Elevated D-dimer Concentration Research Articles

Recurrent cerebrovascular accidents caused by intravascular lymphoma in a dog

An eight-year-old, neutered male labrador was presented with recent recurrent vestibular episodes. MRI was consistent with multiple lacunar ischaemic infarcts in the thalamus and medulla oblongata. The imaging diagnosis was...

Characteristics and Treatment Outcomes of Acute Type A Aortic Dissection With Elevated D-Dimer Concentration.

BackgroundClinical characteristics and treatment outcomes of acute type A aortic dissection with D‐dimer elevation have not been clarified.Methods and ResultsD‐dimer was measured preoperatively within 24 hours of symptom onset in 262 patients with acute type A aortic dissection. The median (and interquartile range) admission D‐dimer concentration in our total patient group was 26.7 (8.3–85.9) μg/mL. Median (interquartile range) D‐dimer concentrations were 5.0 (2.6–18.0) μg/mL for complete false lumen thrombosis (n=33), 60.9 (19.4–160.4) μg/mL for partial thrombosis (n=81), 26.5 (10.0–70.6) μg/mL for a patent false lumen (n=131), and 8.7 (3.2–26.9) μg/mL for ulcerlike projection (n=17) (P<0.01). With a D‐dimer concentration of ≤8.3 μg/mL representing the lower quartile, we then investigated predictors of a low D‐dimer level. Multivariate analysis showed dissection limited to the ascending aorta (P<0.01; odds ratio, 9.81) or descending aorta (P<0.01; odds ratio, 7.68), a completely thrombosed false lumen (P<0.01; odds ratio, 4.02), and absence of brain ischemia (P=0.013; odds ratio, 4.74) to be predictors of the lower D‐dimer concentration. Compared with patients with a low D‐dimer concentration (≤8.3 μg/mL, n=66), patients with a D‐dimer concentration >8.3 μg/mL (n=196) had a reduced preoperative platelet count and increased operation time and transfusion volume. In‐hospital mortality was elevated in this group (1.5% versus 11.2%; P=0.031), although 7‐year survival did not differ for hospital survivors (lower versus higher, 93.1% versus 79.1%; P=0.21).ConclusionsD‐dimer concentrations are strongly influenced by the extent of dissection and false lumen status. Operative risks are increased in patients with a relatively high D‐dimer concentration.

Association of plasma D-dimer level with thromboembolic events after endovascular coil treatment of ruptured cerebral aneurysms.

Although endovascular therapy is favored for acutely ruptured intracranial aneurysms, hematological factors associated with acute subarachnoid hemorrhage (SAH) may predispose to procedure-related ischemic complications. The aim of this study was to evaluate whether an elevated level of plasma D-dimer, a parameter of hypercoagulation in patients with acute SAH, is correlated with increased incidence of thromboembolic events during endovascular coiling of ruptured aneurysms. The authors analyzed data from 103 cases of acutely ruptured aneurysms (in 103 patients) treated with endovascular coil embolization at a single institution. Factors associated with elevated D-dimer level on admission were identified. The authors also evaluated whether D-dimer elevation was independently correlated with increased incidence of perioperative thromboembolic events. An elevated D-dimer concentration (≥ 1.0 μg/ml) on admission was observed in 70 (68.0%) of 103 patients. Increasing age (p < 0.001, Student t-test) and poor initial neurological grade representing World Federation of Neurosurgical Societies (WFNS) grade IV or V (p = 0.0018, chi-square test) were significantly associated with D-dimer elevation. Symptomatic thromboembolic events occurred in 11 cases (10.7%). Elevated D-dimer levels on admission (OR 1.34, 95% CI 1.10-1.62, p = 0.0029) independently carried a higher risk of thromboembolic events after adjustment for potential angiographic confounders, including wide neck of the aneurysm and large aneurysm size. Elevated D-dimer levels on admission of patients with acute SAH were significantly associated with increased incidence of thromboembolic events during endovascular coiling of ruptured aneurysms.

Association of D-dimer Levels with Clinical Event Rates and the Efficacy of Betrixaban versus Enoxaparin in the APEX Trial.

Background Elevated D-dimer concentrations are associated with an increased risk of venous thromboembolism (VTE). However, they may also provide prognostic value. The present analysis sought to study the association of D-dimer levels with VTE event rates and the efficacy of betrixaban versus enoxaparin in the APEX trial. Methods Hospitalized acutely medically ill subjects ( n = 7,513) were randomized in a double-dummy double-blind fashion to either extended-duration oral betrixaban (80 mg once daily for 35–42 days) or standard dose subcutaneous enoxaparin (40 mg once daily for 10 ± 4 days) for venous thromboprophylaxis. D-dimer was assessed using a central core laboratory measurement. Results For every 0.25 µg/mL increase in D-dimer concentration, there was a 2% increase in the relative risk of experiencing the primary efficacy endpoint (asymptomatic deep vein thrombosis [DVT], symptomatic DVT, nonfatal pulmonary embolism, or VTE-related death) in both the betrixaban ( p < 0.001) and enoxaparin ( p < 0.001) treatment arms. Among D-dimer-positive (≥ 2 × upper limit of normal; corresponding to ≥ 1.00 µg/mL) subjects, extended-duration betrixaban reduced the risk of experiencing the primary efficacy outcome (5.4% [ n = 124] vs. 7.6% [ n = 170]; odds ratio = 0.69; 95% confidence interval: 0.55–0.88; absolute risk reduction = 2.2%, number needed to treat = 46, p = 0.003). There was no interaction between D-dimer and the treatment effect ( p int = 0.53). Conclusion Extended-duration betrixaban was superior to standard-duration enoxaparin, irrespective of D-dimer level at baseline. To prevent one VTE event, 46 D-dimer-positive patients would need to be treated with betrixaban.

Evaluation of hemostasis parameters and the role of the oxidative damage to plasma proteins in the modulation of hemostasis in patients with nephrolithiasis before and after extracorporeal shock wave lithotripsy.

PurposeExtracorporeal shock wave lithotripsy (ESWL) is a commonly-used method in urology, which may modulate hemostasis and may induce lipid peroxidation in patients with nephrolithiasis. However, previous studies only examine changes occurring in patients 30–240 min after ESWL. The main aim of the present study was to determine whether oxidative stress may modulate the hemostatic activity of plasma in patients with nephrolithiasis before ESWL and the day after treatment ESWL. This will be performed by measuring selected parameters of hemostasis in these patients, both before ESWL and the following day, and assessing the level of oxidative damage to plasma proteins in these patients by measuring two biomarkers.MethodsTwelve patients with nephrolithiasis and 10 healthy participants were included. The following parameters of hemostasis were measured: the activated partial thromboplastin time (APTT), prothrombin time (PT), and thrombin time (TT) of plasma, the level of fibrinogen, the level of D-dimer and blood platelet count. In addition, two selected biomarkers of oxidative stress were measured: protein carbonylation level and the number of protein thiol groups.ResultsNo difference was observed between patients with nephrolithiasis before and after ESWL and healthy controls with regard to PT, TT or APTT. Fibrinogen concentration and blood platelet count were lower in the nephrolithiasis patients in the period after ESWL than before ESWL. The nephrolithiasis patients demonstrated elevated D-dimer concentration after ESWL. However, although oxidative damage was observed in the plasma proteins in the nephrolithiasis patients, this was not influenced by ESWL.ConclusionOxidative stress may induce changes of hemostasis in patients with nephrolithiasis, both before and after ESWL. In addition, changes of hemostasis parameters such as fibrinogen, blood platelet count and D-dimer level can be observed in these patients, especially after ESWL, and this may suggest that ESWL modulates hemostasis. By having a better understanding of the influence of ESWL on hemostasis, this could lead to modifying patient care for those patients at increased risk of bleeding.

A study of disseminated intravascular coagulation in acute leukemia reveals markedly elevated D-dimer levels are a sensitive indicator of acute promyelocytic leukemia.

While the presence of disseminated intravascular coagulation (DIC) has been implicated in worse clinical outcome in acute leukemia, the relationship between different subtypes of acute leukemia and the clinicopathologic features of DIC has not been systematically well studied. In this study, we retrospectively reviewed 149 cases of newly diagnosed acute leukemia and assessed the utility of evaluating red blood cell morphologic features, and coagulation parameters in determining the presence of DIC as well as differentiating subtypes of acute leukemia. Review of our cohort demonstrates a novel finding, that elevated D-dimer concentrations ≥19 000 ng/mL fibrinogen equivalent units (FEU) are a sensitive diagnostic indicator of acute promyelocytic leukemia (APL) with moderate specificity, sensitivity 96%, specificity 92% in acute leukemia subtyping. Similar to other studies, APL showed an increased incidence of DIC (P < 0.01) compared to other subtypes of acute leukemia. Surprisingly, the presence of schistocytes on the peripheral blood smear was not a statistically significant indicator of DIC, sensitivity of 36% and specificity of 89%. Finally, the presence of DIC was not a significant indicator of poorer prognosis amongst all patients with AML. Overall we identify elevated D-dimer concentrations ≥19 000 ng/mL FEU are a sensitive indicator of acute promyelocytic leukemia (APL), with a sensitivity of 96% and specificity of 92% in the subtyping of acute leukemias, and that the presence of schistocytes in peripheral blood smears is not a diagnostically sensitive screening test for DIC with a sensitivity of 36%.

Prognostic value of D-dimer in elderly patients with Pulmonary Embolism.

In a general population with acute Pulmonary Embolism (PE) elevated D-dimer concentrations associate with increased mortality. The aim of the study was to assess the ability of D-dimer to predict 30 and 90-days mortality in elderly patients with acute PE. Hemodynamically stable patients aged≥65years old with confirmed PE were included in this retrospective cohort study. A pulmonary computerized tomography angiography scan, D-dimer concentrations, simplified Pulmonary Embolism Severity Index (sPESI) variables and vital status were available for all patients. The study included 154 confirmed cases of PE (23.5% of suspected), median age 79.1years. D-dimer was higher in patients dead than in those alive at 30 (median 14,547 vs. 8340ng/mL, p=0.05) and 90days (13,604 vs. 7973ng/mL, p=0.013). When adding D-dimer to sPESI, the discriminant capacity to predict mortality within 30 and 90days was increased by 0.080 and 0.089, respectively. The contribution of D-dimer to the discriminating ability was NRI=0.286 (95% CI -0.198 to 0.770, p value: 0.247) at 30days and NRI=0.605 (95% CI 0.223-0.988, p-value: 0.002) at 90days.D-dimer concentration was associated with 30 and 90-days mortality and showed a higher discriminant capacity than sPESI alone to predict 90-days mortality. Adding D-dimer concentrations to sPESI score seems to improve its prognostic ability, supporting multivariable risk models as the best approach to estimate prognosis in elderly patients with PE.

Bilateral Macular Roth Spots as a Manifestation of Subacute Endocarditis.

A 42-year-old man presented with a 2-day history of impaired vision in the right eye (OD). The best corrected visual acuity (BCVA) (LogMAR) was 1.1 for the right eye and 0.0 for the left eye (OS). Fundus examination revealed white-centered hemorrhages resembling Roth spots in both macular regions. The spectral-domain optical coherence tomography (SD-OCT) showed intraretinal pseudocysts and hyperreflective deposits in the areas corresponding to the Roth spots. Conducted blood tests revealed elevated D-dimer concentration, increased total number of neutrophils, high C-reactive protein concentration, and elevated erythrocyte sedimentation rate. Procalcitonin concentration, platelet count, and body temperature were within normal ranges. A blood culture was ordered and yielded Streptococcus mitis and intravenous antibiotics were started immediately. The patient started complaining of chest and left calf pain. The systemic examination revealed infective endocarditis accompanied by bicuspid aortic valve and paravalvular abscess formation. The patient underwent cardiac surgery with mechanical aortic valve implantation. After recovery, the patient's visual acuities improved fully. Control ophthalmic examination, including SD-OCT, showed no abnormalities.

Incidental finding of pathological coagulation parameters

Pathological coagulation parameters may reflect life-threatening hemorrhagic or thromboembolic diseases but may also be a laboratory result without any clinical significance, result from in vitro phenomena or preanalytical errors. This article gives an overview of potential pitfalls in coagulation diagnostics, lists the differential diagnoses of pathological coagulation parameters and describes further steps in the diagnostic approach to clarify pathological results. The focus lies on coagulation parameters that are frequently determined in routine clinical investigations, e.g. platelet count, prothrombin time, activated partial thromboplastin time (aPTT) and fibrinogen. Besides heparin, fondaparinux, danaparoid, and vitamin K antagonists, direct factor Xa inhibitors and direct thrombin inhibitors are nowadays available for therapeutic anticoagulation. This article gives an overview of the influence of anticoagulants on coagulation parameters which depends on the dose, the time of the last administration, as well as the method used for the determination of coagulation parameters. Moreover, common reasons for elevation of the fibrin degradation product D-dimer are presented. The clinical utility of D-dimer assays is limited by their poor specificity. Elevated D-dimer concentrations can be found in various diseases and also under normal physiological circumstances (e.g. in the elderly). Thus, the most useful clinical application of D-dimer is evidence of normal values to essentially rule out venous thromboembolism.

Apolipoprotein polymorphism is associated with pro-thrombotic profile in non-demented dyslipidemic subjects.

Apolipoprotein gene polymorphism has an important role in lipid metabolism and in the development of cerebro- and cardio-vascular disease (CCVD), including dementia. Dyslipidemia and hemostatic abnormalities are key risk factors associated with athero-sclerotic events preceding CCVD. The aim of this study was to evaluate the possible relationships of various apolipoprotein-species with hemostatic parameters and cognitive function. Lipid profile, gene polymorphism, coagulation markers, and mini-mental state examination (MMSE) scores were assessed in 109 dys-lipidemic subjects and in 107 healthy control volunteers. Thrombin-activatable fibrinolysis inhibitor (TAFI) plasma levels were significantly higher in apolipoprotein-E2 (apoE2) patients when compared to other apoE forms. The apoA5 -1131T>C polymorphism was associated with elevated D-dimer concentration in dyslipidemic TT homozygous individuals. MMSE did not correlate with lipid or coagulation profile. These data suggest that apoE and apoA5 variants have an effect on hemostatic parameters, but they neither influence nor predict cognitive performance in non-demented individuals.

Evidence of disseminated intravascular coagulation in a porcine model following radiation exposure

Recent evidence has suggested that disseminated intravascular coagulation (DIC) plays an integral role in death at the LD50 dose of either gamma or solar particle event (SPE)-like proton radiation in ferrets. In these studies, Yucatan minipigs were evaluated to determine whether they were susceptible to the development of radiation induced DIC. Yucatan minipigs were exposed to a dose of 2.5 Gray (Gy) with X-rays and monitored over the course of 30 days. Evidence of DIC was evaluated by way of thromboelastometry parameters, platelet counts, fibrinogen concentration, and the d-dimer assay. Pigs exposed to X-rays developed signs of DIC within 2 days' post-irradiation. The development of DIC was exacerbated over the course of the studies, and one of the pigs died at day 14 and another had to be euthanized on day 16 post-irradiation. For both of these pigs, DIC was evident at the time of death. The following observations were indicated or were suggestive of DIC: whole blood clotting was impaired (as evidenced by thromboelastometry alterations), there were decreased platelet counts, elevated d-dimer concentrations in the blood, and/or hemorrhaging and the presence of fibrin in tissues observed during post-mortem examination. The extrapolation of data from these studies, in combination with other published data, have led to the hypothesis that there could be a correlation between the propensity to develop DIC, as indicated by hemorrhaging at death at relatively low doses of radiation, and the LD50 for a particular species. Our data suggest that the development of DIC may contribute to death at the LD50 dose in large mammals.

Pre-diagnostic management of patients suspicious of deep vein thrombosis

Background: We analysed the feasibility of the 9th ACCP-guidelines recommendation of starting therapeutic anti- coagulation in patients with a high suspicion of deep vein thrombosis (DVT) and tried to answer the question as to whether it generates a relevant over- or under-use of anti-coagulants in the period prior to the definitive diagnosis. Patients and methods: From March to May 2013 we included 98 consecutive out-patients (mean age 63 ± 17 years, 39 males) suspected of DVT, classifying them according to the 9th ACCP-guidelines recommendations into two groups with high and low clinical suspicion. Those with a high suspicion (Wells Score ≥ 2 and elevated DDimer concentration) initially received Rivaroxaban 15 mg orally. Results: Out of the 80 patients with a high clinical suspicion, 15 (19%) received therapeutic anti-coagulation without any medical necessity because DVT was finally excluded. Out of the 10 patients with a low clinical suspicion, 2 (20%) with a finally proven DVT might have benefited from initial therapeutic anti-coagulation. Females were at a slightly higher risk of receiving therapeutic anti-coagulation unnecessarily. Out of the 45 females with a high clinical suspicion, who received therapeutic anti-coagulation, DVT was excluded in 9 (20%). In males it was 6 (17%) out of 35 patients. The costs for those 80 patients accepting initial anti-coagulation by taking Rivaroxaban 15 mg were €312. By using Certoparin 8000 I.E. the cost would have been €792, which is 150% higher compared to Rivaroxaban within in the same period. Conclusion: Defining patients to have a high suspicion for DVT by Wells score and DDimer is associated with an over-use of therapeutic anticoagulation in almost every fifth patients.

D‐dimer as a predictor of venous thromboembolism in acutely ill, hospitalized patients: a subanalysis of the randomized controlled MAGELLAN trial

D-dimer concentrations have not been evaluated extensively as a predictor of increased venous thromboembolism (VTE) risk in acutely ill, hospitalized medical patients. To analyze the relationships between D-dimer concentration, VTE and bleeding in the MAGELLAN trial (NCT00571649). This was a multicenter, randomized, controlled trial. Patients aged ≥40years, hospitalized for acute medical illnesses with risk factors for VTE received subcutaneous enoxaparin 40mg once daily for 10±4days then placebo up to day 35, or oral rivaroxaban 10mg once daily for 35±4days. Patients (n=7581) were grouped by baseline D-dimer ≤2×or >2×the upper limit of normal. VTE and major plus non-major clinically relevant bleeding were recorded at day 10, day 35, and between days 11 and 35. The frequency of VTE was 3.5-fold greater in patients with high D-dimer concentrations. Multivariate analysis showed that D-dimer was an independent predictor of the risk of VTE (odds ratio 2.29 [95% confidence interval 1.75-2.98]), and had a similar association to established risk factors for VTE, for example cancer and advanced age. In the high D-dimer group, rivaroxaban was non-inferior to enoxaparin at day10 and, unlike the low D-dimer group, superior to placebo at day 35 (P<0.001) and days 11-35 (P<0.001). In both groups, bleeding outcomes favored enoxaparin/placebo. Elevated baseline D-dimer concentrations may identify acutely ill, hospitalized medical patients at high risk of VTE for whom extended anticoagulant prophylaxis may provide greater benefit than for those with low D-dimer concentrations.

Peritoneal inflammatory response to surgical correction of left displaced abomasum using different techniques

The objective of this study was to compare the inflammatory response within the abdominal cavity between three surgical methods. The study comprised 45 cows with left displacement of the abomasum,...

Update of D-dimer testing1)

Abstract D-dimer concentrations are elevated in a variety of clinical situations with hypercoagulability, such as venous thromboembolism (VTE), disseminated intravascular coagulation (DIC), ischemic cardiopathy, stroke, acute aortic dissection, malignomas, pregnancy, after surgery, traumas, and burns. D-dimer testing has become an essential tool for the diagnosis of VTE and pulmonary embolism because of its high negative predictive value, especially when used in conjunction with a clinical pretest score. D-dimer testing can be used for the diagnosis of DIC and other thrombotic diseases. It is also helpful for risk stratification in coronary artery disease, in first and recurrent thrombotic events, and for the timing of the duration of oral anticoagulation after a first episode of VTE. The use of D-dimer testing is limited in certain clinical conditions in which elevated D-dimer concentrations render the test unsuitable for the detection of acute thrombotic events.

IMAGING DIAGNOSIS: CT FINDINGS IN A DOG WITH INTRACRANIAL HEMORRHAGE SECONDARY TO ANGIOSTRONGYLOSIS

A seven-month-old Cocker Spaniel had a cough, acute lethargy, decreased responsiveness, and episodes of hyperexcitability. There were bilateral generalized increased lung sounds, bilateral episcleral hemorrhage, and systemic hypertension. Prolonged buccal mucosal bleeding time and elevated D-dimer concentrations were detected. Radiographically, there was a generalized moderate unstructured interstitial pattern. In thoracic CT images, there was a diffuse moderate hyperattenuating appearance of the bronchial walls and interstitium and diffuse areas of moderate bronchiectasis. The brain CT images were characterized by marked hyperattenuating well-defined masses. In addition, there were smaller hyperattenuating and hypoattenuating masses scattered throughout the cerebral and cerebellar parenchyma. A zinc sulphate flotation test confirmed large numbers of Angiostrongylus vasorum L1 larvae. Despite therapy the dog continued to deteriorate and underwent euthanasia. Postmortem examination confirmed the presence of multiple intracranial and extracranial hemorrhages. Angiostrongylosis should be considered as one of the differential diagnoses in dogs presenting with neurologic signs consistent with acute intracranial haemorrhage.

P8 Use of D-dimer: CRP ratio compared to D-dimer alone to predict PE on VQ scanning

Introduction Pulmonary embolism (PE) is a common presentation in the emergency department and in-patient setting. Measurement of D-dimer in conjunction with clinical risk assessment is used to exclude patients at low risk of PE. Some of the conditions that mimic PE, including infection and inflammation, are also associated with elevated D-dimer concentrations such that the test lacks specificity. Most infectious and inflammatory conditions result in an elevated acute-phase serum response which can be quantified using C-Reactive Protein (CRP) assay. We hypothesised, therefore, that patients with isolated PE would have a higher D-dimer: CRP ratio than patients with infectious or inflammatory mimics of PE and therefore that this ratio would be more discriminatory. Methods We analysed data from all patients who underwent V/Q scanning to confirm or exclude PE at Royal Free Hampstead NHS Trust, London, UK, during 2010. The CRP and D-dimer results closest, but preceding the V/Q scan were analysed using receiver operator characteristic (ROC) curves to test the hypothesis that the D-dimer: CRP ratio (expressed as ng/ml:mg/l) was a better predictor or PE than D-dimer alone. Results 179 patients (mean (SD) age 52.8 (19.7) years) had a V/Q scan for suspected PE during the study period. Of these, 85 had a D-dimer assay, a median (IQR) of 1 (0–1) days prior to the imaging. The median D-dimer concentration was 272 (178–675) ng/ml. 137 patients had CRP assay (12 (3–56) mg/l), measured 1 (0–1) days prior to imaging. It was possible to calculate a D-dimer: CRP ratio in 78 patients (44% of the total), of whom 19 (24%) had a V/Q scan reported as high risk for PE. D-dimer, and the D-dimer: CRP ratio, but not CRP were significantly higher between patients who did and did not have high-risk V/Q scans (Mann–Whitney U test analyses: 764 vs 245 ng/ml, p=0.001; 107 vs 31 units, p=0.020 and 20 vs 10 mg/l, p=0.134 respectively). Biomarker data were log 10 transformed to permit ROC analysis. Area-under-curve (AUC) values using ROC for D-dimer alone, and D-dimer: CRP ratio were 0.74 and 0.68 respectively, both less than the standard criteria for utility of 0.8. Conclusions D-dimer: CRP ratio is not superior to D-dimer alone in predicting PE in patients with a clinical suspicion of this diagnosis sufficient to require V/Q scanning.

Analysis of plasma d‐dimer concentration in patients with delayed pressure urticaria

Activation of fibrinolysis system has been observed in spontaneous urticaria. To investigate the haemostatic activation in DPU, expressed by plasma D-dimer concentration, the index of active fibrinolysis. Plasma D-dimer concentrations were measured in eight patients with pure DPU of varying severity as well as in 30 healthy subjects. The analysis of individual results indicated that three patients of the eight show d-dimer concentration higher than the upper limit of the normal range. All the patients had severe DPU and manifested extensive lesions. The remaining five milder cases showed values within the normal range. Our analysis revealed that DPU patients may differ in their haemostatic activation state depending on severity of the disease. In severe DPU cases hyperfibrinolysis may occur, manifested by elevated plasma d-dimer concentration, probably as a consequence of the systemic inflammatory response.

Update on techniques for the diagnosis of pulmonary embolism

The clinical suspicion of acute pulmonary embolism (PE) is frequently raised. However, the diagnosis of PE is confirmed in only 20 - 30% of these patients. The high incidence in addition to the potential harm from false-positive or false-negative diagnostic decisions underline the importance of a standardised diagnostic algorithm with high sensitivity as well as specificity. This article reviews the diagnostic tests for the diagnosis of PE. This review provides an overview of the different clinical decision rules (CDRs), D-dimer tests and imaging techniques in patients suspected of PE. Furthermore, the diagnostic process in patients with clinically suspected recurrent PE, suspicion during pregnancy and new research areas are discussed. Various diagnostic tests are available to detect or exclude PE with good accuracy. CDRs and D-dimer tests play an important role in the exclusion of PE. Neither is sufficient as a single test, but the combination of an 'unlikely' clinical prediction and a normal D-dimer test result safely excludes PE. In case of a high CDR score and/or an elevated D-dimer concentration, extra imaging is necessary with multi-slice computed tomography pulmonary angiography as first choice modality.

D-Dimer Testing in Patients with Suspected Pulmonary Embolism and Impaired Renal Function

This study from the Netherlands aimed to determine the utility of D-dimer testing in patients with impaired renal function. Because renal impairment is associated with elevated D-dimer concentrations, the specificity of D-dimer testing in patients with suspected pulmonary embolism (PE) and impaired renal function is reduced. Additionally, computed tomography (CT) scanning in patients with impaired renal function is relatively contraindicated given the possibility of worsening renal function from contrast nephropathy.