Clinical Probability Of Pulmonary Embolism Research Articles

Failure rate of D-dimer testing in patients with high clinical probability of pulmonary embolism: Ancillary analysis of three European studies.

In patients with a high clinical probability of pulmonary embolism (PE), the high prevalence can lower the D-dimer negative predictive value and increase the risk of diagnostic failure. It is therefore recommended that these high-risk patients should undergo chest imaging without D-dimer testing although no evidence supports this recommendation. The objective was to evaluate the safety of ruling out PE based on D-dimer testing among patients with a high clinical probability of PE. This was a post hoc analysis of three European studies (PROPER, MODIGLIANI, and TRYSPEED). Patients were included if they presented a high clinical probability of PE (according to either the Wells or the revised Geneva score) and underwent D-dimer testing. The D-dimer-based strategy ruled out PE if the D-dimer level was below the age-adjusted threshold (i.e., <500 ng/mL in patients aged less than 50 and age × 10 ng/mL in patients older than 50). The primary endpoint was a thromboembolic event in patients with negative D-dimer either at index visit or at 3-month follow-up. A Bayesian approach estimated the probability that the failure rate of the D-dimer-based strategy was below 2% given observed data. Among the 12,300 patients included in the PROPER, MODIGLIANI, and TRYSPEED studies, 651 patients (median age 68 years, 60% female) had D-dimer testing and a high clinical probability of PE and were included in the study. PE prevalence was 31.3%. Seventy patients had D-dimer levels under the age-adjusted threshold, and none of them had a PE after follow-up (failure rate 0.0% [95% CI 0.0%-6.5%]). Bayesian analysis reported a credible interval of 0.0%-4.1%, with a 76.2% posterior probability of a failure rate below 2%. In this study, ruling out PE in high-risk patients based on D-dimer below the age-adjusted threshold was safe, with no missed PE. However, the large CI of the primary endpoint precludes a definitive conclusion.

The relationship of clinical presentation, d-dimer levels and previous SARS-CoV-2 positivity in outpatients with suspected pulmonary embolism

Abstract Introduction Elevated D-dimer levels can be detected in patients with pulmonary embolism (PE), but also in patients with the disease caused by the novel coronavirus (COVID-19). Aims To investigate relationship between clinical presentation, D-dimer levels and previous SARS-CoV-2 positivity in outpatients with suspected PE. Material and methods This retrospective study included 609 consecutive outpatients (mean age 68±15 years, 50% female) who underwent computed tomography pulmonary angiography for suspected PE from 2021 to 2023. By reviewing electronic databases, clinical and laboratory data were collected, as well data on previously documented SARS-CoV-2 infection. Results PE was confirmed in 130 (21%) patients who had higher D-dimer values than patients without PE (p&amp;lt;0.001). Patients with previous COVID-19 had significantly higher D-dimer values compared to those without prior COVID-19, but only during the first 8 months from infection to pulmonary angiography (Figure, upper panel). Clinical probability of PE, as indicated by Geneva score [odds ratio (OR) 2.36, 95% confidence interval (CI) 1.55 – 3.58)], and age-adjusted D-dimer (OR 4.52, 95%CI 1.58 – 12.90) were independently associated with PE, while previous COVID-19 was not. Main clinical reasons for emergency department presentation are shown in Figure (bottom panel). In 45/609 (7.4%) patients evaluated primarily for elevated D-dimer, the prevalence of COVID-19 in the previous 6 months was higher in those with PE compared to those without PE (100% vs. 49%, p=0.019). Conclusion Within 8 months of infection, patients with a history of COVID-19 had higher D-dimer levels than those without COVID-19. Age-adjusted D-dimer and standard clinical probability scores retained their predictive power in outpatients with suspected PE, regardless of COVID-19 history.

284 Failure Rate of D-Dimer Testing in Patients With a High Clinical Probability of Pulmonary Embolism: An Ancillary Analysis of Three European Prospective Cohorts

284 Failure Rate of D-Dimer Testing in Patients With a High Clinical Probability of Pulmonary Embolism: An Ancillary Analysis of Three European Prospective Cohorts

Diagnostic value of D-dimer to fibrinogen ratio for pulmonary embolism in postpartum women

BackgroundPulmonary embolism is a common disease associated with high mortality and morbidity. Diagnosing pulmonary embolism is challenging due to diverse clinical presentations and the lack of specific biomarkers. The study aimed to investigate the diagnostic value on pulmonary embolism for postpartum women by D-dimer to fibrinogen ratio, and it combined with neutrophil-to-lymphocyte ratio or platelet-to-lymphocyte ratio.MethodsA total of 537 women with suspected pulmonary embolism were selected as the research subjects from the Shanghai First Maternity and Infant Hospital between 1 January 2019 and 31 October 2022. The D-dimer to fibrinogen ratio and it combined with neutrophil-to-lymphocyte ratio or platelet-to-lymphocyte ratio were applied to evaluate the clinical probability of pulmonary embolism, and the positive predictive value of both scores were calculated using computed tomography pulmonary arteriography as a gold standard. The diagnostic value of D-dimer to fibrinogen ratio, combined with neutrophil-to-lymphocyte ratio or platelet-to-lymphocyte ratio was evaluated by the area under the curve, sensitivity, specificity, and other indicators in the receiver operator characteristic curve.ResultsAmong the 502 women included for analysis, 194 (38.65%) were definitely diagnosed as pulmonary embolism. The positive predictive values of D-dimer to fibrinogen ratio and it combined with platelet-to-lymphocyte ratio or neutrophil-to-lymphocyte ratio were 70.1%, 50.5%, and 56.5%, respectively in the postpartum women, the area under the curve for the D-dimer to fibrinogen ratio and it combined with platelet-to-lymphocyte ratio or neutrophil-to-lymphocyte ratio were 0.606 (95%CI: 0.562–0.650), 0.624 (95%CI: 0.575–0.673), and 0.639 (95%CI: 0.592–0.686), respectively. The negative predictive values of D-dimer to fibrinogen ratio, it combined with platelet-to-lymphocyte ratio or neutrophil-to-lymphocyte ratio were 50.5%, 70.1%, and 69.8%, respectively.ConclusionThe diagnostic value of the D-dimer to fibrinogen ratio was higher than the D-dimer for the postpartum women with suspected pulmonary embolism. The combination of either the neutrophil-to-lymphocyte ratio or the platelet-to-lymphocyte ratio with D-dimer to fibrinogen ratio is an appropriate strategy to rule out pulmonary embolism.

Assessing the Prevalence of Pulmonary Embolism and the Clot Burden in Hospitalized Patients with Chronic Obstructive Pulmonary Disease Exacerbation.

This prospective cohort study aimed to assess the pulmonary embolism (PE) rate and clot burden in patients with chronic obstructive pulmonary disease (COPD) exacerbation. A total of 248 patients entered the study, and their clinical probability of PE was assessed using the Geneva score. Patients with high clinical probability underwent computed tomographic pulmonary angiography, while those with low or intermediate probability underwent a d-dimer test. Among the patients analyzed, 14 individuals (5.6%) were confirmed to have PE using computed tomographic pulmonary angiography. A 3-month follow-up revealed 3 cases of PE out of 232 patients initially deemed PE-free. Mortality rates were higher among patients with venous thromboembolism at admission than those diagnosed with PE during follow-up. Pulmonary embolism (PE) prevalence among patients with COPD exacerbation was 5.6%. The results of this study show the importance of screening for PE in patients with COPD presenting with dyspnea. Not all of them are due to COPD exacerbation; a small minority of them can be due to PE, which needs prompt screening, confirmation, and therapy. However, further research with larger cohorts is required to understand better the potential benefits and implications of systematic screening for pulmonary embolism in this specific patient population.

External validation of the CHEDDAR score for suspected pulmonary embolism in patients with SARS-CoV-2 infection in an independent cohort.

The accuracy of the classic scores that help stratify the pretest clinical probability of pulmonary embolism (PE) in SARS-CoV-2 infection (COVID-19) is low. Therefore, to estimate the risk of PE in these patients, a new set of guidelines must be established. The recently published CHEDDAR score proposes a new diagnostic strategy to reduce the use of computed tomography pulmonary angiography (CTPA) in non-critically ill SARS-COV-2 patients with suspected PE. According to the nomogram, patients are segregated intolow-risk (< 182points) or high-risk (≥ 182points) based on the best cut-off value to discard PE in the original cohort. We aimed to externally validate this diagnostic strategy in an independent cohort. We analyzed data from two retrospective cohorts of hospitalized non-critically ill COVID-19 patients who underwent a CTPA due to suspicion for PE. CHEDDAR score was applied. As per the CHEDDAR nomogram, patients were classified as having a low or high clinical pre-test probability. Of the 270 patients included, 69 (25.5%) had PE. Applying the CHEDDAR score, 182 (67.4%) patients could have had PE excluded without imaging. Among 58 patients classified as having high clinical pre-test probability, 39 (67.2%) had PE. Sensitivity, specificity, positive and negative predictive values, and AUC were 56%, 90%, 67%, 85%, and 0.783 (95% CI 0.71-0.85), respectively. We provide external validation of the CHEDDAR score in an independent cohort. Even though the CHEDDAR score showed good discrimination capacity, caution is required in patients classified as having low clinical pre-test probability with a D-dimer value > 3000ng/mL, and a RALE score ≥ 4.

Assessment of the Utilization of Validated Diagnostic Predictive Tools and D-Dimer in the Evaluation of Pulmonary Embolism: A Single-Center Retrospective Cohort Study from a Public Hospital in New York City.

A significant increase in the use of computed tomography with pulmonary angiography (CTPA) for the diagnosis of pulmonary embolism (PE) has been observed in the past twenty years. We aimed to investigate whether the validated diagnostic predictive tools and D-dimers were adequately utilized in a large public hospital in New York City. We conducted a retrospective review of patients who underwent CTPA for the specific indication of ruling out PE over a period of one year. Two independent reviewers, blinded to each other and to the CTPA and D-dimer results, estimated the clinical probability (CP) of PE using Well's score, the YEARS algorithm, and the revised Geneva score. Patients were classified based on the presence or absence of PE in the CTPA. A total of 917 patients were included in the analysis (median age: 57 years, female: 59%). The clinical probability of PE was considered low by both independent reviewers in 563 (61.4%), 487 (55%), and 184 (20.1%) patients based on Well's score, the YEARS algorithm, and the revised Geneva score, respectively. D-dimer testing was conducted in less than half of the patients who were deemed to have low CP for PE by both independent reviewers. Using a D-dimer cut-off of <500 ng/mL or the age-adjusted cut-off in patients with a low CP of PE would have missed only a small number of mainly subsegmental PE. All three tools, when combined with D-dimer < 500 ng/mL or <age-adjusted cut-off, yielded a NPV of > 95%. All three validated diagnostic predictive tools were found to have significant diagnostic value in ruling out PE when combined with a D-dimer cut-off of <500 ng/mL or the age-adjusted cut-off. Excessive use of CTPA was likely secondary to suboptimal use of diagnostic predictive tools.

Revision of Clinical Pre-Test Probability Scores in Hospitalized Patients with Pulmonary Embolism and SARS-CoV-2 Infection.

The need for computed tomography pulmonary angiography (CTPA) to rule out pulmonary embolism (PE) is based on clinical scores in association with D-dimer measurements. PE is a recognized complication in patients with SARS-CoV-2 infection due to a pro-thrombotic state which may reduce the usefulness of preexisting pre-test probability scores. The purpose was to analyze new clinical and laboratory parameters while comparing existing and newly proposed scoring system for PE detection in hospitalized COVID-19 patients (HCP). We conducted a retrospective study of 270 consecutive HCPs who underwent CTPA due to suspected PE. The Modified Wells, Revised Geneva, Simplified Geneva, YEARS, 4-Level Pulmonary Embolism Clinical Probability Score (4PEPS), and PE rule-out criteria (PERC) scores were calculated and the area under the receiver operating characteristic curve (AuROC) was measured. Overall incidence of PE among our study group of HCPs was 28.1%. The group of patients with PE had a significantly longer COVID-19 duration upon admission, at 10 vs 8 days, p = 0.006; higher D-dimer levels of 10.2 vs 5.3 g/L, p 0.001; and a larger proportion of underlying chronic kidney disease, at 16% vs 7%, p = 0.041. From already established scores, only 4PEPS and the modified Wells score reached statistical significance in detecting the difference between the HCP groups with or without PE. We proposed a new chronic kidney disease, D-dimers, 10 days of illness before admission (CDD-10) score consisting of the three aforementioned variables: C as chronic kidney disease (0.5 points if present), D as D-dimers (negative 1.5 points if normal, 2 points if over 10.0 g/L), and D-10 as day-10 of illness carrying 2 points if lasting more than 10 days before admission or 1 point if longer than 8 days. The CDD-10 score ranged from -1.5 to 4.5 and had an AuROC of 0.672, p 0.001 at cutoff value at 0.5 while 4PEPS score had an AuROC of 0.638 and Modified Wells score 0.611. The clinical probability of PE was low (0%) when the CDD-10 value was negative, moderate (24%) for CDD-10 ranging 0-2.5 and high (43%) when over 2.5. Better risk stratification is needed for HCPs who require CTPA for suspected PE. Our newly proposed CDD-10 score demonstrates the best accuracy in predicting PE in patients hospitalized for SARS-CoV-2 infection.

Risk stratification and risk-adapted management of acute pulmonary embolism.

Pulmonary embolism is one of the leading causes of cardiovascular death in Europe. Rapid diagnosis and treatment initiation are essential, especially in hemodynamically unstable patients. For normotensive patients, the diagnostic workflow is based on the clinical probability of pulmonary embolism. Due to numerous differential diagnoses and ahighly variable clinical presentation, diagnosis of acute pulmonary embolism still remains aclinical challenge. Computed tomography angiography is the common gold standard to confirm pulmonary embolism and bedside echocardiography adds amajor impact in clinical decision making. The European Society of Cardiology guidelines serve as aframework for astandardized diagnostic approach and risk prediction. Based on vital signs, clinical scores, biomarkers and imaging results, four risk categories can be defined and treatment is accordingly. To optimize the individual management of critical patients, multidisciplinary pulmonary embolism response teams are increasingly designated in specialized centers. This article provides an overview of the current risk-adapted management of patients with acute pulmonary embolism.

Assessing the clinical probability of pulmonary embolism during pregnancy: The Pregnancy‐Adapted Geneva (PAG) score

BackgroundThe diagnosis of pulmonary embolism (PE) in pregnant women represents an ongoing challenge. As in the general population, the first step in pregnant women with suspected PE consists of assessing clinical pre‐test probability (PTP). However, no dedicated clinical decision rule has been developed in this population. ObjectiveTo propose a new version of the Geneva score adapted to pregnant women with suspected PE. MethodsData from a multicenter, prospective management outcome study including 395 women with suspected PE, in whom PTP was assessed using the Geneva score, were used. We first removed items which were present in none of the patients (cancer, age >65 years). Receiver operating characteristic (ROC) curve analysis was then performed for quantitative variables and the optimal threshold defined. The obtained Pregnancy‐Adapted Geneva Score (PAG Score) comprised seven items, including an age 40 years or older and a heart rate >110 beats per minute. ResultsThe PAG Score showed a high discriminative power to identify patients with a low, intermediate, or high PTP, associated with increasing prevalence of PE, 2.3%, 11.6%, and 61.5%, respectively. The ROC curves showed an area under the curve of 0.795 for the PAG Score compared to 0.684 for the Geneva score. ConclusionIn pregnant women with suspected PE, the PAG Score shows a high discriminative power to identify patients at low, intermediate, or high PTP. It has the strength of being a fully objective decision rule, is clinically relevant, easy to compute, and should now be tested in a prospective outcome study.

Investigation of perfusion defects by Q-SPECT/CT in patients with mild-to-moderate course of COVID-19 and low clinical probability for pulmonary embolism.

ObjectivePulmonary embolism is a severe source of mortality and morbidity in patients with severe and critical coronavirus disease 2019. It is not yet clear whether the tendency to thrombosis is increased in the mild-to-moderate course of COVID-19. Our research aims to show the clinical benefit of Q-SPECT/CT in diagnosing PD in outpatients treated with mild-to-moderate course of COVID-19 and to determine the frequency of perfusion defects in these patients having relatively lower risk.MethodsAll patients who underwent Q-SPECT/CT with suspicion of embolism were examined retrospectively. Only patients with low clinical probability and mild-to-moderate course of COVID-19 for PE were included in the study. The patients were evaluated comparatively as those with and without perfusion defects. Patients were divided into laboratory suspicion, clinical suspicion, or clinical and laboratory suspicion.ResultsIn outpatients with mild-to-moderate COVID-19 with low clinical probability for PE, PD without CT abnormality was detected with a rate of 36.6% with Q-SPECT/CT performed for complaints of high d-dimer and/or dyspnea. None of the patients had PD at more proximal level than the segment level. PD with no concomitant CT abnormality was observed with a rate of 56.5% in patients with both clinical and laboratory suspicion. For d-dimer = 0.5 mg/dL cut-off sensitivity is 85%, for d-dimer = 1.5 mg/dL cut-off specificity 81%.ConclusionThrombosis tendency is also present in outpatients with mild-to-moderate COVID-19, and these patients should also be offered anticoagulant prophylaxis during the COVID-19 period.

Age-Adjusted D-Dimer in the Prediction of Pulmonary Embolism: Systematic Review and Meta-analysis.

Background:Pulmonary embolism (PE), depending on the severity, carries a high mortality and morbidity. Proper evaluation, especially in patients with low probability for PE, is important to avoid unnecessary diagnostic testing.Objective:To review the diagnostic utility of conventional versus age-adjusted D-dimer cutoff values in patients 50 years and older with suspected pulmonary embolism.Methods:Systematic review with univariant and bivariant meta-analysis.Data sources:We searched PubMed, MEDLINE, and EBSCO for studies published before September 20th, 2020. We cross checked the reference list of relevant studies that compares conventional versus age-adjusted D-dimer cutoff values in patients with suspected pulmonary embolism.Study selection:We included primary published studies that compared both conventional (500 µg/L) and age-adjusted (age × 10 µg/L) cutoff values in patients with non-high clinical probability for pulmonary embolism.Results:Nine cohorts that included 47 720 patients with non-high clinical probability were included in the meta-analysis. Both Age-adjusted D-dimer and conventional D-dimer have high sensitivity. However, conventional D-dimer has higher false positive rate than age-adjusted D-dimer.Conclusion:Age-adjusted D-dimer cutoffs combined with low risk clinical probability assessment ruled out PE diagnosis in suspected patients with a decreased rate of false positive tests.

Antithrombotic Treatment of Pulmonary Embolism

The present article addresses clinical challenges associated with the choice of the anticoagulant agent, the definition of the duration of anticoagulant treatment and the assessment of the risk-to-benefit ratio of prolonged anticoagulation for patients with pulmonary embolism (PE).Anticoagulation is performed with unfractionated heparin (UFH) in hemodynamically unstable patients and with low molecular weight heparins (LWMH) or fondaparinux in normotensive patients. In patients with high or intermediate clinical probability of pulmonary embolism, anticoagulation should be initiated without delay while awaiting the results of diagnostic tests. LMWH and fondaparinux are preferred over UFH in the initial anticoagulation of PE since they are associated with a lower risk of bleeding.All patients with PE require therapeutic anticoagulation for at least three months. The current 2019 guidelines of the European Society of Cardiology (ESC) recommend that all eligible patients should be treated with a non-vitamin K antagonist oral anticoagulant (NOAC) in preference to a vitamin K antagonist (VKA). In patients with active cancer, Apixaban, Edoxaban and Rivaroxaban are effective alternatives to treatment with LMWH.The decision on the duration of anticoagulation should consider both, the individual risk of PE recurrence and the individual risk of bleeding. The risk for recurrent PE after discontinuation of treatment is related to the features of the index PE event. While patients with a strong transient risk factor have a low risk of recurrence and anticoagulation can be discontinued after three months, patients with strong persistent risk factor (such as active cancer) have a high risk of recurrence and thus should receive anticoagulant treatment of indefinite duration. Given the favourable safety profile of NOACs (especially if a reduced dosage of Apixaban or Rivaroxaban is initiated after at least six months of therapeutic anticoagulation), extended oral anticoagulation of indefinite duration should be considered for all patients with intermediate risk of recurrence.

MOdified DIagnostic strateGy to safely ruLe-out pulmonary embolism In the emergency depArtment: study protocol for the Non-Inferiority MODIGLIANI cluster cross-over randomized trial

IntroductionIn the work-up strategy for pulmonary embolism (PE) in the ED, the recently introduced YEARS rule allows the raising of the D-dimer threshold to 1000 ng/ml in patients with no signs of deep venous thrombosis and no hemoptysis and in whom PE is not the most likely diagnosis. However, this decision rule has never been prospectively compared to the usual strategy. Furthermore, it is unclear if the YEARS rule can be used on top of the Pulmonary Embolism Rule-out Criteria (PERC). We aim to assess the non-inferiority of YEARS compared to current guidelines to rule out PE among PERC-positive ED patients with suspicion of PE.Methods/designThe MODIGLIANI study is a multicenter, European, non-inferiority, cluster-randomized, two periods cross-over, controlled trial. Each center will be randomized for the sequence of two 4-month periods: intervention (MOdified Diagnostic Strategy: MODS) followed by control (usual care), or control followed by intervention with 1 month of “wash-out” between the two periods. In the control period, the threshold will be as usual (500 ng/ml for patients aged 50 years or younger and age × 10 for older patients). In the MODS period, the threshold of D-dimers to rule out PE will be raised to 1000 ng/ml if no item of the YEARS score is present or will remain unchanged otherwise. Patients will be included if they have a suspicion of PE, defined as chest pain, dyspnea, or syncope. Non-inclusion criteria comprise a high clinical probability of PE or PERC-negative patients with low clinical probability.Ethics and disseminationThe study has received the following approvals: Comité de protection des personnes Ile de France XI (France) and Comité de Ética de la Investigación con medicamentos del Hospital Clínic de Barcelona (Spain). Results will be made available to all included participants and other researchers.Trial registrationClinicalTrials.gov, NCT04032769. Registered on 24 July 2019.

Assessment of Clinical and Investigations Probabilities for Pulmonary Embolism

Background: pulmonary embolism (PE) is one of the most frequent diseases that could be missed in overcrowded emergency departments. Early and accurate diagnosis could decrease the mortality rate and this standard algorithm should be defined. Aim: The aim of this study was to evaluate the role of estimating clinical probability of pulmonary embolism and to reveal which a combination of presented clinical data that is more predictable to PE. Patients and Methods: The study included 50 patients with suspected pulmonary embolism, admitted to El Hussein and Sayed Galal University hospitals. Results: according clinical probability of patients 90% of patients from 50 cases were approved positive by CT pulmonary angio. In the current study we found that sensitivity accuracy of clinical probability in diagnosing pulmonary embolism in comparison to CT pulmonary angio was 90%. Conclusion: clinical probability of pulmonary embolism was efficient like other diagnostic methods, so biochemical parameters, clinical findings, and scoring systems, when used altogether, can contribute to the diagnosis of PE.

Assessment of Clinical and Investigations Probabilities for Pulmonary Embolism

Background: pulmonary embolism (PE) is one of the most frequent diseases that could be missed in overcrowded emergency departments. Early and accurate diagnosis could decrease the mortality rate and this standard algorithm should be defined. Aim: The aim of this study was to evaluate the role of estimating clinical probability of pulmonary embolism and to reveal which a combination of presented clinical data that is more predictable to PE. Patients and Methods: The study included 50 patients with suspected pulmonary embolism, admitted to El Hussein and Sayed Galal University hospitals. Results: according clinical probability of patients 90% of patients from 50 cases were approved positive by CT pulmonary angio. In the current study we found that sensitivity accuracy of clinical probability in diagnosing pulmonary embolism in comparison to CT pulmonary angio was 90%. Conclusion: clinical probability of pulmonary embolism was efficient like other diagnostic methods, so biochemical parameters, clinical findings, and scoring systems, when used altogether, can contribute to the diagnosis of PE.

D-dimer: A role in ruling out pulmonary embolism in an emergency care department

Background/Aim: Pulmonary embolism (PE) is a diagnostic challenge, particularly in prehospital care. The aim of this study was to determine to what extent the evaluation of D-dimer value helps physicians with differentiation of PE and whether D-dimer values are in correlation with the values of revised Geneva score. Methods: Data have been collected for the patients whose D-dimer has been evaluated at the Emergency Care Department of the City of Banja Luka in 2018. Gender, age, symptoms, working diagnosis and D-dimer value have all been recorded and also the fact whether the patient was referred to hospital treatment or not. For each patient the revised Geneva score was determined. Results: Sixty-eight tests were done in 2018. Out of 68 tests, 41 were negative (60.3 %). D-dimer results helped in making decisions about referring patients to the hospital or not (ch2 = 36.32, p < 0.001). Patients with elevated D-dimer levels, especially where the values were four times higher than the reference ones typically were referred to hospital treatment, whereas 67.5% patients with negative D-dimer results were sent home after giving a treatment and advice. In the elderly patients D-dimer was statistically more positive (F = 10.82, p < 0.001). Values of D-dimer were not significantly different regarding gender (ch2 = 2.19, p = 0.33). According to the results of the revised Geneva score, 5.1 % of patients had high risk of PTE, while moderate and low risk had 47.5 % each. Although it has been found that the values of D-dimer were slightly more elevated at higher values of the revised Geneva score and that the difference was not statistically significant (ch2 = 7.71, p = 0.10). Conclusion: Values of D-dimer considerably helped in differentiation of PE in the Emergency Care Department. D-dimer has a high negative predictive value and should be used to exclude PE diagnosis for patients with low clinical probability of PE.

A comparative analysis of the diagnostic performances of four clinical probability models for acute pulmonary embolism in a sub-Saharan African population: a cross-sectional study

BackgroundThe diagnosis of acute pulmonary embolism (PE) is one of the most challenging in emergency settings where prompt and accurate decisions need to be taken for life-saving purposes. Here, the assessment of the clinical probability of PE is a paramount step in its diagnosis. Although clinical probability models (CPM) for PE are routinely used in emergency departments (EDs) of low-resource settings, few studies have cited their diagnostic performances in sub-Saharan Africa (SSA). We aimed to comparatively assess the accuracy of four CPM in the diagnosis of acute PE in sub-Saharan Africans.MethodsWe carried out a cross-sectional study to compare the sensitivity, specificity, positive and negative predictive values and accuracy of four CPM namely; the Wells, simplified Wells, revised Geneva and the simplified revised Geneva (SRG) Scores to computed tomography pulmonary angiography (CTPA) in all adults patients with suspected PE admitted to the EDs of the Gynaeco-obstetric and Paediatric Hospital of Yaoundé and the Yaoundé Central Hospital in Cameroon between January 1, 2017 and April 30, 2018.ResultsIn total, we enrolled 30 patients with clinical suspicion of acute PE. PE was confirmed on CTPA in 16 (53.3%) cases. Their mean age was 53.7 ± 15.5 years and 36.7% were males. All four scores had a diagnostic performance superior to 50% in all criteria assessed. The simplified Wells score had the highest sensitivity (62.5%) followed by the Wells score (56.3%). The SRG score had the highest specificity (71.4%). The score with highest PPV was the SRG score (66.7%) and that with the highest NPV was the Wells score (56.3%). Overall the models with the highest accuracies were the Wells and SRG scores (60% for each).ConclusionAll CPM had a suboptimal diagnostic performance, perhaps highlighting the need of a more optimal CPM for acute PE in SSA. However, the Wells and the SRG scores appeared to be most accurate than the other two scores in the ED. Hence, both or either of them may be used in first intention to predict PE and guide which ED patients should undergo further investigations in an emergency SSA setting.

Application of D-Dimer in Prognosis of Pulmonary Embolism

Abstract Introduction Pulmonary embolism (PE) is a relatively common cardiovascular emergency. It can lead to a variety of outcomes, from potentially reversible right ventricular failure (by occluding the pulmonary arterial bed) to eventual death. The diagnosis of PE is often missed due to its nonspecific clinical presentation. Materials and Methods This is a descriptive cross-sectional study conducted at tertiary care center in India from October 1, 2016 to September 30, 2018, which includes 36 cases of PE. Institutional ethics committee clearance was obtained before start of the study. Written and informed consent was obtained from all patients. Patients were informed regarding purpose, procedures, risks, and benefits of the study in their own vernacular language. Results The age-wise distribution of patients in this study showed that most patients were up to 40 years amounting to 58.4% of cases. Sex-wise distribution also showed that most patients were male (66.7%). Fifty percent of the patients had no thrombosis on Color Doppler findings of the involved limb, and 31.25% had superficial venous thrombosis. Blood investigation revealed that 94.4% patients had troponin negative and 94.4% had D-dimer positive. This study also attempted to correlate the D-dimer findings and Well's score. It can be seen that as per Well's score, 13 patients were with high probability, 18 with moderate probability, and 5 with low probability. Conclusion This study states that D-dimer assays are highly sensitive and have a low rate of false-negative results. The assays have been found safe and effective when the clinical probability of PE is low. When the D-dimer result is negative in patients with low clinical probability of having PE, the presence of acute PE can be safely ruled out without diagnostic imaging.

Safety of the Combination of PERC and YEARS Rules in Patients With Low Clinical Probability of Pulmonary Embolism: A Retrospective Analysis of Two Large European Cohorts.

This study aimed to determine the failure rate of a combination of the PERC and the YEARS rules for the diagnosis of pulmonary embolism (PE) in the emergency department (ED). We performed a retrospective analysis of two European cohorts of emergency patients with low gestalt clinical probability of PE (PROPER and PERCEPIC). All patients we included were managed using a conventional strategy (D-dimer test, followed, if positive, by computed tomographic pulmonary angiogram (CTPA). We tested a diagnostic strategy that combined PERC and YEARS to rule out PE. The primary endpoint was a thromboembolic event diagnosed in the ED or at 3-months follow-up. Secondary endpoints included a thromboembolic event at baseline in the ED and a CTPA in the ED. Ninety-five percent confidence intervals (CIs) of proportions were calculated with the use of Wilson's continuity correction. We analyzed 1,951 patients (mean±SD age= 47±18years, 56% women) with an overall proportion of patients with PE of 3.5%. Both PERC and YEARS strategies were associated with 11 missed PE in the ED: failure rate 0.57 (95% CI= 0.32-1.02). At 3-month follow-up, the overall failure rate was 0.83% (95% CI= 0.51-1.35). Among the 503 patients who underwent a CTPA (26%), the use of the PERC-YEARS combination would have ruled out PE without CTPA in 249 patients (50% [95%CI= 45%-54%], absolute reduction13% (95% CI= 11%-14%]). The combination of PERC then YEARS was associated with a low risk of PE diagnostic failure and would have resulted in a relative reduction of almost half of CTPA.