Abstract
Background
D-dimer testing rules out deep vein thrombosis (DVT) and pulmonary embolism (PE) in
low-risk emergency department (ED) patients. Most research has measured fibrin-equivalent
units (FEUs), however, many laboratories measure D-dimer units (DDUs).
Objective
Our aim was to determine whether either DDU measurements or FEU measurements can rule
out DVT/PE using traditional or age-related cutoff values.
Methods
We performed a de-identified multicenter retrospective evaluation of D-dimer in nonpregnant
adult ED patients to evaluate for DVT/PE. DDUs were multiplied by 2 to determine equivalent
FEUs prior to analysis. Sensitivity measurements for D-dimer were calculated for FEUs,
DDUs, combined FEU/DDUs, and multiple age-adjusted values.
Results
We identified 47,088 ED patients with a D-dimer laboratory value (27,307 FEUs/19,781
DDUs) and 1623 DVT/PEs. The median combined FEU/DDU D-dimer was 400 ng/mL FEUs (interquartile
range [IQR] 300–900 ng/mL FEUs) for patients without a DVT/PE vs 2530 ng/mL FEU (IQR
1094–6000 ng/mL FEUs) with a DVT/PE (p < 0.001), overall sensitivity of 87.3% (95% confidence interval [CI] 87.0–87.6%)
and negative predictive value of 99.3% (95% CI 99.2–99.4%). Individually, FEUs performed
better than DDUs, with sensitivities of 88.0% (95% CI 85.8–89.9%) and 86.1% (95% CI
83.1–88.7%), respectively; however, this difference was not statistically significant.
Combined age-adjusted performance had a sensitivity of 90.3% (95% CI 88.3–92.0%);
however, a new DDU-only age-adjusted criteria had the highest sensitivity of 91.1%
(95% CI 87.9–93.6%).
Conclusions
Our undifferentiated D-dimer measurements had a slightly lower sensitivity to rule
out DVT/PE than reported previously. Our data support using either DDU or FEU measurements
for all ages or when using various age-adjusted criteria to rule out DVT/PE.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of Emergency MedicineAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Long-term cardiovascular and noncardiovascular mortality of 1023 patients with confirmed acute pulmonary embolism.Circ Cardiovasc Qual Outcomes. 2011; 4: 122-128
- Widely used types and clinical applications of D-dimer assay.Lab Med. 2016; 47: 90-102
- Simplification of the Revised Geneva Score for assessing clinical probability of pulmonary embolism.Arch Intern Med. 2008; 168: 2131-2136
- PERC rule to exclude the diagnosis of pulmonary embolism in emergency low-risk patients: study protocol for the PROPER randomized controlled study.Trials. 2015; 16: 1-8
- Prospective multicenter evaluation of the pulmonary embolism rule-out criteria.J Thromb Haemost. 2008; 6: 772-780
- Clinical characteristics, management, and outcomes of patients diagnosed with acute pulmonary embolism in the emergency department: initial report of EMPEROR (Multicenter Emergency Medicine Pulmonary Embolism in the Real World Registry).J Am Coll Cardiol. 2011; 57: 700-706
- D-dimer testing for suspected pulmonary embolism in outpatients.Am J Respir Crit Care Med. 1997; 156: 492-496
- D-dimer: preanalytical, analytical, postanalytical variables, and clinical applications.Crit Rev Clin Lab Sci. 2018; 55: 548-577
- Wells rule and D-dimer testing to rule out pulmonary embolism a systematic review and individual-patient data meta–analysis.Ann Intern Med. 2016; 165: 253-261
- Review of D-dimer testing: good, bad, and ugly.Int J Lab Hematol. 2017; 39: 98-103
- Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism.J Thromb Haemost. 2004; 2: 1247-1255
- D-dimer: sSimple test, tough problems.Arch Pathol Lab Med. 2013; 137: 1030-1038
- Comparison of Wells and YEARS clinical decision rules with D-dimer for low-risk pulmonary embolus patients.Intern Med J. 2019; 49: 739-744
- Investigation of age-adjusted D-dimer using an uncommon assay.Am J Emerg Med. 2019; 37: 1285-1288
- Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with suspected acute venous thromboembolic disease.Ann Emerg Med. 2018; 71: e59-e109https://doi.org/10.1016/j.annemergmed.2018.03.006
- Comparison of diagnostic accuracies in outpatients and hospitalized patients of D-dimer testing for the evaluation of suspected pulmonary embolism.Clin Chem. 2003; 49: 1483-1490
- 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS).Eur Heart J. 2020; 41: 543-603
- Risk of venous thromboembolic disease in women a qualitative systematic review.Eur J Obstet Gynecol Reprod Biol. 2005; 121: 8-17
- Sex and gender issues and venous thromboembolism.Clin Chest Med. 2004; 25: 281-297
- Impact of gender on the clinical presentation and diagnosis of deep-vein thrombosis.Thromb Haemost. 2010; 103: 710-717
- Differences in clinical presentation of deep vein thrombosis in men and women.J Thromb Haemost. 2008; 6: 1713-1719
- Effectiveness of D-dimer as a screening test for venous thromboembolism: an update.N Am J Med Sci. 2014; 6: 491-499
Article info
Publication history
Published online: April 30, 2022
Accepted:
April 23,
2022
Received in revised form:
February 14,
2022
Received:
October 10,
2021
Footnotes
☆ Portions of the data were presented at the Society for Academic Emergency Medicine Southeastern Regional Meeting in Greenville, SC, February 21–22, 2020.
Identification
Copyright
© 2022 Published by Elsevier Inc.
