van Belle, A. et al. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. JAMA 295, 172-179

Department of Pulmonary Medicine, Academic Hospital, Maastricht, The Netherlands.
JAMA The Journal of the American Medical Association (Impact Factor: 30.39). 02/2006; 295(2):172-9. DOI: 10.1001/jama.295.2.172
Source: PubMed

ABSTRACT Previous studies have evaluated the safety of relatively complex combinations of clinical decision rules and diagnostic tests in patients with suspected pulmonary embolism.
To assess the clinical effectiveness of a simplified algorithm using a dichotomized clinical decision rule, D-dimer testing, and computed tomography (CT) in patients with suspected pulmonary embolism.
Prospective cohort study of consecutive patients with clinically suspected acute pulmonary embolism, conducted in 12 centers in the Netherlands from November 2002 through December 2004. The study population of 3306 patients included 82% outpatients and 57% women.
Patients were categorized as "pulmonary embolism unlikely" or "pulmonary embolism likely" using a dichotomized version of the Wells clinical decision rule. Patients classified as unlikely had D-dimer testing, and pulmonary embolism was considered excluded if the D-dimer test result was normal. All other patients underwent CT, and pulmonary embolism was considered present or excluded based on the results. Anticoagulants were withheld from patients classified as excluded, and all patients were followed up for 3 months.
Symptomatic or fatal venous thromboembolism (VTE) during 3-month follow-up.
Pulmonary embolism was classified as unlikely in 2206 patients (66.7%). The combination of pulmonary embolism unlikely and a normal D-dimer test result occurred in 1057 patients (32.0%), of whom 1028 were not treated with anticoagulants; subsequent nonfatal VTE occurred in 5 patients (0.5% [95% confidence interval {CI}, 0.2%-1.1%]). Computed tomography showed pulmonary embolism in 674 patients (20.4%). Computed tomography excluded pulmonary embolism in 1505 patients, of whom 1436 patients were not treated with anticoagulants; in these patients the 3-month incidence of VTE was 1.3% (95% CI, 0.7%-2.0%). Pulmonary embolism was considered a possible cause of death in 7 patients after a negative CT scan (0.5% [95% CI, 0.2%-1.0%]). The algorithm was completed and allowed a management decision in 97.9% of patients.
A diagnostic management strategy using a simple clinical decision rule, D-dimer testing, and CT is effective in the evaluation and management of patients with clinically suspected pulmonary embolism. Its use is associated with low risk for subsequent fatal and nonfatal VTE.

Download full-text


Available from: Lidwine W Tick, Aug 05, 2015
  • Source
    • "D-dimer was defined negative if lower than 500 ng/ml (Fibrinogen Equivalent Unit). This cutoff has been validated for D-dimer use in venous thromboembolic disease and has already been evaluated for the diagnosis of AD in previous studies [18] [19] [22] [23]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Background: Acute aortic dissection (AD) represents a diagnostic conundrum. Validated algorithms are particularly needed to identify patients where AD could be ruled out without aortic imaging. We evaluated the diagnostic accuracy of a strategy combining the aortic dissection detection (ADD) risk score with D-dimer, a sensitive biomarker of AD. Methods: Patients from two clinical centers with suspected AD were prospectively enrolled in a registry, from January 2008 to March 2013. The ADD risk score was calculated by retrospective blinded chart review. For D-dimer, a cutoff of 500 ng/ml was applied. Results: AD was diagnosed in 233 of 1035 (22.5%) patients. The ADD risk score was 0 in 322 (31.1%), 1 in 508 (49.1%) and >1 in 205 (19.8%) patients. The sensitivity and the failure rate of D-dimer were 100% and 0% in patients with ADD score 0, versus 97.5% (95% CI 91.4-99.6%) and 4.2% (95% CI 0.7-12.5%) in patientswith ADD risk score >1. In patients with ADD risk score <= 1, the sensitivity and the failure rate of D-dimer were 98.7% (95% CI 95.3-99.8%) and 0.8% (95% CI 0.1-2.6%). The diagnostic efficiency of D-dimer in patients with ADD risk score 0 and <= 1 was 8.9% (95% CI 7.2-10.7%) and 23.6% (95% CI 21.1-26.2%) respectively. Conclusions: In a large cohort of patients with suspected AD, the presence of ADD risk score 0 or <= 1 combined with a negative D-dimer accurately and efficiently ruled out AD.
    International Journal of Cardiology 05/2014; 175(1). DOI:10.1016/j.ijcard.2014.04.257 · 6.18 Impact Factor
  • Source
    • "The Wells score separates patients into three different categories of low, intermediate and high clinical probability, and can also be used in a dichotomised manner, PE likely versus PE unlikely [19]. It has been widely validated in prospective management outcome studies [20] [21]. The Geneva score in its original version needed arterial blood sample and chest X-ray [22] hence the development and validation of a revised Geneva score including only clinical characteristics [23] [24] [25]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Elderly patients are a population not only at particularly high risk of venous thromboembolism including pulmonary embolism (PE), but also at high risk of adverse clinical outcomes and treatment-related complications. Major progresses have been achieved in the diagnosis and treatment of PE over the last two decades. Nevertheless, some of elderly patients' specificities still represent important challenges in the management of PE in this population, from its suspicion to its diagnosis and treatment, and are discussed in this review. Perspectives for the future are from a diagnostic point of view the potential implementation of age-adjusted d-dimer cut-offs that will allow ruling out PE in a greater proportion of elderly patients without the need for thoracic imaging. From a therapeutic point of view, acquisition of post-marketing clinical experience with the use of new oral anticoagulants is still necessary, and in the meantime, these drugs should be prescribed with great caution in thoroughly selected elderly patients.
    European Journal of Internal Medicine 04/2014; DOI:10.1016/j.ejim.2014.03.009 · 2.30 Impact Factor
  • Source
    • "D-dimer was normal in 17.1% of the cases, and combined with a low clinical probability, a hundred percent sensitivity was reached. Van Belle et al. [2] have investigated the use of a clinical decision rule in combination with D-dimer testing in the exclusion of PE. In the clinical decision rule, the variable 'previous pulmonary embolism or deep vein thrombosis' is included. "
    [Show abstract] [Hide abstract]
    ABSTRACT: The use of D-dimer in combination with a clinical decision rule has been widely investigated in pulmonary embolism and deep venous thrombosis. Although it has been shown to be safe in excluding venous thromboembolism, the clinician is often faced with specific situations in which the use of D-dimer is controversial. We review the best available evidence on these patients. We conclude that it is not safe to use D-dimer testing in patients with symptoms of a venous thromboembolism for over 14 days, patients receiving therapeutic heparin treatment and patients with suspected deep venous thrombosis during oral anticoagulant therapy. In these populations the levels of D-dimer can be lower then expected giving rise to false-negative results. It is safe to use D-dimer testing in combination with a clinical decision rule in patients of all ages, patients presenting with a suspected recurrent venous thromboembolism or inpatients with suspected pulmonary embolism. As patients with recurrent venous thromboembolism, elderly patients and inpatients have higher levels of D-dimer, D-dimer testing has a low specificity and the need for additional radiological testing is increased.
    European Journal of Internal Medicine 10/2009; 20(5):441-6. DOI:10.1016/j.ejim.2008.12.004 · 2.30 Impact Factor
Show more