Using Quantitative D-Dimer to Determine the Need for Pulmonary CT Angiography in COVID-19 Patients

Abstract

INTRODUCTION: COVID-19 has been frequently cited as a condition causing a pro-inflammatory state leading to hypercoagulopathy and increased risk for venous thromboembolism. This condition has thus prompted prior studies and screening models that utilize D-dimer for pulmonary embolism (PE) into question. The limited research to date has failed to provide tools or guidance regarding what COVID-19 positive patients should receive pulmonary CT angiography screening. This knowledge gap has led to missed diagnoses, CT overutilization, and increased morbidity and mortality. OBJECTIVE: The purpose of this study was to examine the utility of the quantitative D-dimer lab marker in a convenience sample of 426 COVID-19 positive patients to assist providers in determining the utility of pulmonary CT angiography. METHODS: The authors conducted a retrospective analysis on all COVID-19 positive patients within the Henry Ford Medical System between March 1st, 2020 through April 30th, 2020 who received pulmonary CT angiography and had a quantitative D-dimer lab drawn within 24 hours of CT imaging. RESULTS: Our sampling criteria yielded a total of n = 426 patients, of whom 347 (81.5%) were negative for PE and 79 (18.5%) were positive for PE. The average D-dimer in the negative PE group was 2.95 μg./mL. (SD 4.26), significantly different than the 9.15 μg./mL. (SD 6.80) positive PE group (P < 0.05; 95% CI -7.8, -4.6). Theoretically, applying the traditional ≤ 0.5 μg./mL. D-dimer cut-off to our data would yield a sensitivity of 100% and specificity of 7.49% for exclusion of PE. Based on these results, the authors would be able to increase the D-dimer threshold to < 0.89 μg./mL. to maintain their sensitivity to 100% and raise the specificity to 27.95%. Observing a D-dimer cut-off value of ≤ 1.28 μg./mL. would reduce sensitivity to 97.47% but increase the specificity to 57.93%. CONCLUSIONS: These study results support the utilization of alternative D-dimer thresholds to exclude PE in COVID-19 patients. Based on these findings, providers may be able to observe increased D-dimer cut-off values to reduce unnecessary pulmonary CT angiography scans.

Improving risk prediction for pulmonary embolism in COVID‐19 patients using echocardiography

“…D‐dimer is considered a first line test that is used as a screening tool with high sensitivity, with the additional value in ruling out PE with a negative test in low risk patients 5,6 . However, D‐dimer testing lacks specificity for the diagnosis of PE in COVID‐19 patients, reported in the range of 10%–15% according to prior studies 7,8 . Further, patients with suspected PE have significant overlap in terms of symptoms of COVID‐19, making the diagnosis challenging 9 .…”

“…5 , 6 However, D‐dimer testing lacks specificity for the diagnosis of PE in COVID‐19 patients, reported in the range of 10%–15% according to prior studies. 7 , 8 Further, patients with suspected PE have significant overlap in terms of symptoms of COVID‐19, making the diagnosis challenging. 9 This may prevent an underlying PE from being detected and appropriately treated.…”