Validity Of A Diagnostic Algorithm Combining Clinical Probability, D-dimer Testing, And Computed Tomography In Patients With Suspected Pulmonary Embolism In An Emergency Department

Galipienzo, Javier; Segovia, Julio Flores; García-Avello, Ángel; Álvarez, Carlos Forcadell; Arribas, Ignacio; Tena, Jaime García de

doi:10.1164/ajrccm-conference.2010.181.1_meetingabstracts.a1914

Cited by 9 publications

(12 citation statements)

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“…A well-established filter for a potentially serious condition is the use of D-dimer in patients with low-to-intermediate probability of pulmonary embolism. D-dimer has a negative likelihood ratio of 0.13, 5 which is very similar to what we found in patients with suspected CAD and zero calcium score. Patients with low-to-intermediate probability of pulmonary embolism and a negative D-dimer comprise 24% of patients with suspected pulmonary embolism.…”

Section: Discussionsupporting

confidence: 83%

“…Patients with low-to-intermediate probability of pulmonary embolism and a negative D-dimer comprise 24% of patients with suspected pulmonary embolism. 5 In our study, patients with CAD probability < 50% and zero calcium score comprised 29% of patients. The similarities between D-dimer (as a rule-out test for pulmonary embolism) and calcium scoring (as a rule-out test for CAD) highlight the potential of this approach in acute chest pain patients.…”

Section: Discussionmentioning

confidence: 89%

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Zero Calcium Score as a Filter for Further Testing in Patients Admitted to the Coronary Care Unit with Chest Pain

Correia¹,

Esteves²,

Carvalhal³

et al. 2017

Arquivos Brasileiros De Cardiologia

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BackgroundThe accuracy of zero coronary calcium score as a filter in patients with chest pain has been demonstrated at the emergency room and outpatient clinics, populations with low prevalence of coronary artery disease (CAD).ObjectiveTo test the gatekeeping role of zero calcium score in patients with chest pain admitted to the coronary care unit (CCU), where the pretest probability of CAD is higher than that of other populations.MethodsPatients underwent computed tomography for calcium scoring, and obstructive CAD was defined by a minimum 70% stenosis on invasive angiography.ResultsIn 146 patients studied, the prevalence of CAD was 41%. A zero calcium score was present in 35% of the patients. The sensitivity and specificity of zero calcium score yielded a negative likelihood ratio of 0.16. After logistic regression adjustment for pretest probability, zero calcium score was independently associated with lower odds of CAD (OR = 0.12, 95%CI = 0.04-0.36), increasing the area under the ROC curve of the clinical model from 0.76 to 0.82 (p = 0.006). Zero calcium score provided a net reclassification improvement of 0.20 (p = 0.0018) over the clinical model when using a pretest probability threshold of 10% for discharging without further testing. In patients with pretest probability < 50%, zero calcium score had a negative predictive value of 95% (95%CI = 83%-99%), with a number needed to test of 2.1 for obtaining one additional discharge.ConclusionZero calcium score substantially reduces the pretest probability of obstructive CAD in patients admitted to the CCU with acute chest pain. (Arq Bras Cardiol. 2017; [online].ahead print, PP.0-0)

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Section: Discussionsupporting

confidence: 83%

Section: Discussionmentioning

confidence: 89%

Zero Calcium Score as a Filter for Further Testing in Patients Admitted to the Coronary Care Unit with Chest Pain

Correia¹,

Esteves²,

Carvalhal³

et al. 2017

Arquivos Brasileiros De Cardiologia

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“…The study group comprised 7268 patients enrolled in six studies [10][11][12][13][14][15]. The mean age was 56 years and 58% were female.…”

Section: Resultsmentioning

confidence: 99%

“…For the present analysis, we used combined data from six prospective management studies comprising a total of 7268 patients . These studies were previously identified by a systematic review and used for an individual patient data meta‐analysis .…”

Section: Methodsmentioning

confidence: 99%

Is stand‐alone D‐dimer testing safe to rule out acute pulmonary embolism?

Hulle

Büller

et al. 2017

Journal of Thrombosis and Haemostasis

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Background Recently, stand-alone D-dimer testing at a positivity threshold of 750 μg L has been proposed as a safe and efficient approach to rule out acute pulmonary embolism (PE), without additional imaging, but this approach needs validation. Objectives To evaluate stand-alone D-dimer testing at a positivity threshold of 750 μg L to rule out PE. Methods Individual data from 7268 patients with suspected PE previously enrolled in six prospective management studies were used. Patients were assessed by the Wells rule followed by quantitative D-dimer testing in those with a 'PE unlikely' score. Patients were classified post hoc as having a negative (< 750 μg L ) or positive (≥ 750 μg L ) D-dimer. Using a one-stage meta-analytic approach, the negative predictive value (NPV) of stand-alone D-dimer testing was evaluated overall and in different risk subgroups. Results The pooled incidence of PE was 23% (range, 13-42%). Overall, 44% of patients had a D-dimer < 750 μg L , of whom 2.8% were diagnosed with PE at baseline or during 3-month follow-up (NPV, 97.2%; 95% confidence interval [CI], 94.9-98.5). The NPV was highest in patients with a low probability of PE according to the Wells rule (99.2%; 95% CI, 98.6-99.5%) and lowest in those with a high probability of PE (79.3%; 95% CI, 53.0-92.8%). The NPVs in patients with active cancer, patients with previous venous thromboembolism and inpatients were 96.2% (95% CI, 85.6-99.1%), 94.7% (95% CI, 88.6-97.6%) and 92.7% (95% CI, 79.3-97.7%), respectively. Conclusions Our findings suggest that stand-alone D-dimer testing at a positivity threshold of 750 μg L is not safe to rule out acute PE.

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“…The current study was conducted using individual patient data from seven studies investigating one of the algorithms mentioned above. Six studies were identified previously in a systematic review, which aimed at identifying all studies in which the diagnostic management of PE was guided by the dichotomized Wells rule followed by quantitative D‐dimer testing . In brief, MEDLINE and EMBASE were searched from the year of introduction of the Wells score (1 January 1998) up to 13 February 2016, combining terms for ‘pulmonary embolism’ and ‘D‐dimer’.…”

Section: Methodsmentioning

confidence: 99%

Sex‐specific performance of pre‐imaging diagnostic algorithms for pulmonary embolism

Mens

Pol

et al. 2018

Journal of Thrombosis and Haemostasis

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Background In patients suspected of pulmonary embolism (PE), clinical decision rules are combined with D-dimer testing to rule out PE, avoiding the need for imaging in those at low risk. Despite sex differences in several aspects of the disease, including its diagnosis, these algorithms are used indiscriminately in women and men. Objectives To compare the performance, defined as efficiency and failure rate, of three pre-imaging diagnostic algorithms for PE between women and men: the Wells rule with fixed or with age-adjusted D-dimer cut-off, and a recently validated algorithm (YEARS). A secondary aim was to determine the sex-specific prevalence of PE. Methods Individual patient data were obtained from six studies using the Wells rule (fixed D-dimer, n = 5; age adjusted, n = 1) and from one study using the YEARS algorithm. All studies prospectively enrolled consecutive patients with suspected PE. Main outcomes were efficiency (proportion of patients in which the algorithm ruled out PE without imaging) and failure rate (proportion of patients with PE not detected by the algorithm). Outcomes were estimated using (multilevel) logistic regression models. Results The main outcomes showed no sex differences in any of the separate algorithms. With all three, the prevalence of PE was lower in women (OR, 0.66, 0.68 and 0.74). In women, estrogen use, adjusted for age, was associated with lower efficiency and higher prevalence and D-dimer levels. Conclusions The investigated pre-imaging diagnostic algorithms for patients suspected of PE show no sex differences in performance. Male sex and estrogen use are both associated with a higher probability of having the disease.

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Validity Of A Diagnostic Algorithm Combining Clinical Probability, D-dimer Testing, And Computed Tomography In Patients With Suspected Pulmonary Embolism In An Emergency Department

Cited by 9 publications

References 0 publications

Zero Calcium Score as a Filter for Further Testing in Patients Admitted to the Coronary Care Unit with Chest Pain

Zero Calcium Score as a Filter for Further Testing in Patients Admitted to the Coronary Care Unit with Chest Pain

Is stand‐alone D‐dimer testing safe to rule out acute pulmonary embolism?

Sex‐specific performance of pre‐imaging diagnostic algorithms for pulmonary embolism

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