Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Suspected Acute Venous Thromboembolic Disease

Wolf, Stephen J.; Hahn, Sigrid A.; Nentwich, Lauren M.; Raja, Ali S.; Silvers, Scott M.; Brown, Michael D.

doi:10.1016/j.annemergmed.2018.03.006

Cited by 62 publications

(58 citation statements)

References 104 publications

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“…The first-line purpose of using DD is to allow the exclusion of a PE or DVT on the basis of a negative test, and thus to avoid imaging tests and their potential adverse effects, to reduce costs and time associated with less diagnostic testing and improve patient satisfaction as a result of more efficient evaluation [4].…”

Section: Discussionmentioning

confidence: 99%

“…Many decision-making algorithms, notably the WELLS score [5], the pulmonary rule-out criteria (PERC) [4] and revised Geneva score [6], currently used routinely, and offer an adjunct to gestalt clinial assessment to assist in risk stratification and determination of pretest probability. They integrate the DD assay alongside imaging examinations such as pulmonary ventilation or ventilation and perfusion scintigraphy angioscan, or pulmonary angiography which is more invasive.…”

Section: Discussionmentioning

confidence: 99%

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Interest of the D-dimers Assay in the Medical Care of Thromboembolic Disease: Experience of the Hematology Laboratory of the Military Hospital Avicenne of Marrakech

Mouamin¹,

Allali²,

Boufrioua³

et al. 2019

AJBLS

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The objective of our study is to show the benefits of D-dimers (DD) dosing in the diagnostic care of thromboembolic disease. A retrospective study conducted over a 2-year period (2016)(2017), including all DD dosing requests sent to the hematology laboratory at the Avicenne Military Hospital, excluding patients under 18 years of age. The quantitative assay was performed by an immunoturbidimetric method on STA Compact automaton, (STAGO), with STA®-Liatest® D-Di reagents with respect for the pre-analytical phase. We collected 100 samples over the study's two year period. The requests mainly came from the emergencies and polyvalent intensive care unit. The clinical picture suggested a deep vein thrombosis in 56% of cases and pulmonary embolism in 44% of cases. The search was positive in 78% of cases. Sensitivity and negative predictive value were 100%. Specificity in the ambulatory population was 66.66% vs 28% in the hospital population and also decreased with age.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Interest of the D-dimers Assay in the Medical Care of Thromboembolic Disease: Experience of the Hematology Laboratory of the Military Hospital Avicenne of Marrakech

Mouamin¹,

Allali²,

Boufrioua³

et al. 2019

AJBLS

View full text Add to dashboard Cite

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“…Low‐value testing is problematic as it subjects patients to increased costs, ionizing radiation, and risk of anaphylaxis from contrast dye . Further, false‐positive CTPAs are common, estimated at 10% to 26% .…”

Section: Introductionmentioning

confidence: 99%

Provider Perspectives on the Use of Evidence‐based Risk Stratification Tools in the Evaluation of Pulmonary Embolism: A Qualitative Study

Westafer

Kunz

Bugajska

et al. 2020

Academic Emergency Medicine

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Objectives Providers often pursue imaging in patients at low risk of pulmonary embolism (PE), resulting in imaging yields <10% and false‐positive imaging rates of 10% to 25%. Attempts to curb overtesting have had only modest success and no interventions have used implementation science frameworks. The objective of this study was to identify barriers and facilitators to the adoption of evidence‐based diagnostic testing for PE. Methods We conducted semistructured interviews with a purposeful sample of providers. An interview guide was developed using the implementation science frameworks, consolidated framework for implementation research, and theoretical domains framework. Interviews were recorded, transcribed, and analyzed in an iterative process. Emergent themes were identified, discussed, and organized. Results We interviewed 23 providers from four hospital systems, and participants were diverse with regard to years in practice and practice setting. Barriers were predominately at the provider level and included lack of knowledge of the tools, particularly misunderstanding of the validated scoring systems in Wells, as well as risk avoidance and need for certainty. Barriers to prior implementation strategies included the perception of a clinical decision support (CDS) tool for PE as adding steps with little value; most participants reported that they overrode CDS interventions because they had already made the decision. All providers identified institution‐level strategies as facilitators to use, including endorsed guidelines, audit feedback with peer comparison about imaging yield, and peer pressure. Conclusions This exploration of the use of risk stratification tools in the evaluation of PE found that barriers to use primarily exist at the provider level, whereas facilitators to the use of these tools are largely perceived at the level of the institution. Future efforts to promote the evidence‐based diagnosis of PE should be informed by these determinants.

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“…In cases with negative D-dimer test results, together with low or no clinical probability, the venous thromboembolism (VTE) risk is quite low, and advanced, specific imaging methods are not necessary. In prospective study that have supported this suggestion, the risk of VTE at a 3-month interval has been reported to be between 0-0.5% [4]. In cases having high or intermediate probability, the D-dimer test becomes less sensitive, and imaging tests for VTE are recommended [5].…”

Section: Introductionmentioning

confidence: 99%

“…An important next step to improve the diagnostic management of PE was the derivation of an age-adjusted D-dimer positivity threshold, which is defined as a patient's age times 10 μg/L in those older than 50 years [7]. In February 2018, the American College of Emergency Physicians (ACEP) recommended the use of age-adjusted D-dimer values in appropriate patients over 50 years old [4]. By applying this threshold, the proportion of patients in whom imaging can be safely withheld is increased by another 5% to 6%.…”

Section: Introductionmentioning

confidence: 99%

Comparison of normal D-dimer in different category in patient with pulmonary embolism

2020

Ann Clin Anal Med

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Aim: Quantitative D-dimer is used to exclude pulmonary embolism in patients with low clinical probability. In this study, we aimed to compare quantitative ddimer, age-adjusted D-dimer, and age-adjusted D-dimer suggested by the American College of Emergency Physicians (ACEP). Materials and Methods: Emergency service patients above the age of 18, whose D-dimer values were tested due to the suspicion of pulmonary thromboembolism were evaluated retrospectively. Quantitative d-dimer level, age-adjusted D-dimer, and age-adjusted D-dimer suggested by the ACEP levels were compared with patient data. SPSS (Statistical Package for Social Sciences) Windows 20.0 software was used for statistical analysis of all data obtained. Results: Three different categories of D-dimer values were compared. According to ACEP, the D-dimer value skipped the least number of PE diagnosis compared to the other values and it was found to be the most significant in determining PE. sPESI was not significant in predicting mortality in PE patients. Discussion: D-Dimer values vary according to the devices and kits used. Today, D-dimer values are used in many clinics to exclude PE. These include the quantitative d-dimer, age-adjusted d-dimer, and the age-adjusted d-dimer suggested by ACEP. It is identified that the cut-off value of d-dimer, calculated according to age, reduced the need for imaging tests significantly compared to quantitative d-dimer. A systemic meta-analysis found that the d-dimer test results calculated for age reduced the need for imaging by 5% compared to normal d-dimer test results when combined with Wells score. Conclusion: Recommended by ACEP age-adjusted D-Dimer may be preferred for the evaluation of pulmonary embolism patients.

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Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Suspected Acute Venous Thromboembolic Disease

Abstract: This clinical policy from the American College of Emergency Physicians addresses key issues in the evaluation and management of adult patients with suspected venous thromboembolism. A writing subcommittee conducted a systematic review of the literature to derive evidence-

Cited by 62 publications

References 104 publications

Interest of the D-dimers Assay in the Medical Care of Thromboembolic Disease: Experience of the Hematology Laboratory of the Military Hospital Avicenne of Marrakech

Interest of the D-dimers Assay in the Medical Care of Thromboembolic Disease: Experience of the Hematology Laboratory of the Military Hospital Avicenne of Marrakech

Provider Perspectives on the Use of Evidence‐based Risk Stratification Tools in the Evaluation of Pulmonary Embolism: A Qualitative Study

Comparison of normal D-dimer in different category in patient with pulmonary embolism

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