Missed diagnosis of pulmonary embolism with age-adjusted d-dimer cut-off value

Stein, Charlotte E.; Keijsers, Carolina J. P. W.; Bootsma, Janet E. M.; Schouten, Henrike J.

doi:10.1093/ageing/afw132

Cited by 8 publications

(8 citation statements)

References 5 publications

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“…9 Multiple other studies have concluded AADD to be associated with only a small decrease in sensitivity and likely safe in exclusion of PE. [10][11][12][13] Conversely, other reports have questioned whether this loss in sensitivity might lead to an unacceptable risk of missed PEs and potential harm, [30][31][32][33] although some PE diagnoses are of uncertain significance. 34 We evaluated patients who were discharged from the ED without a PE diagnosis and found that implementation of AADD did not lead to any change in the frequency of 30-day mortality or missed PE.…”

Section: Discussionmentioning

confidence: 99%

Effect of Using an Age‐adjusted D‐dimer to Assess for Pulmonary Embolism in Community Emergency Departments

Ghobadi

Lin

Musigdilok

et al. 2020

Academic Emergency Medicine

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Background The objective of this study was to evaluate the effect of changing the laboratory‐reported D‐dimer reference intervals to age‐adjusted reference intervals on the use of advanced chest imaging and 30‐day adverse events among emergency department (ED) encounters. Methods A retrospective interrupted time‐series analysis of ED encounters for patients > 50 years evaluated for suspected pulmonary embolism (PE) from April 2014 to April 2016. The primary outcome was use of advanced diagnostic imaging, and the secondary outcome was 30‐day mortality or PE diagnosis. Secondary analyses also quantified delayed PE diagnoses pre‐ and postintervention. A generalized estimating equation segmented logistic regression model, adjusting for patient and facility characteristics, was used to determine changes in odds of diagnostic imaging and 30‐day mortality or PE diagnoses. Results A total of 10,534 (5,153 pre‐ and 5,381 postimplementation) ED encounters were included. Advanced imaging was obtained in 35.9% of pre‐ versus 33% of postimplementation encounters. Age‐adjusted D‐dimer (AADD) showed a small and nonsignificant decrease in month‐to‐month trends of advanced chest imaging postimplementation (odds ratio [OR] = 0.98, 95% confidence interval [CI] = 0.96 to 1.00). Use of advanced imaging in patients with D‐dimer values lower than 500 ng/mL fibrinogen‐equivalent units (FEU) was similar in the preintervention (5.8%) and postintervention (6.8%) periods. However, imaging was obtained in 30% of patients postintervention with a D‐dimer result less than AADD reference interval , but more than the historical 500 ng/mL FEU reference interval. Implementing an AADD threshold demonstrated no change in the rate of 30‐day adverse events (missed PE or mortality). Conclusion Changing the laboratory‐reported D‐dimer reference intervals for evaluation of PE was not associated with reduction in advanced chest imaging and did not increase 30‐day adverse events. However, there was substantial noncompliance with the age‐adjusted reference intervals in the postintervention period likely blunting the impact of this intervention.

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Section: Discussionmentioning

confidence: 99%

Effect of Using an Age‐adjusted D‐dimer to Assess for Pulmonary Embolism in Community Emergency Departments

Ghobadi

Lin

Musigdilok

et al. 2020

Academic Emergency Medicine

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“…It is important to know that TXA can alter D-dimer test results, causing false-negative results [ 14 , 16 ], and this was probably the case during the second hospital visit of our patient, when her D-dimer test result came back negative. A negative D-dimer finding does not completely exclude VTE diagnosis, particularly when there are suggestive clinical histories and signs of VTE [ 17 , 18 ]. This case report reiterates the need for healthcare practitioners to have a high index of clinical suspicion for PE when patients taking TXA present with pleuritic chest pain and shortness of breath on exertion, particularly in those considered to have low risk for VTE.…”

Section: Discussionmentioning

confidence: 99%

Bilateral pulmonary embolism while receiving tranexamic acid: a case report

Ijaopo

Adjei

2020

J Med Case Reports

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Background We present a case of a suspected tranexamic acid–related bilateral pulmonary embolism in a healthy and active middle-aged woman who was receiving tranexamic acid for menorrhagia with no other known significant risk factors for thromboembolism. Case presentation A 46-year-old Asian woman who was usually fit and well with no remarkable past medical history except for menorrhagia of 1-year duration for which she was receiving tranexamic acid presented to our accident and emergency department with a 2-week history of intermittent pleuritic central chest pain. She was reviewed and discharged to home with a diagnosis of musculoskeletal pain on two hospital visits because she had no significant risk factors for thromboembolism and her workup investigation results for pulmonary embolism and other differential diagnoses were largely unremarkable. On her third visit to the emergency ambulatory clinic with recurring symptoms of pleuritic chest pain, a pulmonary computed tomographic angiogram confirmed bilateral subsegmental pulmonary embolism. Conclusion This case report reinforces the possible increased risk of thromboembolism in patients receiving tranexamic acid.

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“…Atypically, his Wells score was zero, and his age-adjusted D-dimer was 600 mcg/L (normal level for age-adjusted D-dimer). In spite of atypical clinical presentation (ie Wells score of zero) and atypically normal age-adjusted D-dimer, CTPA showed several segmental emboli in both upper and lower parts of the right lung [113].…”

Section: Pulmonary Thromboembolism With Normal Serum D-dimer Levelsmentioning

confidence: 92%

Atypical manifestations of pulmonary embolism

Jolobe¹

2020

Arch Vas Med

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Pulmonary embolism (PE) is an age-related disorder which is potentially fatal, but frequently misdiagnosed. However, the true prevalence of pulmonary embolism is unknown. Inaccurate estimates of PE prevalence might, in part, be attributable to underrecognition of atypical presentations of this disorder. If true prevalence is unknown, the positive predictive values of both typical and atypical symptoms and signs of PE will be unreliable. The negative predictive value of those parameters will, likewise, be unreliable. The aim of this review is to make clinicians more aware of atypical manifestations of PE, thereby increasing the likelihood of correct diagnosis and, hence, ascertainment of the true prevalence of PE. The range of atypical manifestations was explored by a literature search, using MEDLINE from using the search terms atypical, uncommon, unusual, pulmonary embolism, lung embolism, pulmonary thromboembolism.This search revealed atypical presenting features such as non pleuritic retrosternal pain, abdominal pain, atypical breathing patterns, pulmonary oedema, Dressler's syndrome, atypical radiographic manifestations, atypical electrocardiographic features, manifestations associated with oxygen saturation of 95% or more, coexistence of acute myocardial infarction and pulmonary embolism, coexistence of thoracic aortic dissection and pulmonary embolism, neurological manifestations other than stroke, paradoxical embolism, acute venous thrombosis of atypical location, and pulmonary embolism with normal D-dimer levels.Atypical manifestations of pulmonary embolism https://www.heighpubs.org/hjvsm 009 https://dx.

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Missed diagnosis of pulmonary embolism with age-adjusted d-dimer cut-off value

Cited by 8 publications

References 5 publications

Effect of Using an Age‐adjusted D‐dimer to Assess for Pulmonary Embolism in Community Emergency Departments

Effect of Using an Age‐adjusted D‐dimer to Assess for Pulmonary Embolism in Community Emergency Departments

Bilateral pulmonary embolism while receiving tranexamic acid: a case report

Atypical manifestations of pulmonary embolism

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