Douma, R. A. et al. Potential of an age adjusted D-dimer cut-off value to improve the exclusion of pulmonary embolism in older patients: a retrospective analysis of three large cohorts. BMJ 340, c1475

Department of Vascular Medicine, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, Netherlands.
BMJ (online) (Impact Factor: 17.45). 03/2010; 340(mar30 3):c1475. DOI: 10.1136/bmj.c1475
Source: PubMed


In older patients, the the D-dimer test for pulmonary embolism has reduced specificity and is therefore less useful. In this study a new, age dependent cut-off value for the test was devised and its usefulness with older patients assessed.
Retrospective multicentre cohort study.
General and teaching hospitals in Belgium, France, the Netherlands, and Switzerland. Patients 5132 consecutive patients with clinically suspected pulmonary embolism.
Development of a new D-dimer cut-off point in patients aged >50 years in a derivation set (data from two multicentre cohort studies), based on receiver operating characteristics (ROC) curves. This cut-off value was then validated with two independent validation datasets.
The proportion of patients in the validation cohorts with a negative D-dimer test, the proportion in whom pulmonary embolism could be excluded, and the false negative rates.
The new D-dimer cut-off value was defined as (patient's agex10) microg/l in patients aged >50. In 1331 patients in the derivation set with an "unlikely" score from clinical probability assessment, pulmonary embolism could be excluded in 42% with the new cut-off value versus 36% with the old cut-off value (<500 microg/l). In the two validation sets, the increase in the proportion of patients with a D-dimer below the new cut-off value compared with the old value was 5% and 6%. This absolute increase was largest among patients aged >70 years, ranging from 13% to 16% in the three datasets. The failure rates (all ages) were 0.2% (95% CI 0% to 1.0%) in the derivation set and 0.6% (0.3% to 1.3%) and 0.3% (0.1% to 1.1%) in the two validation sets.
The age adjusted D-dimer cut-off point, combined with clinical probability, greatly increased the proportion of older patients in whom pulmonary embolism could be safely excluded.

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Article: Douma, R. A. et al. Potential of an age adjusted D-dimer cut-off value to improve the exclusion of pulmonary embolism in older patients: a retrospective analysis of three large cohorts. BMJ 340, c1475

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    • "As current diagnostic strategies for PE include imaging (most often CTPA) in patients with positive D-dimers, lack of specificity of D-dimers in the elderly leads to a high proportion of these patients undergoing CTPA. The question of a higher D-dimer cut-off in elderly patients was raised a decade ago [34], but studies confirming the potential security of such a strategy by retrospectively applying age-adjusted cut-offs to large prospective cohorts of consecutive patients with suspected VTE were published between 2010 and 2012 [35] [36] [37] [38] [39]. A recent systematic review and meta-analysis of studies in patients with suspected VTE (PE and DVT) showed a dramatic decrease of the pooled specificity from 66.8% (95% CI 61.3–72) in patients b50 years to 14.7% (95% CI 11.3–18.6) in patients N80 years with the conventional D-dimer cut-off [40]. "
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    • "The clinical PTP assessment using the Wells score provides greater accuracy in estimating the clinical PTP score, independent of clinician's experience, and allows the option for alternative diagnosis.[612] Although the sensitivity of the D-dimer test is high, the specificity is not sufficiently high enough for the test to be diagnostic;[13] however, D-dimer is a valuable tool in the exclusion of PE, as the negative predictive value of D-dimer is high.[14] The advantage of the VQ scan are a lower radiation dose than CTPA and the lack of need for iodinated contrast; therefore, VQ scanning is often considered as the preferred alternative chest imaging to CTPA.[1415] "
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    • "In addition, even if the prognostic value of the D-dimer is independent of patient age and comorbidity [78], D-dimer levels are higher, on average, in the elderly [67] and age-specific D-dimer cut-points may increase its specificity [77]. Age-specific D-dimer cut-points, as proposed for the diagnostic use of D-dimer [79], may be helpful. Overall, additional research is needed to identify the optimal manner in which D-dimer can be used as a predictor of recurrent VTE. "
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