D-Dimer Use and Pulmonary Embolism Diagnosis in Emergency Units: Why Is There Such a Difference in Pulmonary Embolism Prevalence between the United States of America and Countries Outside USA?

Abstract

ObjectiveAlthough diagnostic guidelines are similar, there is a huge difference in pulmonary embolism (PE) prevalence between the United States of America (US) and countries outside the USA (OUS) in the emergency care setting. In this study, we prospectively analyze patients’ characteristics and differences in clinical care that may influence PE prevalence in different countries.MethodsAn international multicenter prospective diagnostic study was conducted in a standard-of-care setting. Consecutive outpatients presenting to the emergency unit and suspected for PE were managed using the Wells score, STA-Liatest® D-Dimers and imaging.ResultsThe prevalence of PE in the study was 7.9% in low and moderate risk patients. Among the 1060 patients with low or moderate pre-test probability (PTP), PE prevalence was four times higher in OUS (10.7%) than in the US (2.5%) (P < 0.0001). The mean number of imaging procedures performed for one new PE diagnosis was 3.3 in OUS vs 17 in the US (P < 0.001). Stopping investigation in the case of negative D-dimers (DD combined) with low/moderate PTP was more frequent in OUS (92.7%) than in the US (75.7%) (P < 0.01). Moreover, the use of imaging was much higher in the US (44.4% vs 19.2% in OUS) in the case of moderate PTP combined with negative DD.ConclusionDifferences between US and OUS PE prevalence in emergency setting might be explained by differences in patients' characteristics and mostly in care patterns. US physicians performed computed tomographic pulmonary angiography more often than in Europe in cases of low/moderate PTP combined with negative DD.Trial RegistrationClinicalTrials.gov NCT01221805

Multicenter Evaluation of the YEARS Criteria in Emergency Department Patients Evaluated for Pulmonary Embolism

“…Naturally, increasing the positivity threshold decreases the sensitivity of the D‐dimer test. However, patients with a low PTP have a very low prevalence of PE (about 3% in the United States), and the sensitivity of most commercially available D‐dimer tests is >95% when the standard 500 mg/dL threshold is used . Given this, Bayesian analysis suggests that using a higher positivity threshold to rule out PE in low PTP patients should be safe, with no resulting decrease in negative predictive value (NPV) .…”

Subconjunto terminológico CIPE® para pacientes com tromboembolismo venoso associado a câncer

“…(8) In spite of its validation with CI 0.83, the diagnosis was based on evidence of hemoptysis in cases of pulmonary embolism. (13,19) One of the experts questioned the fact that nasal bleeding is more appropriate to characterize the epistaxis condition, since hemoptysis is usually identified in cases of cough with bloody discharge. Another expert suggested the diagnosis should not be included and that evidence of hemoptysis should be part of the diagnoses Risk for hemorrhaging or Cough, validated with CI 0.88 and 0.81, respectively.…”

Comparison of Wells and YEARS clinical decision rules with D‐dimer for low‐risk pulmonary embolus patients

“…In this low‐risk group of patients only 2.2% were found to have a PE. Reports from North America and Europe in low‐risk patients have reported rates of PE of between 2.5% and 10.7% . The significant range reported in the literature is suggested to be due to a lower threshold for investigating patients for PE in some healthcare settings, predominantly North America.…”

“…Reports from North America and Europe in low-risk patients have reported rates of PE of between 2.5% and 10.7%. 13 The significant range reported in the literature is suggested to be due to a lower threshold for investigating patients for PE in some healthcare settings, predominantly North America. Another explanation could be the increasing risk averse practice in some emergency departments, with clinicians and patients less willing to accept the risk of missed pathology over the risk of further investigations.…”