Safety and Efficiency of Diagnostic Strategies for Ruling Out Pulmonary Embolism in Clinically Relevant Patient Subgroups

Stals, Milou A.M.; Takada, Toshihiko; Kraaijpoel, Noémie; Es, Nick van; Büller, Harry R.; Courtney, D. Mark; Freund, Yonathan; Galipienzo, Javier; Gal, Grégoire Le; Huisman, Menno V.; Kline, Jeffrey A.; Moons, Karel G.M.; Parpia, Sameer; Perrier, Arnaud; Righini, Marc; Robert‐Ebadi, Helia; Roy, Pierre‐Marie; Smeden, Maarten van; Wells, Phil; Wit, Kerstin de; Geersing, Geert‐Jan; Klok, Frederikus A.

doi:10.7326/m21-2625

Cited by 35 publications

(41 citation statements)

References 55 publications

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“…In our study, the age-adjusted D-dimer threshold happened to be the best choice. The failure rates of rule outstrategies based on D-dimers alone or D-dimers combined with pre-test clinical probability scores were close to those reported by Stals et al in their meta-analysis on the safety and efficiency of diagnostic strategies for ruling out PE in the general population, with 0.36 to 1.1% depending on the use of fixed or age-adjusted D-dimer thresholds [8]. These failure rates are lower than the maximum acceptable failure rate according to the International Society on Thrombosis and Haemostasis (ISTH) recommendation [29].…”

Section: Discussionsupporting

confidence: 82%

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Strategies to safely rule out pulmonary embolism in COVID-19 outpatients: a multicenter retrospective study

et al. 2023

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ObjectivesThe objective was to define a safe strategy to exclude pulmonary embolism (PE) in COVID-19 outpatients, without performing CT pulmonary angiogram (CTPA). Methods COVID-19 outpatients from 15 university hospitals who underwent a CTPA were retrospectively evaluated. D-Dimers, variables of the revised Geneva and Wells scores, as well as laboratory findings and clinical characteristics related to COVID-19 pneumonia, were collected. CTPA reports were reviewed for the presence of PE and the extent of COVID-19 disease. PE rule-out strategies were based solely on D-Dimer tests using different thresholds, the revised Geneva and Wells scores, and a COVID-19 PE prediction model built on our dataset were compared. The area under the receiver operating characteristics curve (AUC), failure rate, and efficiency were calculated. Results In total, 1369 patients were included of whom 124 were PE positive (9.1%). Failure rate and efficiency of D-Dimer > 500 µg/l were 0.9% (95%CI, 0.2-4.8%) and 10.1% (8.5-11.9%), respectively, increasing to 1.0% (0.2-5.3%) and 16.4% (14.4-18.7%), respectively, for an age-adjusted D-Dimer level. D-dimer > 1000 µg/l led to an unacceptable failure rate to 8.1% (4.4-14.5%). The best performances of the revised Geneva and Wells scores were obtained using the age-adjusted D-Dimer level. They had the same failure rate of 1.0% (0.2-5.3%) for efficiency of 16.8% (14.7-19.1%), and 16.9% (14.8-19.2%) respectively. The developed COVID-19 PE prediction model had an AUC of 0.609 (0.594-0.623) with an efficiency of 20.5% (18.4-22.8%) when its failure was set to 0.8%. Conclusions The strategy to safely exclude PE in COVID-19 outpatients should not differ from that used in non-COVID-19 patients. The added value of the COVID-19 PE prediction model is minor. Key Points• D-dimer level remains the most important predictor of pulmonary embolism in COVID-19 patients.• The AUCs of the revised Geneva and Wells scores using an age-adjusted D-dimer threshold were 0.587 (95%CI, 0.572 to 0.603) and 0.588 (95%CI, 0.572 to 0.603). • The AUC of COVID-19-specific strategy to rule out pulmonary embolism ranged from 0.513 (95%CI: 0.503 to 0.522) to 0.609 (95%CI: 0.594 to 0.623).

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Section: Discussionsupporting

confidence: 82%

“…Conventional strategies to exclude PE without performing CTPA rely on a pre-test assessment of the clinical probability using a validated clinical decision rule, combined with D-dimer testing [8]. The most widely used and recommended clinical decision rules are the Wells [9] and the revised Geneva [10] scores.…”

Section: Introductionmentioning

confidence: 99%

Strategies to safely rule out pulmonary embolism in COVID-19 outpatients: a multicenter retrospective study

et al. 2023

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“…A recently published meta-analysis by Stals et al 41 examining the safety of CDRs and D-dimer assay showed that the failure rates in elderly patients and cancer-related pulmonary embolism previously reported have been overestimated due to misclassifications related to VTE and not to other co-morbidities.…”

Section: Discussionmentioning

confidence: 99%

Current use of D-dimer for the exclusion of venous thrombosis in hospitalized patients

Karny-Epstein

Abuhasira

Grossman

2022

Sci Rep

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D-dimer assay’s utility for excluding venous thromboembolism (VTE) in hospitalized patients is debatable. We aimed to assess the current use of D-dimer as a diagnostic tool for excluding VTE in hospitalized patients and examine a mandatory age-adjusted D-dimer (AADD) threshold for diagnostic imaging. Retrospective cohort study between 2014 to 2019 that included patients from medical and surgical wards with a positive AADD result drawn during their hospitalization. The outcomes were determining a D-dimer threshold requiring further evaluation and assessing the prognostic value of D-dimer in predicting clinically relevant VTE in hospitalized patients. The cohort included 354 patients, 56% of them underwent definitive diagnostic imaging, and 7.6% were diagnosed with VTE after a positive AADD within 90 days of follow-up. Mortality rates were higher in patients diagnosed with VTE (33.3% vs. 15.9%, p = 0.03). Patients with pneumonia and other infectious etiologies were less likely to be further evaluated by definitive imaging (p = 0.001). Patients with a respiratory complaint (p = 0.02), chest pain (p < 0.001), or leg swelling (p = 0.01) were more likely to undergo diagnostic imaging. Patients with D-dimer levels > X2 the AADD were at increased risk of VTE [OR 3.87 (1.45–10.27)]. At 90 days of follow-up, no excess mortality was observed for patients without diagnostic evaluation following elevated AADD. D-dimer may be used in hospitalized patients to exclude VTE using the traditional AADD thresholds, with a high negative predictive value. D-dimer levels > X2 the AADD usually mandates further diagnostic imaging, while lower levels, probably do not require additional workup, with a sensitivity of almost 80% and no excess mortality.

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“…Another important point, if PE detection is clinical, is in the assessment of probability scores such as the Geneva or Wells score. Probability scores give information on the likelihood of a PE in a certain patient, and therefore the need if PE evaluation with CT is needed or not [ 36 ].…”

Section: Discussionmentioning

confidence: 99%

Impact of Photon Counting Detector CT Derived Virtual Monoenergetic Images on the Diagnosis of Pulmonary Embolism

et al. 2022

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Purpose: To assess the impact of virtual-monoenergetic-image (VMI) energies on the diagnosis of pulmonary embolism (PE) in photon-counting-detector computed-tomography (PCD-CT). Methods: Eighty patients (median age 60.4 years) with suspected PE were retrospectively included. Scans were performed on PCD-CT in the multi-energy mode at 120 kV. VMIs from 40–70 keV in 10 keV intervals were reconstructed. CT-attenuation was measured in the pulmonary trunk and the main branches of the pulmonary artery. Signal-to-noise (SNR) ratio was calculated. Two radiologists evaluated subjective-image-quality (noise, vessel-attenuation and sharpness; five-point-Likert-scale, non-diagnostic–excellent), the presence of hardening artefacts and presence/visibility of PE. Results: Signal was highest at the lowest evaluated VMI (40 keV; 1053.50 HU); image noise was lowest at the highest VMI (70 keV; 15.60 HU). Highest SNR was achieved at the lowest VMI (p < 0.05). Inter-reader-agreement for subjective analysis was fair to excellent (k = 0.373–1.000; p < 0.001). Scores for vessel-attenuation and sharpness were highest at 40 keV (both:5, range 4/3–5; k = 1.000); scores for image-noise were highest at 70 keV (4, range 3–5). The highest number of hardening artifacts were reported at 40 keV (n = 22; 28%). PE-visualization was rated best at 50 keV (4.7; range 4–5) and decreased with increasing VMI-energy (r = −0.558; p < 0.001). Conclusions: While SNR was best at 40 keV, subjective PE visibility was rated highest at 50 keV, potentially owing to the lower image noise and hardening artefacts.

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Safety and Efficiency of Diagnostic Strategies for Ruling Out Pulmonary Embolism in Clinically Relevant Patient Subgroups

Cited by 35 publications

References 55 publications

Strategies to safely rule out pulmonary embolism in COVID-19 outpatients: a multicenter retrospective study

Strategies to safely rule out pulmonary embolism in COVID-19 outpatients: a multicenter retrospective study

Current use of D-dimer for the exclusion of venous thrombosis in hospitalized patients

Impact of Photon Counting Detector CT Derived Virtual Monoenergetic Images on the Diagnosis of Pulmonary Embolism

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