Uses of different D-dimer levels can reduce the need for venous duplex scanning to rule out deep vein thrombosis in patients with symptomatic pulmonary embolism

Abstract

This study investigated the prevalence and distribution of deep vein thrombosis (DVT) in patients with symptomatic pulmonary embolism (PE) to establish a screening protocol to reduce unnecessary venous duplex scanning using different D-dimer level rather than single cutoff point of 0.5 microg/mL in patients with low and moderate pretest clinical probability (PTP). The PTP score and D-dimer testing were used to evaluate 85 consecutive patients with symptomatically proven PE before venous duplex scanning. After calculating the PTP score, patients were divided into low (<or=0 points), moderate (1 to 2 points), and high (>or=3 points) PTP groups. The receiver operating characteristic (ROC) curves analysis was used to determine the appropriate D-dimer cutoff point in low and moderate PTP, with a negative predictive value of >98%. The study enrolled 81 patients. The prevalence of DVT was 63%, with 27 patients (33%) classified as low, 38 (47%) as moderate, and 16 (20%) as high PTP. DVT was detected in nine patients (33%) in the low PTP group, in 27 (71%) in the moderate group, and in 15 (94%) in the high group. In the low PTP patients, the difference in the value of D-dimer assay between positive-scan and negative-scan patients was statistically significant (9.99 +/- 7.33 vs 3.46 +/- 4.20, respectively; P = .008). Conversely, no significant difference in the D-dimer assay value between positive and negative scan results was found in the moderate PTP patients. ROC curves analysis were used to select D-dimer cutoff points of 2.0 microg/mL for the low PTP group and 0.7 microg/mL for the moderate PTP groups. For both groups, D-dimer testing provided 100% sensitivity and 100% negative predictive value in the diagnosis of DVT. In the low PTP group, specificity increased from 33% to 67% (P = .046). In the moderate PTP group, however, the determined D-dimer level did not improve the specificity. Overall, venous duplex scanning could have been reduced by 17% (14/81) by using different D-dimer cutoff points. A combination of specific D-dimer level and clinical probability score is most effective in the low PTP patients in excluding DVT. In the moderate PTP group, however, the recommended cutoff point of 0.5 microg/mL may be preferable. These results show that a different D-dimer level is more useful than single cutoff point of 0.5 microg/mL in excluding DVT in established PE patients.