D-dimer Cut-off Level Research Articles

Diagnostic management of acute pulmonary embolism

Straightforward, accurate diagnostic management in patients presenting with clinically suspected pulmonary embolism (PE) is essential, since starting anticoagulant treatment may give important adverse effects of bleeding, while false exclusion of the disease may lead to recurrent VTE, with associated morbidity and mortality. In the past three decades, considerable improvement in the diagnostic management of PE has been made. Computed tomography pulmonary angiography (CTPA) has largely replaced conventional pulmonary angiography and ventilation-perfusion lung scanning as the imaging methods of choice. Several diagnostic algorithms, all able to minimize the need for radiological imaging have been developed and validated. Lastly, within the diagnostic algorithms, varying d-dimer cut-off levels have successfully been introduced to further downsize the need for radiological imaging.

Optimizing resource allocation: Cost-effectiveness of specified D-dimer cut-offs in cancer patients with suspected venous thromboembolism

An accurate diagnosis of venous thromboembolism (VTE) is crucial, given the potential for high mortality in undetected cases. Strategic D-dimer testing may aid in identifying low-risk patients, preventing overdiagnosis and reducing imaging costs. We conducted a retrospective, comparative analysis to assess the potential cost savings that could be achieved by adopting different approaches to determine the most effective D-dimer cut-off value in cancer patients with suspected VTE, compared to the commonly used rule-out cut-off level of 0.5 mg/L. The study included 526 patients (median age 65, IQR 55–75) with a confirmed cancer diagnosis who underwent D-dimer testing. Among these patients, the VTE prevalence was 29% (n = 152). Each diagnostic strategy's sensitivity, specificity, negative likelihood ratio (NLR), as well as positive likelihood ratio (PLR), and the proportion of patients exhibiting a negative D-dimer test result, were calculated. The diagnostic strategy that demonstrated the best balance between specificity, sensitivity, NLR, and PLR, utilized an inverse age-specific cut-off level for D-dimer [0.5 + (66-age) × 0.01 mg/L]. This method yielded a PLR of 2.9 at a very low NLR for the exclusion of VTE. We observed a significant cost reduction of 4.6% and 1.0% for PE and DVT, respectively. The utilization of an age-adjusted cut-off [patient’s age × 0.01 mg/L] resulted in the highest cost savings, reaching 8.1% for PE and 3.4% for DVT. Using specified D-dimer cut-offs in the diagnosis of VTE could improve economics, considering the limited occurrence of confirmed cases among patients with suspected VTE.Graphical In the context of accurate diagnosis of VTE, strategic D-dimer testing helps identify low-risk patients, preventing overdiagnosis and reducing imaging costs. In our retrospective study, the diagnostic strategy that demonstrated the best balance between specificity, sensitivity, and best PLR, utilized an inverse age-specific cut-off level for D-dimer. We observed a significant cost reduction of 4.6% for PE and 1% for DVT. Abbreviations: CTPA, computed tomography pulmonary angiography; CUS, compression ultrasound; DVT, deep vein thrombosis; PE, pulmonary embolism; VTE, venous thromboembolism.

Diagnostic Strategies in Pulmonary Embolism

AbstractKey to the diagnosis of pulmonary embolism (PE) is a careful bedside evaluation. After this, there are three further diagnostic steps. In all patients, estimation of the clinical probability of PE is performed. The other two steps are measurement of D-dimer when indicated and chest imaging when indicated. The clinical probability of PE is estimated at low, moderate, or high. The prevalence of PE is less than 15% among patients with low clinical probability, 15 to 40% with moderate clinical probability, and >40% in patients with high clinical probability. Clinical gestalt has been found to be very useful in estimating probability of PE. However, clinical prediction rules, such as Wells criteria, the modified Geneva score, and the PE rule out criteria have been advocated as adjuncts. In patients with high clinical probability, the high prevalence of PE can lower the D-dimer negative predictive value, which could increase the risk of diagnostic failure. Consequently, patients with high probability for PE need to proceed directly to chest imaging, without prior measurement of D-dimer level. Key studies in determining which low to moderate probability patients require chest imaging are the Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism (ADJUST-PE), the Simplified diagnostic management of suspected pulmonary embolism (YEARS), and the Pulmonary Embolism Graduated D-Dimer trials. In patients with low clinical probability, PE can be excluded without imaging studies if D-dimer is less than 1,000 ng/mL. In patients in whom there is not a low likelihood for PE, this can be excluded without imaging studies if the D-dimer is below the age-adjusted threshold.

Deep vein thrombosis and pulmonary embolism: a prospective, observational study to evaluate diagnostic performance of the Tina-quant D-Dimer Gen.2 assay.

D-Dimer testing is a diagnostic tool for exclusion of deep vein thrombosis (DVT) and pulmonary embolism (PE). This study evaluated the diagnostic performance of the Tina-quant® D-Dimer Gen.2 assay (Roche Diagnostics International Ltd, Rotkreuz, Switzerland) in patients with low/intermediate pre-test probability of DVT/PE using standard, age-, and clinical probability-adjusted cut-offs. In this prospective, observational, multicenter study (July 2017-August 2019), plasma samples were collected from hospital emergency departments and specialist referral centers. DVT/PE was diagnosed under hospital standard procedures and imaging protocols. A standard D-dimer cut-off of 0.5 µg fibrinogen equivalent units (FEU)/ml was combined with the three-level Wells score; cut-offs adjusted for age (age × 0.01 µg FEU/ml for patients >50 years) and clinical probability (1 µg FEU/ml for low probability) were also evaluated. An assay comparison was conducted in a subset of samples using the Tina-quant D-Dimer Gen.2 assay and the previously established routine laboratory assay, STA-Liatest D-Di Plus assay (Stago Deutschland GmbH, Düsseldorf, Germany). 2,897 patients were enrolled; 2,516 completed the study (DVT cohort: 1,741 PE cohort: 775). Clinical assessment plus D-dimer testing using the standard cut-off resulted in 317 (DVT) and 230 (PE) false positives, and zero (DVT) and one (PE) false negatives. Negative predictive value (NPV) was 100.0% (95% confidence interval [CI]: 99.7%-100.0%) and 99.8% (95% CI: 98.8%-100.0%) for DVT and PE, respectively. After age-adjustment, NPV was 99.9% (95% CI: 99.6%-100.0%) and 99.1% (95% CI: 97.8-99.7) for DVT and PE, respectively. False positive rates decreased (>50%) in clinical probability-adjusted analyses vs. primary analysis. In the assay comparison, the performances of the two assays were comparable. The Tina-quant D-Dimer Gen.2 assay and standard D-dimer cut-off level combined with the three-level Wells score accurately identified patients with a very low probability of DVT/PE.

Prognostic Value of D-Dimer in Younger Patients with Pulmonary Embolism

Abstract In patients with pulmonary embolism (PE), the D-dimer assay is commonly utilized as part of the diagnostic workup, but data on D-dimer for early risk stratification and short-term mortality prediction are limited. The purpose of this study was to determine D-dimer levels as a predictive biomarker of PE outcomes in younger (<50 years of age) compared to older patients. We conducted retrospective analysis for 930 patients diagnosed with PE between 2015 and 2019 as part of the Serbian University Multicenter Pulmonary Embolism Registry (SUPER).All patients had D-dimer levels measured within 24 hours of hospital admission. The primary outcome was mortality at 30 days or during hospitalization. Patients were categorized into two groups based on age (≤ 50 and >50 years of age). Younger patients constituted 20.5% of the study cohort. Regarding all-cause mortality, 5.2% (10/191)of patients died in group under the 50 years of age; the short-term all-causemortality was 12.4% (92/739) in older group.We have found that there was significant difference in plasma D-dimer level between patients ≤ 50 years of age and older group (>50), p= 0.006.D-dimer plasma level had good predictive value for the primary outcome in younger patients (c-statistics 0.710; 95% CI, 0.640-0.773; p<0.031). The optimal cutoff level for D-dimer to predict PE-cause death in patients aged > 50 years was found to be 8.8 mg/l FEU(c-statistics 0,580; 95% CI 0.544-0.616; p=0.049). In younger PE patients, D-dimer levels have good prognostic performance for 30-day all-cause mortalityand concentrations above 6.3 mg/l FEU are associated with increased risk of death. D-dimer in patients aged over 50 years does not have predictive ability for all-caused short-term mortality. The relationship between D-dimer and age in patients with PE may need further evaluation.

A study of modified Wells score for pulmonary embolism and age-adjusted D-dimer values in patients at risk for deep venous thrombosis.

Pulmonary embolism (PE) is the most severe complication of deep venous thrombosis (DVT). This study was designed to evaluate the usefulness of modified Wells score combined with age-adjusted D-dimer cut-off levels as a clinical pre-test probability assessment for predicting PE in patients 'at risk for DVT.' This was a cross-sectional study including 200 in-patients at risk for DVT. Patients were categorized as 'pulmonary embolism unlikely' or 'pulmonary embolism likely' using modified Wells score and underwent D-dimer testing. PE was considered excluded in patients classified as unlikely with normal D-dimer levels, whereas the rest of the patients underwent computed tomography pulmonary angiogram (CTPA). Out of 200 patients, 163 patients (81.50%) were 'pulmonary embolism unlikely,' whereas 37 patients (18.50%) were 'pulmonary embolism likely.' Of 163 patients categorized as 'pulmonary embolism unlikely,' 67 patients (41.5%) had normal D-dimer values and were excluded from CTPA. PE was detected in 24.2% of the patients who underwent CTPA. The combined strategy using modified Wells score and age-adjusted D-dimer cut-off value has 100% sensitivity and a negative predictive value and can be used to safely exclude PE in in-patients.

Utility and limitations of patient-adjusted D-dimer cut-off levels for diagnosis of venous thromboembolism-A systematic review and meta-analysis.

To systematically assess test performance of patient-adapted D-dimer cut-offs for the diagnosis of venous thromboembolism (VTE). Systematic review and analysis of articles published in PubMed, Embase, ClinicalTrials.gov, and Cochrane Library databases. Investigations assessing patient-adjusted D-dimer thresholds for the exclusion of VTE were included. A hierarchical summary receiver operating characteristic model was used to assess diagnostic accuracy. Risk of bias was assessed by Quality Assessment of Diagnostic Accuracy Studies 2 score. A total of 68 studies involving 141,880 patients met the inclusion criteria. The standard cut-off revealed a sensitivity of 0.99 (95% confidence interval [CI] 0.98-0.99) and specificity of 0.23 (95% CI 0.16-0.31). Sensitivity was comparable to the standard cut-off for age-adjustment (0.97 [95% CI 0.96-0.98]) and YEARS algorithm (0.98 [95% CI 0.91-1.00]) but lower for pretest probability (PTP)-adjusted (0.95 [95% CI 0.89-0.98) and COVID-19-adapted thresholds (0.93 [95% CI 0.82-0.98]). Specificity was significantly higher across all adjustment strategies (age: 0.43 [95% CI 0.36-0.50]; PTP: 0.63 [95% CI 0.51-0.73]; YEARS algorithm: 0.65 [95% CI 0.39-0.84]; and COVID-19: 0.51 [95% CI 0.40-0.63]). The YEARS algorithm provided the best negative likelihood ratio (0.03 [95% CI 0.01-0.15]), followed by age-adjusted (both 0.07 [95% CI 0.05-0.09]), PTP (0.08 [95% CI 0.04-0.17), and COVID-19-adjusted thresholds (0.13 [95% CI 0.05-0.32]). This study indicates that adjustment of D-dimer thresholds to patient-specific factors is safe and embodies considerable potential for reduction of imaging. However, robustness, safety, and efficiency vary considerably among different adjustment strategies with a high degree of heterogeneity.

261 Racial and Ethnic Disparities in the Use of Computed Tomography With Angiography (CTA) for the Diagnosis of Pulmonary Embolism (PE)

Current guidelines or the utilization of CTA in the diagnosis of PE, mostly relying on Wells’ Score for Pulmonary Embolism and D-dimer cut-off levels, have not been examined in different racial and ethnic groups. Barriers to such research have historically included difficulty in capturing a full and objective set of data that includes: CTA ordering, Wells’ scores, and PE data across diverse cohorts.

Adjusted D-dimer cutoff levels to rule out pulmonary embolism in patients hospitalized for COPD exacerbation: results from the SLICE trial

BackgroundFor patients with suspected pulmonary embolism (PE), age- or clinically-adjusted D-dimer threshold level can be used to define a negative test that safely excludes PE and reduces the use of imaging. However, the utility of this approach in patients hospitalized for chronic obstructive pulmonary disease (COPD) exacerbation is undefined.MethodsWe ran an analysis of the patients hospitalized for COPD exacerbation and randomized to the intervention in the SLICE trial. Using the conventional strategy as the reference, we compared the proportion of patients with a negative D-dimer result, and the negative predictive value and sensitivity of three D-dimer threshold strategies for initial PE or subsequent diagnosis of venous thromboembolism (VTE): the age-adjusted strategy, the Wells-adjusted strategy, and the YEARS-adjusted strategy.ResultsWe included 368 patients. Using a conventional threshold, 182 (49.5%) patients had negative D-dimer values, of whom 1 (0.6%) had PE (sensitivity, 94.1%). The use of an age-adjusted threshold increased the number of patients in whom PE could be excluded from 182 to 233 patients (63.3%), and the proportion of false-negative findings increased from 0.5% to 1.7% (sensitivity, 76.5%). With the use of the Wells or YEARS strategies, 64.4% and 71.5% had negative values, and the proportion of false-negative findings was 2.5% (sensitivity, 64.7%) and 2.7% (sensitivity, 58.8%), respectively.ConclusionsIn patients hospitalized for COPD exacerbation, compared with the conventional strategy, age- or clinically-adjusted strategies of D-dimer interpretation were associated with a larger proportion of patients in whom PE was ruled out with a higher failure rate.Trial RegistrationClinicalTrials.gov number: NCT02238639.

Pulmonary Embolism Detection in COVID-19 Patients

Background: A clinically important impact of Coronavirus Disease 2019 (COVID-19) is the increased likelihood of thromboembolism, mainly pulmonary embolism (PE). To screen for these complications a biochemical marker, D-dimer, is usually done. There is a plethora of research validating the use of D-dimer cutoff levels in non-COVID-19 patients, however less so in the COVID-19 population. Aim: To determine the number of suspected COVID patients with D-dimer ≥ 0.5 and PE reported on CTPA. Methods: Non-interventional single-centre retrospective clinical correlational study. Patient cohort was patients admitted with suspected COVID-19 over a 5-week period. N=690. Results: 76.5% of suspected COVID-19 patients were PCR positive. 40% of these patients had a CTPA completed with 19% reported to have a PE. 52% of patients had a D-dimer value ≥ 0.5 10.6% patients had a PE with a D-dimer ≥ 0.5. Conclusion: Nationally, hospitals are adopting existing D-dimer cut off levels to rule out PEs, however this leads to a large proportion of admitted COVID-19 patients having possibly unnecessary computed tomography pulmonary angiogram. This study highlights that majority of patients with D-dimers above the cut off level have negative PEs and contributes to the notion that standard D-dimer cutoffs are insufficiently accurate to be used as a standalone test in diagnosis in the context of an underlying SARS-CoV-2 infection.

Pulmonary embolism in patients with COVID-19 and value of D-dimer assessment: a meta-analysis.

PurposeTo investigate, in a meta-analysis, the frequency of pulmonary embolism (PE) in patients with COVID-19 and whether D-dimer assessment may be useful to select patients for computed tomography pulmonary angiography (CTPA).MethodsA systematic literature search was performed for original studies which reported the frequency of PE on CTPA in patients with COVID-19. The frequency of PE, the location of PE, and the standardized mean difference (SMD) of D-dimer levels between patients with and without PE were pooled by random effects models.ResultsSeventy-one studies were included. Pooled frequencies of PE in patients with COVID-19 at the emergency department (ED), general wards, and intensive care unit (ICU) were 17.9% (95% CI: 12.0–23.8%), 23.9% (95% CI: 15.2–32.7%), and 48.6% (95% CI: 41.0–56.1%), respectively. PE was more commonly located in peripheral than in main pulmonary arteries (pooled frequency of 65.3% [95% CI: 60.0–70.1%] vs. 32.9% [95% CI: 26.7–39.0%]; OR = 3.540 [95% CI: 2.308–5.431%]). Patients with PE had significantly higher D-dimer levels (pooled SMD of 1.096 [95% CI, 0.844–1.349]). D-dimer cutoff levels which have been used to identify patients with PE varied between 1000 and 4800 μg/L.ConclusionThe frequency of PE in patients with COVID-19 is highest in the ICU, followed by general wards and the ED. PE in COVID-19 is more commonly located in peripheral than in central pulmonary arteries, which suggests local thrombosis to play a major role. D-dimer assessment may help to select patients with COVID-19 for CTPA, using D-dimer cutoff levels of at least 1000 μg/L.Key Points• The frequency of PE in patients with COVID-19 is highest in the ICU, followed by general wards and the ED.• PE in COVID-19 is more commonly located in peripheral than in central pulmonary arteries.• D-dimer levels are significantly higher in patients with COVID-19 who have PE.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00330-021-08003-8.

Age‐adjusted D‐dimer cut‐off levels to rule out venous thromboembolism in patients with non‐high pre‐test probability: Clinical performance and cost‐effectiveness analysis

As aging was found to be associated with increased D-dimer levels, the question arose whether D-dimer measurement was useful in the diagnostic strategy of venous thromboembolism (VTE) in elderly patients. To compare retrospectively the performance of six diagnostic strategies based on the three-level Wells scores and various cut-off levels for D-dimer, evaluated using the HemosIL D-Dimer HS 500 assay, in a derivation cohort of 644 outpatients with non-high pretest probability (PTP) of VTE. The clinical usefulness of the best-performing strategy was then confirmed in a multicenter validation study involving 1255 consecutive outpatients with non-high PTP. The diagnostic strategy based on the age-adjusted cut-off level calculated by multiplying the patient's age by 10 above 50years was found to perform the best in the derivation study with a better sensitivity-to-specificity ratio than the conventional strategy based on the fixed cut-off level (500ng/ml), a higher specificity and a negative predictive value (NPV) above 99%. Such an increase in test specificity was confirmed in the validation cohort, with the NPV remaining above 99%. Taking into account the local reimbursement rates of diagnostic tests, using this strategy led to a 6.9% reduction of diagnostic costs for pulmonary embolism and a 5.1% reduction for deep vein thrombosis, as imaging tests would be avoided in a higher percentage of patients. The diagnostic strategy of VTE based on the age-adjusted cut-off level for D-dimer in patients over 50years was found to be safe, with NPV above 99%, and cost-effective.

Elevation of the D-dimer cut-off level might be applicable to rule out pulmonary embolism for active cancer patients in the emergency department.

Recent guidelines for diagnosing acute pulmonary embolism (PE) are based on clinical decision rules and D-dimer. D-dimer measurement is recommended only for patients who are 'PE-unlikely'. We aimed to assess the current guidelines for cancer patients and to determine an optimal D-dimer cut-off level. This retrospective observational study was conducted in the emergency department of Asan Medical Center (Seoul, Korea) between 02/2017 and 09/2017 for the development cohort and between 06/2018 and 02/2019 for the validation cohort. Among adult active cancer patients with suspected PE, we included those who were 'PE-unlikely' according to Wells' criteria and who underwent D-dimer testing and computed tomographic pulmonary angiography (CTPA). A total of 498 patients (227 in the development cohort and 271 in the validation cohort) were included, and PE was diagnosed in 8.8% and 18.5% of patients, respectively. The optimal D-dimer cut-off level was 2.0μg/mL. This elevated cut-off level showed a much higher specificity of 21.3% (95% confidence interval [CI] 16.2-27.3%) and 21.7% (95% CI 16.8-7.6%) in the development and validation sets, respectively, compared with the specificity of 4.4% (95% CI 2.3-8.1%) and 4.1% (95% CI 2.2-7.6%) using the age-adjusted cut-off. The new D-dimer cut-off value identified unnecessary CTPA for 21.3% of patients (absolute difference, 16.9%, 35 of 207) in the development cohort and 21.7% (absolute difference, 17.6%, 39 of 221) of patients in the validation cohort compared to using the standard age-adjusted cut-off. The elevated D-dimer cut-off value combined with Wells' criteria might reduce unnecessary CTPA in active cancer patients with a 'PE-unlikely' classification. Further clinical trials are warranted to improve the PE diagnostic strategy in cancer patients.

The impact of using different age-adjusted cutoffs of D-dimer in the diagnosis of pulmonary thromboembolism.

Background This study was conducted to evaluate the relationship of age-adjusted D-dimer value with different coefficients in diagnosis of pulmonary embolism (PE) in geriatric patients. Methods The emergency admissions of the patients aged 65 and over with suspected PE during 2018 were reviewed retrospectively. The demographic characteristics, laboratory tests and radiologic findings of computed tomography pulmonary angiogram (CTPA) or single photon emission computed tomography ventilation/perfusion scintigraphy (V/Q) were recorded. The characteristics of the patients with PE were statistically compared with the patients without PE. The specificity and sensitivity for higher cut-off levels (age × 10-15) were presented. Results PE was detected in 39.2% (n=246) of 628 patients aged 65years and older included in the study. The multivariate analysis revealed that higher D-dimer level (OR=1,00011; p<0.001) and BUN level (OR=1.025; p = 0.013) were independent risk factors for PE diagnosis in elderly patients. Diagnostic statistics for D-dimer cut-off levels selected from ROC analysis and calculated values as 10-15 times of age showed that if the D-dimer cut-off value used is chosen higher, lower sensitivity rates are obtained. Our results also indicated that the patients with malignancy, renal failure, central PE on CTPA and PE with high probability on SPECT VQ were presented with higher D-dimer values. Conclusion Our results do not support the use of higher D-dimer cut-off levels such as 15 times the age in geriatric population. The impact of the location of PE and comorbidities on the outcomes of these patients must be clarified for determining cut-offs with higher specificity.

A Retrospective Analysis of Thromboembolic Phenomena in Mechanically Ventilated Patients with COVID-19.

Background Recent studies have shown an increased prevalence of thromboembolic disease in critically ill patients with the novel SARS-CoV-2 disease (COVID-19). However, the use of enhanced anticoagulation therapy in these patients remains controversial. Objectives To determine the incidence of thromboembolic phenomena (TEP) and hemorrhagic events (HEs) in intensive care unit (ICU) COVID-19 patients. Methods One hundred and sixty ICU patients with COVID-19 were enrolled. Clinical examination results, laboratory data, and imaging studies (computed tomography/Doppler ultrasound scans) for these patients were retrospectively collected and analyzed. Outcome measures including days on mechanical ventilation, ICU length of stay, and day-28 mortality were recorded. Results Sixty patients (37.5%) developed TEP including thirty patients with deep vein thrombosis, 55 patients with pulmonary embolism, and 7 patients with arterial thromboembolism. Cardiac arrhythmias, lymphocytopenia, and increased D-dimers were more frequently observed in the TEP group compared to the non-TEP group of patients (all p < 0.05). The sensitivity, specificity, and positive and negative predictive values of a cutoff D-dimer level of 3.0 μg/mL for predicting PE were 74.5%, 95.1%, 86.8%, and 91.9%, respectively. Thirteen patients experienced HEs, which were more frequently observed in the TEP group (p < 0.05). Twenty-eight-day mortality was higher in the TEP group (60%) compared to the non-TEP group (30%) of patients (p=0.02). Conclusions The rates of TEP and HEs in mechanically ventilated critically ill COVID-19 patients were 37. 5% and 8.1%. Twenty-eight-day mortality was higher in the TEP group (60%) compared to the non-TEP group (30%) of patients.

Diagnostic and Prognostic Relevance of Serum Irisin Level in Patients with Pulmonary Embolism.

We aimed to determine the diagnostic and prognostic value of serum irisin level in patients with acute pulmonary embolism (PE) admitted to the emergency department. Ninety patients who underwent computed tomography pulmonary angiography (CTPA) due to suspected PE were included in the study. Demographic data, PE risk factors, and associated diseases, vital signs, Wells score, Revised Geneva score, pulmonary embolism severity index (PESI), and simplified PESI (sPESI) were recorded. Irisin levels were measured by enzyme linked-immunosorbent assay. Serum irisin level in patients with confirmed PE (n = 45) was significantly lower than that in patients (n = 45) without PE (p = 0.001). On receiver operating characteristic curve analysis, use of optimal irisin cutoff level of 8.6 µg/mL for diagnosis of PE was associated with 82.2% sensitivity, 60% specificity, 67.3% positive predictive value (PPV), and 77.1% negative predictive value (NPV) [area under the curve (AUC): 0.744, 95% confidence in-terval (CI): 0.641 - 0.830, p < 0.001)]. Use of optimal D-dimer cutoff level of 1,720 µg/L was associated with 86.7% sensitivity, 62.2% specificity, 69.6% PPV, and 82.4% NPV (AUC: 0.801, 95% CI: 0.704 - 0.878, p < 0.001). Irisin level showed no significant correlation with Wells score or revised Geneva score; however, irisin level showed a significant negative correlation with PESI and sPESI. Patients with acute PE showed significantly lower serum levels of irisin. The sensitivity, specificity, NPV, and PPV of irisin level for diagnosis of PE were lower than those of D-dimer.

Significance of preoperative screening of deep vein thrombosis and its indications for patients undergoing urological surgery.

PurposePreoperative deep vein thrombosis (pre-DVT) is a risk of symptomatic venous thromboembolism (VTE) and a serious postoperative surgical complication. However, little is known about pre-DVT in patients undergoing surgery. This study aimed to investigate the incidence and screening criteria of pre-DVT in patients undergoing urological surgery.Materials and MethodsBetween 2015 and 2017, 320 patients admitted to our hospital for urological surgery were included in this retrospective study. All patients underwent preoperative D-dimer testing. Patients with elevated D-dimer (≥1.0 µg/mL) levels underwent lower-limb compression ultrasonography (CUS). Clinical parameters were analyzed as predictors of pre-DVT, and modest cutoff value of D-dimer to predict pre-DVT were evaluated.ResultsOf 320 patients, preoperative elevated D-dimer levels and DVT were found in 81 (25.3%) and 20 (6.3%) patients, respectively. The positive predictive value (PPV) was 24.7% (20/81). ROC curve analysis revealed a cutoff D-dimer level of 1.8 µg/mL, yielding a PPV of 40.7% for pre-DVT among patients with elevated D-dimer levels. Preoperative DVT was detected in 16 (7.6%, n=210) patients with malignancy, 3 (5.7%, n=53) with adrenal tumors, and in 1 (1.8%, n=57) kidney donor. An age of >70 years was significantly associated with risk for pre-DVT (odds ratio, 2.81; 95% confidence interval, 1.12–7.19; p=0.0270). During a postoperative follow-up period of 90 days, no patient developed symptomatic VTE.ConclusionsThe incidence of pre-DVT was 6.3% in patients undergoing urological surgery. Elderly patients and/or a cutoff D-dimer level of 1.8 µg/mL might be good indications for pre-DVT screening by CUS.

Lower-Extremity Venous Ultrasound in DVT-Unlikely Patients with Positive D-Dimer Test

To review the clinical data, D-dimer level and the ultrasonographic findings from complete venous ultrasound of the lower extremity in deep venous thrombosis (DVT)-unlikely patients with abnormal D-dimer test were compared to DVT-likely patients to ascertain the appropriate ultrasound examination protocol for patients in this group. A retrospective cohort study was conducted of all patients who underwent a complete (whole leg) venous ultrasound in one 13-month period. The medical history, demographic, clinical risk factors, and ultrasonographic findings of the patients with high clinical probability for deep vein thrombosis (Wells score ≥2), along with patients with a low clinical probability of deep vein thrombosis (Wells score ≤1) but with a D-dimer level higher than the threshold (≥500 ng/ml FEU) were evaluated. There were 96 patients in the DVT-likely group and 86 patients in the DVT-unlikely group. The indication for ultrasound examination in the DVT-unlikely group was preoperative assessment to avoid the risk of pulmonary thromboembolism. The patients in the DVT-likely group had more positive ultrasound results for DVT (15.63% vs. 5.18%, p value = 0.03) than the patients in the DVT-unlikely group. In the DVT-unlikely group, the median D-dimer level in the patients with positive ultrasound for DVT showed statistically significantly higher levels than the patients with negative ultrasound for DVT did (2208 vs. 921 ng/ml FEU, p value = 0.02). The optimal D-dimer cut-off from the receiver operating characteristics analysis shows the maximized summation of sensitivity and specificity (80% and 66.67%) at 1251 ng/ml FEU. The prevalence of acute thrombus in a thigh vein in DVT-unlikely, preoperative patients is low (1.2%). To minimize the number of unnecessary complete venous ultrasound lower-extremity examinations, the use of a higher D-dimer cut-off level and limiting proximal or thigh vein ultrasound examinations in the preoperative patient is considered.

D-dimer as a biomarker for disease severity and mortality in COVID-19 patients: a case control study

BackgroundOver 5,488,000 cases of coronavirus disease-19 (COVID-19) have been reported since December 2019. We aim to explore risk factors associated with mortality in COVID-19 patients and assess the use of D-dimer as a biomarker for disease severity and clinical outcome.MethodsWe retrospectively analyzed the clinical, laboratory, and radiological characteristics of 248 consecutive cases of COVID-19 in Renmin Hospital of Wuhan University, Wuhan, China from January 28 to March 08, 2020. Univariable and multivariable logistic regression methods were used to explore risk factors associated with in-hospital mortality. Correlations of D-dimer upon admission with disease severity and in-hospital mortality were analyzed. Receiver operating characteristic curve was used to determine the optimal cutoff level for D-dimer that discriminated those survivors versus non-survivors during hospitalization.ResultsMultivariable regression that showed D-dimer > 2.0 mg/L at admission was the only variable associated with increased odds of mortality [OR 10.17 (95% CI 1.10–94.38), P = 0.041]. D-dimer elevation (≥ 0.50 mg/L) was seen in 74.6% (185/248) of the patients. Pulmonary embolism and deep vein thrombosis were ruled out in patients with high probability of thrombosis. D-dimer levels significantly increased with increasing severity of COVID-19 as determined by clinical staging (Kendall’s tau-b = 0.374, P = 0.000) and chest CT staging (Kendall’s tau-b = 0.378, P = 0.000). In-hospital mortality rate was 6.9%. Median D-dimer level in non-survivors (n = 17) was significantly higher than in survivors (n = 231) [6.21 (3.79–16.01) mg/L versus 1.02 (0.47–2.66) mg/L, P = 0.000]. D-dimer level of > 2.14 mg/L predicted in-hospital mortality with a sensitivity of 88.2% and specificity of 71.3% (AUC 0.85; 95% CI = 0.77–0.92).ConclusionsD-dimer is commonly elevated in patients with COVID-19. D-dimer levels correlate with disease severity and are a reliable prognostic marker for in-hospital mortality in patients admitted for COVID-19.

Evaluation of analytic and clinical performance of thrombin-antithrombin complex and D-dimer assay in prognosis of acute ischemic stroke.

: To evaluate analytic and clinical performance of plasma thrombin-antithrombin complex (TAT) and D-dimer assay in assessing the severity and outcome of acute ischemic stroke. The prospective study was conducted and extended from January 2018 to December 2018. A total of 236 patients admitted within 24 h after neurologic symptoms onset were recruited. The median TAT and D-dimer levels were significantly higher in the acute ischemic stroke patients than in the controls. The average TAT levels in patients with mild, moderately severe and severe stroke were 1.75 [interquartile ranges (IQR), 1.1-2.6], 3.3 (IQR, 1.8-4.5) and 13.5 (IQR, 7.2-15.3) ng/ml. The D-dimer levels of respective patient groups were 0.39 (IQR, 0.22-0.73), 0.58 (IQR, 0.39-1.25) and 3.59 (IQR, 1.73-4.74) mg/l. With the optimal cut-off TAT level (1.75 ng/ml) determined from receiver operating characteristic analysis, the Area under the curve (AUC), the sensitivity and specificity of TAT for stroke diagnosis were 0.763, 58.1 and 87.8%. The cut-off D-dimer level was 0.38 mg/l and the AUC, the sensitivity and specificity were 0.772, 60.2 and 88.9%. The Area under the receiver operating characteristic curves (AUROCs) and sensitivity in the moderate to severe stroke increased to 0.903 and 86.9% for TAT, and 0.880 and 80.3% for D-dimer, respectively. Age and high TAT level were significant independent risk factors for stroke severity. Age, high initial National Institutes of Health Stroke Scale score and high TAT level were significant independent poor prognostic factors on multivariate analysis. TAT and D-dimer were superior in separating the moderate-to-severe stroke than mild stroke. A high TAT plasma level is an independent predictor for stroke severity and poor prognosis during 1-month follow-up.