Performance of a diagnostic algorithm based on a prediction rule, D-dimer and CT-scan for pulmonary embolism in patients with previous venous thromboembolism

2015 ◽  
Vol 113 (02) ◽  
pp. 406-413 ◽  
Author(s):  
Paul L. den Exter ◽  
Inge C. M. Mos ◽  
Menno V. Huisman ◽  
Frederikus A. Klok ◽  
Maria José Fabiá Valls ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Venous Thromboembolism ◽  
Random Effect ◽  
Prediction Rule ◽  
Diagnostic Algorithm ◽  
Clinical Prediction Rule ◽  
Incidence Rates ◽  
Specific Patient ◽  
History Of ◽  
D Dimer

SummaryDiagnostic management of suspected pulmonary embolism (PE) in patients with a history of venous thromboembolism (VTE) is complicateddue to persistent abnormal D-dimer levels, residual embolic obstruction and higher clinical prediction rule (CPR) scores. We aimed to evaluate the safety and efficiency of the standard diagnostic algorithm consisting of a CPR, D-dimer test and computed tomography pulmonary angiography (CTPA) in this specific patient category. We performed a systematic literature search for prospective studies evaluating a diagnostic algorithm in consecutive patients with clinically suspected PE and a history of VTE. The VTE incidence rates during three-month follow-up and the number of indicated CTPAs were pooled using random effect models. Four studies concerning 1,286 patients were included with a pooled baseline PE prevalence of 36 % (95 % confidence interval [CI] 30–42). In only 217 patients (15 %; 95 %CI 11–20) PE could be excluded without CTPA. The three-month VTE incidence rate was 0.8 % (95 %CI 0.06–2.4) in patients managed without CTPA, 1.6 % (95 %CI 0.3–4.0) in patients in whom PE was excluded by CTPA and 1.4 % (95 %CI 0.6–2.7) overall. In the pooled studies, PE was safely excluded in patients with a history of VTE based on a CPR followed by a D-dimer test and/or CTPA, although the efficiency of the algorithm is relatively low compared to patients without a history of VTE.

scholarly journals Advances in the Diagnosis of Venous Thromboembolism: A Literature Review

Diagnostics ◽  
2020 ◽  
Vol 10 (6) ◽  
pp. 365 ◽  
Author(s):  
Harish Patel ◽  
Haozhe Sun ◽  
Ali N. Hussain ◽  
Trupti Vakde
Keyword(s):  
Pulmonary Embolism ◽  
Venous Thromboembolism ◽  
Valsalva Maneuver ◽  
Imaging Modality ◽  
Diagnostic Algorithm ◽  
Pulmonary Angiography ◽  
Vein Thrombosis ◽  
Compression Ultrasound ◽  
Test Probability ◽  
D Dimer

The incidence of venous thromboembolism (VTE), including lower extremity deep vein thrombosis (DVT) and pulmonary embolism (PE) is increasing. The increase in suspicion for VTE has lowered the threshold for performing imaging studies to confirm diagnosis of VTE. However, only 20% of suspected cases have a confirmed diagnosis of VTE. Development of pulmonary embolism rule-out criteria (PERC) and update in pre-test probability have changed the paradigm of ruling-out patient with low index of suspicion. The D-dimer test in conjunction to the pre-test probability has been utilized in VTE diagnosis. The age appropriate D-dimer cutoff and inclusion of YEARS algorithm (signs of the DVT, hemoptysis and whether PE is the likely diagnosis) for the D-dimer cutoff have been recent updates in the evaluation of suspected PE. Multi-detector computed tomography pulmonary angiography (CTPA) and compression ultrasound (CUS) are the preferred imaging modality to diagnose PE and DVT respectively. The VTE diagnostic algorithm do differ in pregnant individuals. The prerequisite of avoiding excessive radiation has recruited planar ventilation-perfusion (V/Q) scan as preferred in pregnant patients to evaluate for PE. The modification of CUS protocol with addition of the Valsalva maneuver should be performed while evaluating DVT in pregnant individual.

D-dimer Testing and Venous Thromboembolism

2009 ◽  
Vol 03 (01) ◽  
pp. 37
Author(s):  
Domenico Prisco ◽  
Elisa Grifoni ◽  
Daniela Poli ◽  
◽  
◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
Diagnostic Yield ◽  
Prediction Rule ◽  
High Sensitivity ◽  
Clinical Prediction Rule ◽  
Patient Characteristics ◽  
Optimal Timing ◽  
Clinical Settings ◽  
Diagnostic Work ◽  
D Dimer

With its high sensitivity and negative predictive value, D-dimer (DD) testing has gained a role in the diagnostic work-up of suspected venous thromboembolism (VTE) for the exclusion of the disease, potentially reducing the need for imaging tests. The diagnostic yield of DD testing is affected not only by the choice of the appropriate assay for its measurement, but also by patient characteristics. As a consequence, its clinical usefulness for the exclusion of suspected VTE should be carefully evaluated in special clinical settings. There is increasing evidence that DD testing after anticoagulation withdrawal for a first unprovoked VTE episode may be useful to identify patients at higher risk of recurrence, and may help clinicians with the decision of whether to continue or stop anticoagulant treatment. However, further studies are needed to establish the optimal timing of DD testing and the best DD cut-off level that predicts recurrence, and to develop a clinical prediction rule for recurrent VTE.

Clinically suspected acute recurrent pulmonary embolism: A diagnostic challenge

2007 ◽  
Vol 97 (06) ◽  
pp. 944-948 ◽  
Author(s):  
Hanneke Kwakkel-van Erp ◽  
Maaike Söhne ◽  
Lidwine Tick ◽  
Marieke Kruip ◽  
Eric Ullmann ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Thrombotic Event ◽  
Diagnostic Algorithm ◽  
Clinical Decision ◽  
Clinical Suspicion ◽  
Diagnostic Challenge ◽  
Recurrent Venous Thromboembolism ◽  
History Of ◽  
D Dimer

SummaryIt is unknown whether strategies validated for diagnosing pulmonary embolism (PE) are valid in patients with a history of PE. It was the objective of this study to investigate whether a diagnostic algorithm consisting of sequential application of a clinical decision rule (CDR), a quantitative D-dimer test and computed tomography (CT) safely ruled out a clinical suspicion of acute recurrent PE. Data were obtained from a diagnostic outcome study of patients suspected of PE. Acute recurrent PE was ruled out by an unlikely probability of PE (CDR score ≤4 points) combined with a normal D-dimer test (≤500 ng/ml) or by a normal CT in all other patients. The primary outcome was the incidence of acute recurrent venous thromboembolism during three months of follow-up in patients with normal tests and not treated with anticoagulants. Of 3,306 patients suspected of acute PE, 259 patients (7.8%) had a history of PE of whom 234 were not treated with anticoagulants. The probability of PE was unlikely in 82 of 234 patients (35%), and 42 had a normal D-dimer test (18%), excluding recurrent PE. None of these patients had a thrombotic event during follow-up (0%, 95%CI: 0–6.9). A CT was indicated in all other patients (192) and ruled out recurrent PE in 127 patients (54%). Only one patient with a negative CT had a fatal recurrent PE during follow-up (0.8%; 95%CI: 0.02–4.3). In conclusion, this prospective study demonstrates the safety of ruling out a clinical suspicion of acute recurrent PE by a simple diagnostic algorithm in patients with a history of PE.

Derivation of a Simple Clinical Model to Categorize Patients Probability of Pulmonary Embolism: Increasing the Models Utility with the SimpliRED D-dimer

2000 ◽  
Vol 83 (03) ◽  
pp. 416-420 ◽  
Author(s):  
David Anderson ◽  
Marc Rodger ◽  
Jeffrey Ginsberg ◽  
Clive Kearon ◽  
Michael Gent ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Scoring System ◽  
Clinical Symptoms ◽  
Prediction Rule ◽  
Scoring Systems ◽  
Clinical Prediction Rule ◽  
Clinical Prediction ◽  
Clinical Model ◽  
Validation Set ◽  
D Dimer

SummaryWe have previously demonstrated that a clinical model can be safely used in a management strategy in patients with suspected pulmonary embolism (PE). We sought to simplify the clinical model and determine a scoring system, that when combined with D-dimer results, would safely exclude PE without the need for other tests, in a large proportion of patients. We used a randomly selected sample of 80% of the patients that participated in a prospective cohort study of patients with suspected PE to perform a logistic regression analysis on 40 clinical variables to create a simple clinical prediction rule. Cut points on the new rule were determined to create two scoring systems. In the first scoring system patients were classified as having low, moderate and high probability of PE with the proportions being similar to those determined in our original study. The second system was designed to create two categories, PE likely and unlikely. The goal in the latter was that PE unlikely patients with a negative D-dimer result would have PE in less than 2% of cases. The proportion of patients with PE in each category was determined overall and according to a positive or negative SimpliRED D-dimer result. After these determinations we applied the models to the remaining 20% of patients as a validation of the results. The following seven variables and assigned scores (in brackets) were included in the clinical prediction rule: Clinical symptoms of DVT (3.0), no alternative diagnosis (3.0), heart rate >100 (1.5), immobilization or surgery in the previous four weeks (1.5), previous DVT/PE (1.5), hemoptysis (1.0) and malignancy (1.0). Patients were considered low probability if the score was <2.0, moderate of the score was 2.0 to 6.0 and high if the score was over 6.0. Pulmonary embolism unlikely was assigned to patients with scores <4.0 and PE likely if the score was >4.0. 7.8% of patients with scores of less than or equal to 4 had PE but if the D-dimer was negative in these patients the rate of PE was only 2.2% (95% CI = 1.0% to 4.0%) in the derivation set and 1.7% in the validation set.Importantly this combination occurred in 46% of our study patients. A score of <2.0 and a negative D-dimer results in a PE rate of 1.5% (95% CI = 0.4% to 3.7%) in the derivation set and 2.7% (95% CI = 0.3% to 9.0%) in the validation set and only occurred in 29% of patients. The combination of a score <4.0 by our simple clinical prediction rule and a negative SimpliRED D-Dimer result may safely exclude PE in a large proportion of patients with suspected PE.

Development of A Clinical Prediction Rule for Risk Stratification of Recurrent Venous Thromboembolism In Patients with Cancer-Associated Venous Thromboembolism

Blood ◽  
2010 ◽  
Vol 116 (21) ◽  
pp. 475-475 ◽  
Author(s):  
Martha L Louzada ◽  
Alejandro Lazo-Langner ◽  
Vi Dao ◽  
Jerry Zhang ◽  
Michael J. Kovacs ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
High Risk ◽  
Prediction Rule ◽  
Clinical Prediction Rule ◽  
Low Risk ◽  
Clinical Prediction ◽  
Potential Predictor ◽  
Patients With Cancer ◽  
History Of ◽  
Recurrent Vte

Abstract Abstract 475 Background: Current guidelines suggest that all cancer patients with venous thromboembolism be treated with long-term low molecular weight heparin (LMWH). However, whether treatment strategies should vary according to patient and malignancy characteristics, in particular whether patients with low risk of VTE recurrence can be identified, remains unknown. Methods: We performed a single centre retrospective cohort study conducted at the Thrombosis Unit of the Ottawa Hospital. The charts of patients with cancer and VTE followed from 2002 to 2004 and from 2007 to 2008 were reviewed to assess the feasibility of derivation of a clinical prediction rule that stratifies VTE recurrence risk in patients with cancer—associated venous thrombosis through identification and evaluation of characteristics of malignancy and other clinical characteristics. We analysed only the patients who had a recurrent VTE within the first 6 months of anticoagulation. A univariate analysis determined the strength of association between each potential predictor and VTE recurrence. All potential predictor variables (p<0.25) were evaluated in a logistic regression model. Result: Of 543 patients 55 (10.1%) presented with a VTE recurrence during the first 6 months of anticoagulation. At VTE recurrence 19 (9.5%) patients were using VKA and 36 (10.5%) patients were using LMWH. The relative risk for VTE recurrence was not significantly different between patients who used VKA or LMWH [RR= 1. 13 (95%CI, 0.743 – 1.711; p= 0.565)]. A multivariate analysis suggested that gender, primary tumour site, tumour stage and history of prior VTE were significant variables to include in the clinical prediction rule. The final model included female gender, lung cancer and prior history of VTE as increasing risk and breast cancer and stage I disease as lowering risk. Patients with a score equal or less than 0 have low risk (4.5%) for VTE recurrence and this represented 48% of our patients. Patients with a score equal or above 1 have high risk (> 19%) for VTE recurrence (Tables 1 and 2). Conclusion: We were able to derive a simple and easy scoring system that stratifies patients with cancer-associated thrombosis into low or high risk of recurrent VTE. Future prospective validation of the model is warranted and may be very relevant to better tailor anticoagulation treatment in this heterogeneous population. Disclosure: No relevant conflicts of interest to declare.

scholarly journals Can pregnancy-adapted algorithms avoid diagnostic imaging for pulmonary embolism?

Hematology ◽  
2020 ◽  
Vol 2020 (1) ◽  
pp. 184-189
Author(s):  
Wee-Shian Chan
Keyword(s):  
Pulmonary Embolism ◽  
Diagnostic Imaging ◽  
Risk Perceptions ◽  
Clinical Signs ◽  
Prediction Rule ◽  
Signs And Symptoms ◽  
Clinical Prediction Rule ◽  
Pulmonary Angiography ◽  
Low Prevalence ◽  
D Dimer

Abstract The low prevalence of pulmonary embolism (PE) among pregnant patients presenting with suspected PE implies that most of these patients will be found not have the disease. Given this low prevalence, excluding PE in this population has necessitated the use of sensitive and specific diagnostic imaging, such as computed tomography pulmonary angiography or ventilation-perfusion scanning. Recent studies suggest that a clinical prediction rule with D-dimer testing can also be used to exclude a subset of pregnant patients with suspected PE without the need for diagnostic imaging. The YEARS criteria, which consist of clinical signs and symptoms of deep venous thrombosis, hemoptysis, and PE as the most likely diagnosis (a subjective variable), combined with selective D-dimer levels, seem to safely exclude up to one-third of these patients without imaging. The revised Geneva rule using objective variables, combined with nonpregnancy cutoffs for D-dimer levels, offers some promise, although fewer patients avoided imaging (14%). These recent studies provide evidence in support of radiation avoidance for some patients; however, for most, imaging remains the only option. Future studies should focus on improving the safety and techniques of imaging modalities, in addition to improving the specificity of D-dimer testing and objective prediction rules. Studies assessing patients’ and physicians’ values, preferences, and risk perceptions are also required to assist clinicians in shared decision making when counseling pregnant patients with suspected PE.

Familial thrombophilia associated with fibrinogen Paris V: Dusart syndrome

Blood ◽  
2000 ◽  
Vol 96 (3) ◽  
pp. 1191-1193 ◽  
Author(s):  
Takashi Tarumi ◽  
Danko Martincic ◽  
Anne Thomas ◽  
Robert Janco ◽  
Mary Hudson ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Venous Thromboembolism ◽  
Early Onset ◽  
Family Members ◽  
Initial Presentation ◽  
Pulmonary Emboli ◽  
Common Cause ◽  
History Of ◽  
Prophylactic Anticoagulation ◽  
Fibrin Clots

Abstract We report on a family with a history of venous thromboembolism associated with fibrinogen Paris V (fibrinogen A-Arg554→Cys). Ten members experienced thrombotic events, including 4 with fatal pulmonary emboli. Pulmonary embolism was the presenting feature in 4. Those with the mutation and a history of thrombosis had somewhat higher fibrinogen concentrations than those with the mutation and no thrombosis (294 ± 70 mg/dL vs 217 ± 37 mg/dL, respectively). The Paris V mutation consistently caused a prolongation of the reptilase time, and fibrin clots containing the abnormal fibrinogen were more translucent than normal clots. Given the early onset of symptoms and the initial presentation with pulmonary embolism in some family members, it was justifiable to offer prophylactic anticoagulation with warfarin to carriers of the mutation. Fibrinogen Paris V has now been reported in 4 apparently unrelated families, indicating that it is a relatively common cause of dysfibrinogenemia-associated thrombosis.

Prospective assessment of the natural history of positive D-dimer results in persons with acute venous thromboembolism (DVT or PE)

2003 ◽  
Vol 89 (02) ◽  
pp. 284-287 ◽  
Author(s):  
John Kuruvilla ◽  
Phil Wells ◽  
Bev Morrow ◽  
Karen MacKinnon ◽  
Michael Keeney ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
Natural History ◽  
Positive Result ◽  
Recurrent Events ◽  
Recurrent Venous Thromboembolism ◽  
Prospective Assessment ◽  
History Of ◽  
Acute Venous Thromboembolism ◽  
D Dimer

SummaryThe natural history of initially positive D-dimers for venous thromboembolism is not known. If it returns to negative in the majority of patients, it would be potentially helpful to diagnose a recurrence. In this study, we prospectively measured D-dimer levels in outpatients with a diagnosis of venous thrombo-embolism. There were a total of 152 patients with an average age of 57. D-dimer results were performed at baseline and repeated at one week, one month and three months.At baseline 120 of 152 (79%) had a positive D-dimer result. Of those with an initially positive result, 80% were still positive at one week and 39% were still positive at one month. Finally at three months, 13% remained positive. Seven patients had recurrent events and all had persistently elevated D-dimers at one month. This study suggests that a persistently positive D-dimer result after one month of treatment may indicate a higher risk of recurrent venous thromboembolism. D-dimer testing for the diagnosis of recurrence of venous thromboembolism deserves further study.

Family history of venous thromboembolism predicts the diagnosis of acute pulmonary embolism in the emergency department

2018 ◽  
Vol 36 (9) ◽  
pp. 1550-1554 ◽  
Author(s):  
Christopher Kelly ◽  
Chad Agy ◽  
Margaret Carlson ◽  
Jacob Steenblik ◽  
Joseph Bledsoe ◽  
...  
Keyword(s):  
Emergency Department ◽  
Pulmonary Embolism ◽  
Venous Thromboembolism ◽  
Family History ◽  
Acute Pulmonary Embolism ◽  
History Of
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