Value of Quantitative D-dimer Assays in Identifying Pulmonary Embolism: Implications from a Sequential Decision Model

Duriseti, Ram; Shachter, Ross D.; Brandeau, Margaret L.

doi:10.1111/j.1553-2712.2006.tb01716.x

Cited by 13 publications

(18 citation statements)

References 38 publications

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“…In our two-center study of ED patients with suspected PE, we found that the tandem use of D-dimer and MPO had the potential to decrease the number of patients subjected to unnecessary pulmonary imaging by 13% while remaining 100% sensitive. Duriseti et al 15 recently concluded that Ddimer screening was not a cost-effective method of screening patients with suspected PE at institutions where CT with venography is available, because of the limited specificity of D-dimer screening. However, the alternative strategy of simply imaging patients without an initial screening step would seem likely to increase the number of patients subjected to unnecessary pulmonary vascular imaging with its risks from contrast and radiation exposure.…”

Section: Discussionmentioning

confidence: 99%

“…This threshold is based on the manufacturer recommendations and is consistent with the values used clinically at the study hospitals for the purpose of screening patients for PE. [13][14][15] The optimal test threshold for the tandem test (MPO or CRP) was determined as the value resulting in 100% sensitivity within the subset of patients with a positive D-dimer, and we report change in specificity for the following tandem combinations: 1) D-dimer and MPO and 2) D-dimer and CRP compared to the D-dimer alone. Diagnostic performance was assessed by diagnostic indexes from 2 · 2 contingency table analyses and areas under the receiver operating characteristic curves.…”

Section: Discussionmentioning

confidence: 99%

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Tandem Measurement of D‐dimer and Myeloperoxidase or C‐reactive Protein to Effectively Screen for Pulmonary Embolism in the Emergency Department

Mitchell

Nordenholz

Kline

2008

Academic Emergency Medicine

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Objectives: The hypothesis was that the tandem measurement of D-dimer and myeloperoxidase (MPO) or C-reactive protein (CRP) could significantly decrease unnecessary pulmonary vascular imaging in emergency department (ED) patients evaluated for pulmonary embolism (PE) compared to D-dimer alone.Methods: The authors measured the sequential combinations of D-dimer and MPO and D-dimer and CRP in a prospective sample of ED patients evaluated for PE at two centers. Patients were followed for 90 days for venous thromboembolism (VTE, either PE or deep venous thrombosis [DVT]), which required the consensus of two of three blinded physician reviewers. Results:The authors enrolled 304 patients, 22 with VTE (7%; 95% confidence interval [CI] = 5% to 10%). The sensitivity and specificity of a D-dimer alone (cutoff ‡ 500 ng ⁄ mL) were 100% (95% CI = 85% to 100%) and 59% (95% CI = 53% to 65%), respectively, and was followed by pulmonary vascular imaging negative for PE in 38% (115 ⁄ 304; 95% CI = 32% to 44%). The combination of either a negative D-dimer, or MPO < 22 mg ⁄ dL, had a sensitivity of 100% and specificity of 73% (95% CI = 67% to 78%). Thus, tandem measurement of D-dimer and MPO would have decreased the frequency of subsequent negative pulmonary vascular imaging from 38% to 25% (95% CI of the difference of )13% = )5% to )20%). The combination of CRP and D-dimer would not have significantly improved the rate of negative imaging. Conclusions:The tandem measurement of D-dimer and MPO would have significantly decreased negative pulmonary vascular imaging compared with D-dimer alone and should be validated prospectively. ACADEMIC EMERGENCY MEDICINE 2008; 15:800-805 ª 2008 by the Society for Academic Emergency MedicineKeywords: biological markers, pulmonary embolism E mergency physicians' awareness of pulmonary embolism (PE) as an important and potentially life-threatening illness is increasing. Currently, emergency physicians employ a diagnostic strategy that involves an assessment of pretest probability based on clinical evaluation followed by D-dimer testing in low-and moderate-risk patients. Patients with a positive D-dimer, or those at high risk, generally defined as a pretest probability for venous thromboembolism (VTE) of about 40% or greater, go on to pulmonary vascular imaging.1 While the D-dimer has proven to be a sensitive marker for PE, a low specificity leads to frequent negative pulmonary vascular imaging.Pulmonary vascular imaging is a significant source of the overall increase in imaging studies performed in emergency departments (EDs). Currently, approximately 10% of ED patients receive either a computed tomography (CT) scan or magnetic resonance imaging as a part of their ED care, and more than 1% receive

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Tandem Measurement of D‐dimer and Myeloperoxidase or C‐reactive Protein to Effectively Screen for Pulmonary Embolism in the Emergency Department

Mitchell

Nordenholz

Kline

2008

Academic Emergency Medicine

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“…For each of these six possibilities, we considered ten imaging strategies (including three different cutoffs for a VQ scan, which we denote as Low, Normal, and Intermediate) 30 (Figure 2). Figure 3 depicts the clinician’s assessment and decision sequence.…”

Section: Methodsmentioning

confidence: 99%

“…Cutoff III (500 mcg/L) represents the current widely employed cutoff for the VIDAS ™ ELISA D-dimer (Table 2). 14, 16, 30, 37, 40–42, 44, 77–80 …”

Section: Methodsmentioning

confidence: 99%

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Cost-Effectiveness of Strategies for Diagnosing Pulmonary Embolism Among Emergency Department Patients Presenting With Undifferentiated Symptoms

Duriseti

Brandeau

2010

Annals of Emergency Medicine

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Objective Symptoms associated with pulmonary embolism (PE) can be nonspecific and similar to many competing diagnoses, leading to excessive costly testing and treatment as well as missed diagnoses. Objective studies are essential for diagnosis. This study evaluates the cost-effectiveness of different diagnostic strategies in an Emergency Department (ED) for patients presenting with undifferentiated symptoms suggestive of PE. Methods Using a probabilistic decision model, we evaluated the incremental costs and effectiveness (quality-adjusted life years (QALYs) gained) of 60 testing strategies for five patient pretest categories (distinguished by Wells score (High, Moderate, or Low) and whether deep venous thrombosis (DVT) is clinically suspected). We performed deterministic and probabilistic sensitivity analyses. Results In the base case, for all patient pretest categories, the most cost-effective diagnostic strategy is to use an initial ELISA D-dimer test, followed by compression ultrasound (CUS) of the lower extremities if the D-dimer is above a specified cutoff. The level of the preferred cutoff varies with the Wells pretest category and whether a DVT is clinically suspected. D-dimer cutoffs higher than the current recommended cutoff were often preferred for even Moderate and High Wells category patients. CUS accuracy had to fall below commonly cited levels in the literature before it was not part of a preferred strategy. Conclusions When PE is suspected in the ED, use of an ELISA D-dimer assay, often at cutoffs higher than those currently in use (for patients in whom DVT is not clinically suspected), followed by CUS as appropriate, can reduce costs and improve outcomes.

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A Primer on the Complicated Subject of Cost-Effectiveness Analyses for Pulmonary Embolism

Kline

2010

Annals of Emergency Medicine

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Value of Quantitative D-dimer Assays in Identifying Pulmonary Embolism: Implications from a Sequential Decision Model

Cited by 13 publications

References 38 publications

Tandem Measurement of D‐dimer and Myeloperoxidase or C‐reactive Protein to Effectively Screen for Pulmonary Embolism in the Emergency Department

Tandem Measurement of D‐dimer and Myeloperoxidase or C‐reactive Protein to Effectively Screen for Pulmonary Embolism in the Emergency Department

Cost-Effectiveness of Strategies for Diagnosing Pulmonary Embolism Among Emergency Department Patients Presenting With Undifferentiated Symptoms

A Primer on the Complicated Subject of Cost-Effectiveness Analyses for Pulmonary Embolism

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