Prediction rules and POC D-dimer testing as a way to prevent diagnostic delay of fatal pulmonary embolism (original) (raw)
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Annals of Internal Medicine, 2001
When you're called to the bedside to evaluate an acutely hypoxic patient, one of the first things running through your mind that you would not want to miss is pulmonary embolism. This article is one of a few studies in which Dr. Wells demonstrated the utility of his scoring system for determining the pre-test probability for PEs, known now as the Wells Criteria. This study evaluated 946 patients, and based on the criteria, divided them into low, moderate and high probability of having a PE. These criteria included: clinical signs and symptoms of DVT (3 points), PE as the most likely diagnosis (3 points), tachycardia (1.5 points), immobilization for at least 3 days or surgery within the previous 4 weeks (1.5 points), previous objectively diagnosed PE or DVT (1.5 points), hemoptysis (1 point), and malignancy (1 point). Risk score interpretation (probability of PE) was the following: >6 points: high risk (78.4%); 2 to 6 points: moderate risk (27.8%); <2 points: low risk (3.4%) Based on their pre-test probability, further tests to risk stratify these patients included D-dimer, V/Q scan, and LE ultrasound. They treated patients found to have PE or DVT by V/Q and LE ultrasound and followed all patients for 3 months. The proportion of patients found to have PE was 1.3% of the low probability group, 16.2% of the moderate probability group, and 37.5% of the high probability group. Of the 849 patients not treated for PE, 5 (0.6%) developed PE or DVT in follow-up. In low suspicion of PE, a normal D-dimer level was shown to be enough to exclude the possibility of thrombotic PE without ordering other excessive diagnostic modalities.
Journal of Thrombosis and Haemostasis, 2005
To cite this article: Kline JA, Mitchell AM, Kabrhel C, Richman PB, Courtney DM. Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. J Thromb Haemost 2004; 2: 1247-55. See also Le Gal G, Bounameaux H. Diagnosing pulmonary embolism: running after the decreasing prevalence of cases among suspected patients. This issue, pp 1244-6; Linkins L.-A., Bates SM, Ginsberg JS, Kearon C. Use of different D-dimer levels to exclude venous thromboembolism depending on clinical pretest probability. This issue, pp 1256-60.
Thrombosis Research, 2010
Background In patients with suspected pulmonary embolism (PE), an unlikely or non-high probability assessment combined with a normal D-dimer test can safely exclude the diagnosis. We, therefore, studied the influence of early D-dimer knowledge on clinical probability assessment. Methods A questionnaire was sent to 150 randomly selected pulmonologists and internists in the Netherlands, presenting six hypothetical case-descriptions of patients with suspected PE. Physicians were randomized to receive one of three versions. The version contained a normal, an abnormal or no D-dimer result with each case-description. Each version contained two cases with an abnormal D-dimer result, two cases with a normal D-dimer result and two cases with no D-dimer result. Results A total of 71 physicians (47%) returned the questionnaire; the three versions were equally represented. Compared to the control cases in which no D-dimer was given, knowledge of an abnormal D-dimer resulted in more "likely" clinical scores using the Wells' rule (absolute increase in "likely" of 25-37%, p=0.005, 0.111 and 0.144), while knowledge of a normal D-dimer resulted in more "unlikely" scores (absolute increase in "unlikely" of 27-44%, p=0.001 and 0.070). D-dimer knowledge did not influence the probability assessment when the clinical suspicion was very high. Conclusion Knowledge of the D-dimer test influences the physician in how the clinical probability for PE is scored. This will have direct clinical consequences, such as unnecessary imaging testing or inappropriate exclusion of the diagnosis. Physicians should therefore make sure that they examine the patient before they take notice of the D-dimer test result.
Thrombosis and haemostasis, 2000
We 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 wi...
Academic Emergency Medicine, 2006
This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology The study examined the use of the quantitative D-dimer assay in evaluating patients for suspected pulmonary embolism (PE). Type of intervention Diagnosis. Economic study type Cost-utility analysis. Study population The study population comprised patients presenting to an urban emergency department with suspected PE. Setting The setting was secondary care. The economic study was carried out in the USA.
BMC Family Practice, 2010
Background: In secondary care the Wells clinical decision rule (CDR) combined with a quantitative D-dimer test can exclude pulmonary embolism (PE) safely. The introduction of point-of-care (POC) D-dimer tests facilitates a similar diagnostic strategy in primary care. We estimated failure-rate and efficiency of a diagnostic strategy using the Wells-CDR combined with a POC-D-dimer test for excluding PE in primary care. We considered ruling out PE safe if the failure rate was <2% with a maximum upper confidence limit of 2.7%. Methods: We performed a scenario-analysis on data of 2701 outpatients suspected of PE. We used test characteristics of two qualitative POC-D-dimer tests, as derived from a meta-analysis and combined these with the Wells-CDR-score.