D‐dimer as a predictor of venous thromboembolism in acutely ill, hospitalized patients: a subanalysis of the randomized controlled MAGELLAN trial

Cohen, Alexander T.; Spiro, Theodore E.; Spyropoulos, Alex C.; DeSanctis, Yoriko; Homering, Martin; Büller, Harry R.; Haskell, Lloyd; Hu, Dayi; Hull, Russell D.; Mebazaa, Alexandre; Merli, Geno J.; Schellong, Sebastian; Tapson, Victor F.; Burton, Paul

doi:10.1111/jth.12515

Cited by 99 publications

(85 citation statements)

References 20 publications

(39 reference statements)

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“…16 The IMPROVE RAM was also found to have good calibration characteristics when applied to a large, global, phase 3 study of thromboprophylaxis in hospitalized, acutely ill medical patients, with an area under the ROC curve of ≈0.65. 18 More recently, the IMPROVE VTE score has been externally validated in another large‐scale study in this patient population and revealed good discrimination and calibration characteristics. 19 Based on a recent systematic review which was performed using validated quality criteria for risk modelling, only a few high quality evidence‐derived VTE RAMs exist which include the IMPROVE RAM and that of Woller et al 10–11,20 The model by Woller et al incorporated a validation cohort as part of the same population as the derivation cohort, and this may have led to overly optimistic discrimination characteristics.…”

Section: Discussionmentioning

confidence: 91%

External Validation of the Risk Assessment Model of the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) for Medical Patients in a Tertiary Health System

Rosenberg

Eichorn

Alarcon

et al. 2014

JAHA

116

164

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BackgroundHospitalized medical patients are at risk for venous thromboembolism (VTE). Universal application of pharmacological thromboprophylaxis has the potential to place a large number of patients at increased bleeding risk. In this study, we aimed to externally validate the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) VTE risk assessment model in a hospitalized general medical population.Methods and ResultsWe identified medical discharges that met the IMPROVE protocol. Cases were defined as hospital‐acquired VTE and confirmed by diagnostic study within 90 days of index hospitalization; matched controls were also identified. Risk factors for VTE were based on the IMPROVE risk assessment model (aged >60 years, prior VTE, intensive care unit or coronary care unit stay, lower limb paralysis, immobility, known thrombophilia, and cancer) and were measured and assessed. A total of 19 217 patients met the inclusion criteria. The overall VTE event rate was 0.7%. The IMPROVE risk assessment model identified 2 groups of the cohort by VTE incidence rate: The low‐risk group had a VTE event rate of 0.42 (95% CI 0.31 to 0.53), corresponding to a score of 0 to 2, and the at‐risk group had a VTE event rate of 1.29 (95% CI 1.01 to 1.57), corresponding to a score of ≥3. Low‐risk status for VTE encompassed 68% of the patient cohort. The area under the receiver operating characteristic curve was 0.702, which was in line with the derivation cohort findings.ConclusionsThe IMPROVE VTE risk assessment model validation cohort revealed good discrimination and calibration for both the overall VTE risk model and the identification of low‐risk and at‐risk medical patient groups, using a risk score of ≥3. More than two thirds of the entire cohort had a score ≤2.

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Section: Discussionmentioning

confidence: 91%

External Validation of the Risk Assessment Model of the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) for Medical Patients in a Tertiary Health System

Rosenberg

Eichorn

Alarcon

et al. 2014

JAHA

116

164

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“…26 This difference was most marked for the patients with more severe HF, who had noticeably higher D-dimer levels than patients without HF at each time point tested. The Kaplan-Meier curves of symptomatic VTE and cardiovascular death further support the finding that patients with severe HF are a high-risk group.…”

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confidence: 95%

Predicting the Risk of Venous Thromboembolism in Patients Hospitalized With Heart Failure

et al. 2014

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Background-Whether heart failure (HF) increases the risk of venous thromboembolism (VTE) is not well established.In the phase III MAGELLAN (Multicenter, rAndomized, parallel Group Efficacy and safety study for the prevention of venous thromboembolism in hospitalized medically iLL patients comparing rivaroxabAN with enoxaparin) trial, extended-duration rivaroxaban was compared with standard-duration enoxaparin followed by placebo for VTE prevention in 8101 hospitalized acutely ill patients with or without HF. The aim of this analysis was to evaluate the relationship between HF severity and the risk of VTE in MAGELLAN patients. Methods and Results-Hospitalized patients diagnosed with HF were included according to New York Heart Association class III or IV at admission (n=2593). HF severity was determined by N-terminal probrain natriuretic peptide (NT-proBNP) plasma concentrations (median 1904 pg/mL). Baseline plasma D-dimer concentrations ranged from 0.6 to 1.7 μg/L for the less and more severe HF subgroups. Patients with more severe HF had a greater incidence of VTE versus patients with less severe HF, with a significant trend up to

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“…However, there are other clinical scenarios such as malignancy, inflammation, hemorrhage, trauma, and surgery that cause D -dimer abnormalities [6,15,16]. Importantly, among 7,581 patients with acute illness, the frequency of deep vein thrombosis increased 3.5-fold in the group with high D -dimer concentrations compared with the normal D -dimer group [17]. Another study also revealed that D -dimer rising in the general population is associated with an increased risk of deep vein thrombosis [18].…”

Section: Discussionmentioning

confidence: 99%

Troponin I and <smlcap>D</smlcap>-Dimer for Discriminating Acute Pulmonary Thromboembolism from Myocardial Infarction

Kim¹,

Kim²,

Lee

et al. 2016

Cardiology

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Background: Acute pulmonary thromboembolism (APTE) is a life-threatening condition, often manifesting with chest pain, dyspnea, and increased cardiac biomarkers including cardiac troponin I (CTI) and D-dimer. Therefore, APTE is often misdiagnosed with classical non-ST elevation myocardial infarction (NSTEMI), resulting in unnecessary coronary interventions and a delay of therapy. Objectives: Our aim was to distinguish APTE from NSTEMI based on CTI and D-dimer levels. Methods: Complete clinical and laboratory data sets from APTE patients (n = 123) were compared with matched NSTEMI patients (n = 123) who presented with chest pain. The APTE diagnosis was confirmed by chest tomography, angiography, or radionuclide ventilation-perfusion scan, while NSTEMI was established by clinical symptoms, cardiac biomarkers, and coronary angiography. Clinical characteristics, CTI (initial and peak), and D-dimer levels at presentation were retrospectively analyzed. Results: The clinical characteristics were not different between APTE and NSTEMI patients. However, significantly lower initial CTI (0.2 ± 0.5 vs. 4.4 ± 9.5 ng/ml) and peak CTI (0.7 ± 2.7 vs. 17.1 ± 20.4 ng/ml), but higher initial D-dimer (9.8 ± 9.4 vs. 1.6 ± 3.6 ng/ml), distinguished APTE from NSTEMI. By receiver operating characteristic curve analysis, the cutoff values for initial CTI, peak CTI, and D-dimer were 0.25, 0.98, and 3.18 ng/ml, respectively. Conclusion: Patients with APTE exhibited lower initial and peak CTI but higher D-dimer levels than NSTEMI patients. Assessing cardiac biomarkers is useful for differentiating APTE from NSTEMI. Further large randomized biomarker studies are urgently needed to facilitate a better APTE diagnosis since clinical characteristics are not particularly helpful.

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D‐dimer as a predictor of venous thromboembolism in acutely ill, hospitalized patients: a subanalysis of the randomized controlled MAGELLAN trial

Abstract: Elevated baseline D-dimer concentrations may identify acutely ill, hospitalized medical patients at high risk of VTE for whom extended anticoagulant prophylaxis may provide greater benefit than for those with low D-dimer concentrations.

Cited by 99 publications

References 20 publications

External Validation of the Risk Assessment Model of the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) for Medical Patients in a Tertiary Health System

External Validation of the Risk Assessment Model of the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) for Medical Patients in a Tertiary Health System

Predicting the Risk of Venous Thromboembolism in Patients Hospitalized With Heart Failure

Troponin I and <smlcap>D</smlcap>-Dimer for Discriminating Acute Pulmonary Thromboembolism from Myocardial Infarction

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