scholarly journals P136: Evaluating the use of the YEARS clinical decision rule for diagnosing pulmonary embolism in the Emergency Department

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S105-S105 ◽  
Author(s):  
S. Sharif ◽  
C. Kearon ◽  
M. Eventov ◽  
M. Li ◽  
R. Jiang ◽  
...  
Keyword(s):  
Emergency Department ◽  
Pulmonary Embolism ◽  
Deep Vein Thrombosis ◽  
False Negative ◽  
False Negative Rate ◽  
Clinical Signs ◽  
Vein Thrombosis ◽  
Negative Rate ◽  
Deep Vein ◽  
D Dimer

Introduction: Diagnosing pulmonary embolism (PE) can be challenging because the signs and symptoms are often non-specific. Studies have shown that evidence-based algorithms are not always adhered to in the Emergency Department (ED) and are often not used correctly, which leads to unnecessary CT scanning. The YEARS diagnostic algorithm, consisting of three items (clinical signs of deep vein thrombosis, hemoptysis, and whether pulmonary embolism is the most likely diagnosis) and D-dimer, is a novel and simplified way to approach suspected acute PE. The purpose of this study was to 1) evaluate the use of the YEARS algorithm in the ED and 2) to compare the rates of testing for PE if the YEARS algorithm was used. Methods: This was a health records review of ED patients investigated for PE at two emergency departments over a two-year period (April 2013-March 2015). Inclusion criteria were ED physician ordered CT pulmonary angiogram, ventilation-perfusion scan, or D-dimer for investigation of PE. Patients under the age of 18 and those without a D-dimer test were excluded. PE was considered to be present during the emergency department visit if PE was diagnosed on CT or VQ (subsegmental level or above), or if the patient was subsequently found to have PE or deep vein thrombosis during the next 30 days. Trained researchers extracted anonymized data. The rate of CT/VQ imaging and the false negative rate was calculated. Results: There were 1,163 patients that were tested for PE and 1,083 patients were eligible for our analysis. Of the total, 317/1,083 (29.3%; 95%CI 26.6-32.1%) had CT/VQ imaging for PE, and 41/1,083 (3.8%; 95%CI 2.8-5.1%) patients were diagnosed with PE at baseline. Three patients had a missed PE, resulting in a false negative rate of 0.4% (95%CI 0.1-1.2%). If the YEARS algorithm was used, 211/1,083 (19.5%; 95%CI 17.2-22.0%) would have required imaging for PE. Of the patients who would not have required imaging according to the YEARS algorithm, 8/872 (0.9%; 95%CI 0.5-1.8%) would have had a missed PE. Conclusion: If the YEARS algorithm was used in all patients with suspected PE, fewer patients would have required imaging with a small increase in the false negative rate.

scholarly journals LO55: Comparison of the age-adjusted D-dimer, clinical probability-adjusted D-dimer, and Wells rule with D-dimer for diagnosing deep vein thrombosis in the emergency department.

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S27-S27
Author(s):  
S. Sharif ◽  
C. Kearon ◽  
M. Eventov ◽  
P. Sneath ◽  
M. Li ◽  
...  
Keyword(s):  
False Negative ◽  
False Negative Rate ◽  
Duplex Ultrasonography ◽  
Vein Thrombosis ◽  
Clinical Probability ◽  
Negative Rate ◽  
Wells Score ◽  
Wells Rule ◽  
Deep Vein ◽  
D Dimer

Introduction: Diagnosing deep vein thrombosis (DVT) is of critical importance because of its associated morbidity and mortality. Diagnosing DVT can be challenging in the Emergency Department (ED) due to inconsistent adherence to, and utilization of the Wells rule. Both the age-adjusted and clinical probability adjusted D-dimer have been shown to decrease ultrasound (US) utilization rates. We aimed to compare the safety and efficacy of the Wells score with D-dimer to the age-adjusted and clinical probability-adjusted D-dimer in Canadian ED patients tested for DVT. Methods: This was a health records review of ED patients investigated for DVT at two EDs over a two-year period. Inclusion criteria were ED physician ordered duplex ultrasonography or D-dimer for investigation of lower limb DVT. Patients under the age of 18 were excluded. DVT was considered to be present during the ED visit if DVT was diagnosed on duplex ultrasonography and was treated for acute DVT, or if the patient was subsequently diagnosed with pulmonary embolism (PE) or DVT during the next 30 days. Trained researchers extracted anonymized data. The Wells D-dimer, age-adjusted D-dimer, and the clinical probability-adjusted D-dimer rules were applied retrospectively. The rate of duplex ultrasonography imaging and the false negative rate was calculated for each rule. Results: Between April 1st 2013 and March 31st 2015, there were 1,198 patients tested for DVT. Of the low and moderate clinical pretest probability patients (Wells score ≤ 2), only 436 had a D-Dimer test and were eligible for our analysis. The average age of the patients was 59, 56% were female, and 4% had a malignancy. 207/436 patients (47.4%, 95%CI 42.8-52.2%) would have had US imaging for DVT if the age-adjusted D-dimer rule was used. 214/436 patients (49.1%, 95%CI 44.4-53.8%) would have had imaging for DVT if the clinical probability-adjusted D-dimer was used. If the Wells rule was used with the standard D-dimer cutoff of 500, 241/436 patients (55.2%, 95%CI 50.6-59.9%) would have had imaging for DVT. The false-negative rate for the Wells rule was 1.5% (95%CI 0.5-4.4%). The false-negative rate for the age-adjusted D-dimer rule was 1.3% (95%CI 0.4-3.8%). The false-negative rate for the clinical-probability adjusted D-Dimer was 1.8% (95%CI 0.7-4.5%). Conclusion: In comparison with the approach of the Wells score and D-dimer, both the age-adjusted and clinical probability-adjusted D-dimer diagnostic strategies could reduce the proportion of patients who require US imaging.

scholarly journals LO21: Ability of single negative ultrasound to rule out deep vein thrombosis in pregnant women. A systematic review and meta analysis

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S13-S14
Author(s):  
K. Al Lawati ◽  
J. Aljazeeri ◽  
W. Chan ◽  
K. de Wit
Keyword(s):  
Deep Vein Thrombosis ◽  
Pregnant Women ◽  
False Negative ◽  
False Negative Rate ◽  
Risk Of Bias ◽  
Hard Copy ◽  
Vein Thrombosis ◽  
Negative Rate ◽  
Deep Vein

Introduction: The accuracy of ultrasound (US) for diagnosing lower extremity deep vein thrombosis (DVT) in non-pregnant patients has been well validated. However, in pregnant women with suspected DVT and an initial negative US (with imaging of the iliac veins), serial US is recommended. We aimed to determine the ability of single negative US to exclude DVT in symptomatic pregnant women. Methods: Two authors independently reviewed the following databases: MEDLINE, PubMed and EMBase from inception until May 2017. Three authors reviewed all full text papers and data were extracted from included studies by four authors. An overlap among study populations was identified in 4 of the manuscripts, all from one multicentre Canadian study. Two authors performed data re-extraction from the hard copy research charts from this study. We assessed the risk of bias using the CLARITY group tool for prognostic studies. Results: Of 109 potentially relevant articles, 8 studies (7 prospective studies and 1 retrospective) were included. Risk of bias was low for the included populations, and low or moderate for method of measurement and for completeness of follow up. A total of 635 pregnant patients with symptoms of DVT had an initial negative US examination. Of those, 6 had positive DVT during serial US (0.94%) and 3 developed DVT during 3-month follow-up after serial ultrasound (0.47%). Using random-effects model, the pooled false negative rate of a single ultrasound was 1.27% (95% confidence interval, 0.42 to 2.56), I2= 27%. Conclusion: The false negative rate of a single ultrasound with iliac vein imaging for DVT in pregnancy is low. Our results will help inform shared decision making around planning repeat ultrasound scans in these patients.

scholarly journals LO81: Optimizing the use of CT scanning for pulmonary embolism in the emergency department

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S56
Author(s):  
S. Sharif ◽  
C. Kearon ◽  
M. Li ◽  
M. Eventov ◽  
P.E. Sneath ◽  
...  
Keyword(s):  
Emergency Department ◽  
Pulmonary Embolism ◽  
False Negative ◽  
False Negative Rate ◽  
Ct Scanning ◽  
Negative Rate ◽  
Wells Score ◽  
Wells Rule ◽  
Acute Pe ◽  
D Dimer

Introduction: Diagnosing pulmonary embolism (PE) can be challenging because the signs and symptoms are often non-specific. Studies have shown that evidence-based diagnostic algorithms are not always adhered to in the Emergency Department (ED), which leads to unnecessary CT scanning. In 2013, the American College of Chest Physicians identified CT pulmonary angiography as one of the top five avoidable tests. One solution is to use a clinical prediction rule combined with the D-dimer, which safely reduces the use of CT scanning. The objective of this study was to compare the proportion of patients tested for PE in two emergency departments, who 1) had a CT-PE and 2) whose diagnosis of PE was missed. We compared these rates to those if the Wells rule and D-dimer had been applied as standard. Methods: This was a retrospective chart review of ED patients investigated for PE at two hospitals from April 2013 to March 2015 (24 months). Inclusion criteria were the ED physician ordered CT-PE, Ventilation-Perfusion (VQ) scan or D-dimer for investigation of PE. Patients under the age of 18 were excluded. PE was defined as CT/VQ diagnosis of acute PE or acute PE/DVT in 30-day follow-up. Trained researchers extracted anonymized data. The rate of CT/VQ imaging and the false-negative rates were calculated. The false-negative rate was calculated as the number of patients diagnosed with PE within 30 days as a proportion of those patients who did not have a CT/VQ scan at initial presentation. Results: There were 1,189 patients included in this study. 55/1,189 patients (4.6%; 95%CI 3.6-6.0%) were ultimately diagnosed with PE within 30 days. 397/1,189 patients (33.4%; 95%CI 30.8-36.1%) had CT/VQ scans for PE. 3 out of 792 who were not scanned had a missed PE resulting in a false-negative rate of 0.4% (95% CI 0.1-1.1%). 80 patients had an elevated D-dimer or high Wells score but were not imaged. Furthermore, 75 patients who did not have an elevated D-dimer nor a high Wells score were imaged. Had Wells rule/D-dimer been adhered to, 402/1,189 patients (33.8%; 95%CI 31.9-36.6%) would have undergone imaging and the false negative rate would be 0/727, 0% (95%CI 0.0-0.5%). Conclusion: If the Wells rule and D-dimer was used in all patients tested for PE, a similar proportion would have a CT scan but fewer PEs would be missed.

Diagnostic Accuracy of a New d-Dimer Assay (Sclavo Auto d-Dimer) for Exclusion of Deep Vein Thrombosis in Symptomatic Outpatients

2016 ◽  
Vol 23 (3) ◽  
pp. 221-228 ◽  
Author(s):  
Cristina Legnani ◽  
Michela Cini ◽  
Mirella Frascaro ◽  
Giuseppina Rodorigo ◽  
Michelangelo Sartori ◽  
...  
Keyword(s):  
Deep Vein Thrombosis ◽  
Imaging Techniques ◽  
False Negative ◽  
High Specificity ◽  
Predictive Values ◽  
Cutoff Value ◽  
Vein Thrombosis ◽  
Number Of Patients ◽  
Deep Vein ◽  
D Dimer

In patients presenting non-high clinical pretest probability (PTP), a negative d-dimer can exclude venous thromboembolism without imaging tests. However, each d-dimer assay should be validated in prospective studies. We evaluated an automated d-dimer immunoassay using the Sclavo Auto d-dimer (Sclavo Diagnostics Int, Sovicille, Italy) provided by Dasit Diagnostica (Cornaredo, Milan, Italy). Three hundred two consecutive outpatients suspected of leg deep vein thrombosis (DVT) with non-high PTP were included. The Sclavo Auto d-dimer assay was evaluated on 2 analyzers (Sysmex CA-7000 and Sysmex CS-2100; Sysmex Corporation, Kobe, Japan, provided by Dasit). The cutoff value (200 ng/mL) was established a priori. Prevalence of DVT was 11.9%. Since no false-negative patients were detected, the sensitivity and negative predictive values (NPVs) were 100% (sensitivity = CA-7000: 100% [95% confidence interval, CI: 93.3-100], CS-2100: 100% [95% CI: 93.3-100]; NPV = CA-7000: 100% [95% CI: 97.9-100], CS-2100: 100% [95% CI: 98.0-100]). Specificity was 65.4% (95% CI: 59.4-71.1) and 69.2% (95% CI: 63.3-74.7) for CA-7000 and CS-2100, respectively. Specificity increased when a higher cutoff value (234 ng/mL) was used for patients aged ≥60 years without compromising the safety. Assay reproducibility was satisfactory at concentrations near the cutoff value (total coefficient of variations <10%). In conclusion, the Sclavo Auto d-dimer assay was accurate when used for DVT diagnostic workup in outpatients with non-high PTP. Based on its high sensitivity and NPV, it can be used as a stand-alone test in outpatients with non-high PTP. Given its high specificity, the number of patients in whom further imaging techniques can be avoided increased, improving the yield of the test.

Prognostic value of D-dimer in patients with pulmonary embolism with and without deep vein thrombosis

2018 ◽  
Vol 36 (6) ◽  
pp. 1099-1100
Author(s):  
Cem Çil ◽  
Oğuzhan Çelik ◽  
Bülent Özlek ◽  
Eda Özlek ◽  
Murat Biteker ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Deep Vein Thrombosis ◽  
Prognostic Value ◽  
Vein Thrombosis ◽  
Deep Vein ◽  
D Dimer

scholarly journals THE ASSOCIATION BETWEEN D-DIMER AND DEEP VEIN THROMBOSIS LOCATION AND ITS ABILITY TO PREDICT PULMONARY EMBOLISM, a retrospective pilot study

2019 ◽  
Author(s):  
Sarah Ali Althomali ◽  
Adel S. Alghamdi ◽  
Tareef H. Gnoot ◽  
Mohammad A. Alhassan ◽  
Abdullatif H. Ajaimi ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Deep Vein Thrombosis ◽  
Risk Group ◽  
Great Role ◽  
Vein Thrombosis ◽  
Increased Risk ◽  
Risk Patients ◽  
Deep Vein ◽  
Limb Deep Vein Thrombosis ◽  
D Dimer

Abstract Background In lower limb deep vein thrombosis; it is important to identify proximal from distal deep vein thrombosis as it carries the highest risk of pulmonary embolism. It is known that D-dimer has a great role in deep vein thrombosis diagnosis. Yet, the use of D-dimer to predict the location of deep vein thrombosis and the risk of pulmonary embolism in deep vein thrombosis patients has not been investigated before. Objective To address the correlation between D-dimer and the location of deep vein thrombosis and to study the efficacy of D-dimer to predict risk of PE in patients with proximal or extensive deep vein thrombosis. Method We included 110 consecutive patients who were hospitalized with the diagnosis of deep vein thrombosis, with or without a concomitant diagnosis of PE, and with D-dimer measured at initial presentation. We categorized the location of deep vein thrombosis as: distal, proximal, and extensive. In the analysis, patients were grouped into high-risk (patients with Proximal or Extensive deep vein thrombosis and pulmonary embolism) and low risk group (patients without pulmonary embolism). Results There was no significant association between D-dimer level and the location of deep vein thrombosis (p=0.519). However, D-dimer level was greater among patients with pulmonary embolism (9.6mg/L) than among patients without pulmonary embolism (7.4mg/L), (p=0.027). D-dimer was a significant predictor of pulmonary embolism as patients with proximal or extensive deep vein thrombosis had 8-folds increased risk of pulmonary embolism than patients with D-dimer less than 4.75mg/L (OR=7.9, p=0.013). Conclusion Though D-dimer was not significantly associated with the location of deep vein thrombosis, it was a significant predictor of pulmonary embolism in patients hospitalized with proximal or extensive deep vein thrombosis.

Case 16: Use of D-dimer assay in suspected deep vein thrombosis or pulmonary embolism

1999 ◽  
Vol 56 (9) ◽  
pp. 529-532
Author(s):  
Caliezi ◽  
Holtz ◽  
Wuillemin
Keyword(s):  
Pulmonary Embolism ◽  
Deep Vein Thrombosis ◽  
Venöse Thromboembolie ◽  
Monoklonaler Antikörper ◽  
Vein Thrombosis ◽  
Deep Vein ◽  
D Dimer

D-Dimere sind Abbauprodukte des quervernetzten Fibrins nach fibrinolytischer Spaltung durch Plasmin. D-Dimere können im Plasma oder im Vollblut mittels gegen Epitope des D-Dimers gerichteter monoklonaler Antikörper nachgewiesen werden. Erhöhte D-Dimer-Werte finden sich bei Patienten mit tiefer Venenthrombose (TVT) oder Lungenembolie (LE), aber auch z.B. bei Patienten mit Infektionen, malignen Tumoren oder Herzinsuffizienz. Die Bestimmung der D-Dimere hat sich als früher Abklärungsschritt in der Diagnostik venöser Thromboembolien (TVT/LE) etabliert. Die hohe Sensitivität verschiedener ELISA-Teste ermöglicht es, die Diagnose einer TVT oder LE zuverlässig auszuschließen, falls die Konzentration der D-Dimere unterhalb einer kritischen Schwelle (sog. cut-off) liegt. Bei ambulanten Patienten gelingt es so, in rund 30% der Fälle mit Hilfe eines gut validierten Testes eine venöse Thromboembolie auszuschließen und auf weitere diesbezügliche Untersuchungen zu verzichten.

scholarly journals P113: Comparison of age-adjusted and clinical probability-adjusted D-dimer for diagnosing pulmonary embolism

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S116
Author(s):  
S. Sharif ◽  
C. Kearon ◽  
M. Li ◽  
M. Eventov ◽  
R. Jiang ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
False Negative ◽  
False Negative Rate ◽  
Retrospective Chart Review ◽  
Ct Scanning ◽  
Clinical Probability ◽  
Negative Rate ◽  
Wells Score ◽  
Acute Pe ◽  
D Dimer

Introduction: Diagnosing pulmonary embolism (PE) in the emergency department can be challenging due to non-specific signs and symptoms; this often results in the over-utilization of CT pulmonary angiography (CT-PA). In 2013, the American College of Chest Physicians identified CT-PA as one of the top five avoidable tests. Age-adjusted D-dimer has been shown to decrease CT utilization rates. Recently, clinical-probability adjusted D-dimer has been promoted as an alternative strategy to reduce CT scanning. The aim of this study is to compare the safety and efficacy of the age-adjusted D-dimer rule and the clinical probability-adjusted D-dimer rule in Canadian ED patients tested for PE. Methods: This was a retrospective chart review of ED patients investigated for PE at two hospitals from April 2013 to March 2015 (24 months). Inclusion criteria were the ED physician ordered CT-PA, Ventilation-Perfusion (VQ) scan or D-dimer for investigation of PE. Patients under the age of 18 were excluded. PE was defined as CT/VQ diagnosis of acute PE or acute PE/DVT in 30-day follow-up. Trained researchers extracted anonymized data. The age-adjusted D-dimer and the clinical probability-adjusted D-dimer rules were applied retrospectively. The rate of CT/VQ imaging and the false negative rates were calculated. Results: In total, 1,189 patients were tested for PE. 1,129 patients had a D-dimer test and a Wells score less than 4.0. 364/1,129 (32.3%, 95%CI 29.6-35.0%) would have undergone imaging for PE if the age-adjusted D-dimer rule was used. 1,120 patients had a D-dimer test and a Wells score less than 6.0. 217/1,120 patients (19.4%, 95%CI 17.2-21.2%) would have undergone imaging for PE if the clinical probability-adjusted D-dimer rule was used. The false-negative rate for the age-adjusted D-dimer rule was 0.3% (95%CI 0.1-0.9%). The false-negative rate of the clinical probability-adjusted D-dimer was 1.0% (95%CI 0.5-1.9%). Conclusion: The false-negative rates for both the age-adjusted D-dimer and clinical probability-adjusted D-dimer are low. The clinical probability-adjusted D-dimer results in a 13% absolute reduction in CT scanning compared to age-adjusted D-dimer.

Risk Assessment Model to Predict Recurrence in Patients with Unprovoked Deep Vein Thrombosis or Pulmonary Embolism.

Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 452-452
Author(s):  
Sabine Eichinger ◽  
Georg Heinze ◽  
Paul Alexander Kyrle
Keyword(s):  
Risk Assessment ◽  
Pulmonary Embolism ◽  
Deep Vein Thrombosis ◽  
Recurrence Risk ◽  
Assessment Model ◽  
Risk Scores ◽  
Risk Assessment Model ◽  
Vein Thrombosis ◽  
Deep Vein ◽  
D Dimer

Abstract Abstract 452 Background: Venous thrombosis is a chronic and potentially fatal disease (case fatality 5-9%). Predicting the likelihood of recurrence is important, as most recurrences can be prevented by antithrombotic therapy, albeit at the price of an increased bleeding risk during anticoagulation. Despite a substantial progress in identifying the determinants of the recurrence risk, predicting recurrence in an individual patient is often not feasible. Venous thromboembolism (VTE) is a multicausal disease and the combined effect of clinical and laboratory factors on the recurrence risk is unknown. It was the aim of our study to develop a simple risk model that improves prediction of the recurrence risk in patients with unprovoked VTE. Methods and Findings: In a prospective multicenter cohort study we followed 929 patients with a first VTE after completion of at least 3 months of anticoagulation. The median observation time was 43.3 months. Patients with VTE provoked by surgery, trauma, cancer, pregnancy or oral contraceptive intake were excluded as were those with a natural inhibitor deficiency or the lupus anticoagulant. The main outcome measure was symptomatic recurrent VTE, which occurred in 176 patients. The probability of recurrence (95% CI) after 2, 5 and 10 years was 13.8% (11.6% to16.5%), 24.6% (21.6% to 28.9%), and 31.8% (27.6% to 37.4%), respectively. To develop a simple and easy to apply risk assessment model, clinical and laboratory variables (age, sex, location of VTE, body mass index, factor V Leiden, prothrombin G20210A mutation, D-Dimer, in vitro thrombin generation) were preselected based on their established relevance for the recurrence risk, simple assessment, and reproducibility. All variables were analyzed in a Cox proportional hazards model, and those significantly associated with recurrence were used to compute risk scores. Only male sex [HR vs. female 1.90 (95% CI 1.31–2.75)], proximal deep vein thrombosis [HR vs. distal 2.08 (95% CI 1.16–3.74)], pulmonary embolism [HR vs. distal thrombosis 2.60 (95% CI 1.49– 4.53)] and elevated levels of D-Dimer [HR per doubling 1.27 (95% CI 1.08–1.51)] or peak thrombin [HR per 100 nM increase 1.38 (95% CI 1.17–1.63)] were related to a higher recurrence risk. We developed a nomogram (Fig. 1) based on sex, location of initial thrombosis, and D-Dimer that can be used to calculate risk scores and to estimate the cumulative probabilities of recurrence in an individual patient. The model has undergone extensive validation by a cross-validation process. The cohort was divided into test and validation samples thereby mimicking independent validation. This process was repeated 1000 times and the results were averaged to avoid dependence of the validation results on a particular partition of our cohort. Patients were assigned to different risk categories according to their risk score, which corresponded well with the recurrence rate as patients with lower scores had lower recurrence rates. Conclusion: By use of a simple scoring system the assessment of the recurrence risk in patients with a first unprovoked VTE can be improved in routine care. Patients with unprovoked VTE in whom the recurrence risk is low enough to consider a limited duration of anticoagulation, can be identified. Disclosures: No relevant conflicts of interest to declare.

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