Abstract
Background
Assessment for pulmonary embolism (PE) in the emergency department (ED) remains complex,
involving clinical decision tools, blood tests, and imaging.
Objective
Our objective was to examine the test characteristics of the high-sensitivity d-dimer for the diagnosis of PE at our institution and evaluate use of the d-dimer and factors associated with a falsely elevated d-dimer.
Methods
We retrospectively collected data on adult patients evaluated with a d-dimer and computed tomography (CT) pulmonary angiogram or ventilation perfusion scan
at two EDs between June 4, 2012 and March 30, 2016. We collected symptoms (dyspnea,
unilateral leg swelling, hemoptysis), vital signs, and medical and social history
(cancer, recent surgery, medications, history of deep vein thrombosis or PE, chronic
obstructive pulmonary disease, smoking). We calculated test characteristics, including
sensitivity, specificity, and likelihood ratios for the assay using conventional threshold
and with age adjustment, and performed a univariate analysis.
Results
We found 3523 unique visits with d-dimer and imaging, detecting 198 PE. Imaging was pursued on 1270 patients with negative
d-dimers, revealing 9 false negatives, and d-dimer was sent on 596 patients for whom negative Pulmonary Embolism Rule-Out Criteria
(PERC) were documented with 2% subsequent radiographic detection of PE. The d-dimer showed a sensitivity of 95.7% (95% confidence interval [CI] 91–98%), specificity
of 40.0% (95% CI 38–42%), negative likelihood ratio of 0.11 (95% CI 0.06–0.21), and
positive likelihood ratio of 1.59 (95% CI 1.53–1.66) for the radiographic detection
of PE. With age adjustment, 347 of the 2253 CT scans that were pursued in patients
older than 50 years with an elevated d-dimer could have been avoided without missing any additional PE. Many risk factors,
such as age, history of PE, recent surgery, shortness of breath, tachycardia and hypoxia,
elevated the d-dimer, regardless of the presence of PE.
Conclusions
Many patients with negative d-dimer and PERC still received imaging. Our data support the use of age adjustment,
and perhaps adjustment for other factors seen in patients evaluated for PE.
Keywords
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Article info
Publication history
Published online: March 01, 2018
Accepted:
January 21,
2018
Received in revised form:
January 7,
2018
Received:
April 26,
2017
Identification
Copyright
© 2018 Elsevier Inc. All rights reserved.
