Role Of D-dimer Testing Research Articles

Post-Anticoagulation Cessation D-Dimer Testing and VTE Recurrence in Real-World Australian Audit

AimElevated D-dimer post-anticoagulation cessation is a recognised risk factor for recurrent venous thromboembolic events (VTE). In particular, raised D-dimer post cessation has been associated with increased risk of recurrence in unprovoked major VTE. Currently in Australia, D-dimer has not been widely used in practice to stratify the risk of VTE recurrence. This study aims to retrospectively analyse the effect of routine D-dimer testing and it's association with VTE recurrence.MethodsA retrospective evaluation was performed on 1024 patients with a diagnosis of VTE at a tertiary hospital in Australia between January 2013 and December 2016. Data collected included demographics, results and timing of D-dimer testing and serial imaging results.Results1024 patients were reviewed with a total median follow up of 12 months (range 0-59 months). D-dimer was tested in 189 patients (18.5%) within 90 days after cessation of anticoagulation. Of these patients, median age was 58 (18-92) and 55.3% (n=105) were female. 33.3% (n=63) had isolated distal deep vein thrombosis (IDDVT), 66.3% (n=126) had above knee DVT (AKDVT)/pulmonary embolus (PE), 54.5% (n=103) of VTE were provoked.Abnormal post cessation D-dimer (>500) was found in 72 patients (37.9%). Of these, 25 patients were restarted on anticoagulation; one had recurrent VTE whilst on low dose apixaban 2.5mg BD and one had recurrence after cessation of anticoagulation at a later date. Patients with elevated D-dimer post cessation had a higher rate of recurrence with the highest risk in patients with D-dimer >1000 (RR 7.38, p=<0.01) outlined in Table 1.Of the 164 patients with post cessation D-dimer testing who remained off anticoagulation there were a total of 24 (12.6%) episodes of recurrent VTE. Elevated D-dimer post anticoagulation cessation was a significant risk factor for recurrence in both provoked VTE (RR 4.21, p=0.01) and unprovoked VTE cohorts (RR 4.55, p=0.008) outlined in Table 2. When provoked VTE were sub-categorised, raised D-dimer demonstrated the most statistical significance in VTE provoked by travel (RR 13.5 p=0.06).Of the patients with post anticoagulation cessation D-dimer testing 170 patients (89.9%) had repeat imaging to assess for residual thrombus. In the subgroup of patients with no residual thrombus, elevated D-dimer was a significant risk factor for VTE recurrence (RR 6.4, p=<0.01). Patients with normal D-dimer and no residual thrombus had the lowest rate of recurrence 5.4% (n=4) see Table 3.When stratified by type of VTE, elevated D-dimer post anticoagulation cessation was significantly related to risk for recurrence in the overall IDDVT sub-cohort (RR 4.09, p=0.007). This was not significant for the AKDVT/PE sub cohort (RR 3.24, p=0.079). However, for patients with unprovoked AKDVT or PE, having D-dimer tested post anticoagulation, regardless of result, was associated with lower rates of VTE recurrence RR 0.30 (p=0.02) compared to those who had no D-dimer testing as part of follow-up.ConclusionPost treatment D-dimer testing may have a clinical role in stratifying the risk of VTE recurrence along with repeat imaging to detect residual thrombus. Elevated D-dimer post anticoagulation cessation is associated with increased risk of VTE recurrence for both provoked and unprovoked VTE with highest risk in patients with D-dimer >1000. Patients with no residual thrombus and a negative D-dimer post anticoagulation cessation had the lowest rate of recurrence. In the subgroup of patients with provoked VTE and IDDVT a positive D-dimer post cessation was associated with 4.21 and 4.09 relative risk of recurrence respectively, suggesting that the role of D-dimer testing can be extended to these subpopulations. Interestingly, in patients with unprovoked AKDVT or PE, having post-cessation D-dimer testing performed, regardless of result, was associated with a significantly lower rate of VTE recurrence compared to patients without D-dimer testing, which may be related to specialist review and recommencement of anticoagulation in high-risk patients. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Review of D-dimer testing: Good, Bad, and Ugly.

D-dimer assays are commonly used in clinical practice to exclude a diagnosis of deep vein thrombosis or pulmonary embolism. More recently, they have been also been used to guide patients with unprovoked venous thromboembolism (VTE) when faced with the decision to continue or stop anticoagulation after initial treatment is complete. D-dimer assays vary widely with respect to the antibody used, method of capture, instrumentation required, and calibration standard. These differences have an important influence on the operating characteristics of the assays. Consequently, the evidence available in the literature for one assay cannot simply be extrapolated to another. In this review, we will outline the general properties of D-dimer assays, discuss the concept of raising the D-dimer threshold used in diagnosis of VTE according to pretest probability and age, and provide clinical perspective on the role of D-dimer testing in the diagnosis and prognosis of VTE.

Age-Adjusted D-Dimer in the Prediction of Pulmonary Embolism: Does a Normal Age-Adjusted D-Dimer Rule Out PE?

Risk assessment for pulmonary embolism (PE) currently relies on physician judgment, clinical decision rules (CDR), and D-dimer testing. There is still controversy regarding the role of D-dimer testing in low or intermediate risk patients. The objective of the study was to define the role of clinical decision rules and D-dimer testing in patients suspected of having a PE. Records of 894 patients referred for computed tomography pulmonary angiography (CTPA) at a University medical center were analyzed. The clinical decision rules overall had an ROC of approximately 0.70, while signs of DVT had the highest ROC (0.80). A low probability CDR coupled with a negative age-adjusted D-dimer largely excluded PE. The negative predictive value (NPV) of an intermediate CDR was 86–89%, while the addition of a negative D-dimer resulted in NPVs of 94%. Thus, in patients suspected of having a PE, a low or intermediate CDR does not exclude PE; however, in patients with an intermediate CDR, a normal age-adjusted D-dimer increases the NPV.

Role of d-dimer testing in severe pelvic inflammatory disease: a new usable marker to assess the need for fertility-impairing surgery?

Pelvic inflammatory disease (PID), like many other inflammatory diseases, can be characterized by an inflammation-induced activation of the coagulation cascade, resulting in the production of D-dimers. In this study it is demonstrated how high levels of D-dimers, assayed at the time of hospitalization, are encountered in patients diagnosed with PID and how the levels of this parameter are significantly higher in patients, which due to the severity of the disease, needed surgical treatment. Therefore the d-dimer is shown to be an important parameter to be considered in the therapeutic counseling of severe forms of PID.

The Role of D-dimer Testing in Patients with Suspected Venous Thromboembolism

D-dimer, the final degradation product of cross-linked fibrin, is typically elevated in patients with acute venous thromboembolism. With its high sensitivity and negative predictive value, D-dimer testing may have a role for ruling-out the diagnosis in patients with suspected deep vein thrombosis or pulmonary embolism. For this purpose, D-dimer testing has been integrated in sequential diagnostic strategies including those using pretest clinical probability assessment and imaging techniques. A large variety of assays are now available for D-dimer measurement, with different sensitivities and specificities for the diagnosis of venous thromboembolism. Attempts to standardize the various D-dimer assays have been made but without any definitive answers as yet. The diagnostic yield of D-dimer testing is affected not only by the choice of the appropriate assay but also by patient characteristics. As a consequence, the clinical usefulness of D-dimer testing for the exclusion of suspected venous thromboembolism should be carefully evaluated in special clinical settings.

Value of D-Dimer Testing in Acute Aortic Dissection

To the Editor: We read with great interest the recent review on etiology, diagnosis and management in aortic dissection.1 In their discussion on diagnostic strategies, the authors state that useful biomarkers for aortic dissection are currently absent. We recently reported on 24 patients with acute aortic dissection in whom D-dimer, a degradation product of cross-linked fibrin, was tested as a part of the initial diagnostic strategy.2 We found that, actually, all patients with acute aortic dissection …

Variation of plasma D-dimer following surgery: implications for prediction of postoperative venous thromboembolism.

The prognosis of venous thromboembolism is considerably influenced by an accurate and fast diagnosis. Although the role of D-dimer testing in the diagnosis of suspected venous thromboembolism is well established for outpatients, there is controversial evidence on the clinical usefulness of its measurement in surgical patients. In order to recognize patterns of variation of D-dimer following surgery and identify potential pitfalls in prediction of venous thromboembolic complications, plasma D-dimer was assayed in 30 patients undergoing major elective hip surgery and 20 patients undergoing laparoscopic cholecystectomy for acute cholecystitis. The postoperative variation of plasma D-dimer differed widely between the two subgroups. Patients undergoing laparoscopic cholecystectomy showed D-dimer concentrations persistently increased from the baseline to the 15th postoperative day, whereas patients undergoing hip surgery were characterized by a double peak, on the 1st and 7th postoperative days. Mean inter-individual daily coefficient of variations of plasma D-dimer throughout the postoperative period were 49% (range 39%-61%) for laparoscopic cholecystectomy and 101% (range 72%-156%) for orthopedic surgery. The markedly heterogeneous fluctuation of plasma D-dimer suggests that the postoperative activation of the hemostatic system depends on the type and time since surgery, thus limiting the clinical usefulness of D-dimer testing in the diagnostic approach to postoperative venous thromboembolism.