cause of chest discomfort and tachypnea. In patients with acute pulmonary embolism, non-specific lab findings include: leukocytosis, elevated ESR with an elevated serum LDH and serum transaminase (especially AST or SGOT). A negative D-dimer in a patient with low to intermediate probability of pulmonary embolism strongly suggests pulmonary embolism is not present.

Laboratory Findings

D-dimer Test

Fore more information about D-dimer, click here.

  • The D-dimer cut-off values varies among tests; however, plasma D-dimer > 500 ng/mL is the most commonly used cut-off concentration.[1]
    • Plasma D-dimer>500 ng/ml, PE present (sensitivity: 84.8%; specificity:68.4%)[2]
    • Plasma D-dimer<500 excludes PE (high negative predictive value)
  • However, the use of the cut off value 500 ng/mL for abnormal D-dimer limits the diagnostic role of D-dimer in the elderly, among whom D-dimer increases with age in the absence of any ongoing venous thromboembolism process. The age adjusted cut off value of D-dimer is the following:
    • If age <50 years, the cut off value for D-dimer is 500 ng/mL.
    • If age >50 years, the cut off value for D-dimer is age multiplied by 10.[3][4][5]

Routine Blood Tests

  • In patients with acute pulmonary embolism, routine laboratory findings are non-specific and include:

Workup for Hypercoagulability

The 2008 Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)[10]

Suspected Non High-risk PE Patients (DO NOT EDIT)[10]

Class I
"1. Plasma D-dimer measurement is recommended in emergency department patients to reduce the need for unnecessary imaging and irradiation, preferably with the use of a highly sensitive assay. (Level of Evidence: A) "

Low Clinical Probability (DO NOT EDIT)[10]

Class I
"1. Normal D-dimer level using either a highly or moderately sensitive assay excludes pulmonary embolism. (Level of Evidence: A) "

Intermediate Clinical Probability (DO NOT EDIT)[10]

Class I
"1. Normal D-dimer level using a highly sensitive assay excludes pulmonary embolism. (Level of Evidence: A) "
Class IIa
"1. Further testing should be considered if D-dimer level is normal when using a less sensitive assay. (Level of Evidence: B) "

High Clinical Probability (DO NOT EDIT)[10]

Class III
"1. 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) "

References

  1. ↑ 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)
  2. ↑ Ginsberg JS, Wells PS, Kearon C, Anderson D, Crowther M, Weitz JI; et al. (1998). "Sensitivity and specificity of a rapid whole-blood assay for D-dimer in the diagnosis of pulmonary embolism". Ann Intern Med. 129 (12): 1006–11. PMID 9867754.
  3. ↑ Douma RA, Tan M, Schutgens RE, Bates SM, Perrier A, Legnani C; et al. (2012). "Using an age-dependent D-dimer cut-off value increases the number of older patients in whom deep vein thrombosis can be safely excluded". Haematologica. 97 (10): 1507–13. doi:10.3324/haematol.2011.060657. PMC 3487551. PMID 22511491.
  4. ↑ Schouten HJ, Geersing GJ, Koek HL, Zuithoff NP, Janssen KJ, Douma RA; et al. (2013). "Diagnostic accuracy of conventional or age adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism: systematic review and meta-analysis". BMJ. 346: f2492. doi:10.1136/bmj.f2492. PMC 3643284. PMID 23645857.
  5. ↑ 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. doi:10.1001/jama.2014.2135.
  6. ↑ Afzal A, Noor HA, Gill SA, Brawner C, Stein PD (1999). "Leukocytosis in acute pulmonary embolism". Chest. 115 (5): 1329–32. PMID 10334148.
  7. ↑ Kokturk N, Demir N, Oguzulgen IK, Demirel K, Ekim N (2005). "Fever in pulmonary embolism". Blood Coagul Fibrinolysis. 16 (5): 341–7. PMID 15970718.
  8. ↑ Hasegawa K, Sawayama T, Ibukiyama C, Muramatsu J, Ozawa Y, Kanemoto N; et al. (1993). "[Early diagnosis and management of acute pulmonary embolism: clinical evaluation those of 225 cases]". Kokyu To Junkan. 41 (8): 773–7. PMID 8351437.
  9. ↑ Hu ZJ, Zhou YQ, Zhang HB, Li L (2008). "[Clinical value of monitoring serum cardiac biomarkers in pulmonary thromboembolism-induced myocardial injury]". Nan Fang Yi Ke Da Xue Xue Bao. 28 (10): 1853–5. PMID 18971188.
  10. ↑ 10.0 10.1 10.2 10.3 10.4 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)

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