No added value of the age‐adjusted D‐dimer cut‐off to the YEARS algorithm in patients with suspected pulmonary embolism

No added value of the age‐adjusted D‐dimer cut‐off to the YEARS algorithm in patients with suspected pulmonary embolism

Essentials Imaging is warranted in the majority of patients to confirm or rule out pulmonary embolism (PE). The age‐adjusted D‐dimer (ADJUST) reduced the number of required imaging tests in patients ≥ 50 years. The YEARS algorithm was designed to improve the efficiency in patients with suspected PE....

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Bibliographic Details
Published in:Journal of thrombosis and haemostasis Vol. 15; no. 12; pp. 2317 - 2324
Main Authors: Pol, L. M., Hulle, T., Cheung, Y. W., Mairuhu, A. T. A., Schaar, C. G., Faber, L. M., Wolde, M., Hofstee, H. M. A., Hovens, M. M. C., Nijkeuter, M., Klink, R. C. J., Kruip, M. J. H. A., Middeldorp, S., Huisman, M. V., Klok, F. A.
Format: Journal Article
Language:English
Published: England Elsevier Limited 01-12-2017
Subjects:
Aged
Algorithms
Angiography
clinical decision rule
Computed tomography
Computed Tomography Angiography
diagnosis
D‐dimer
Embolism
Embolisms
Female
Fibrin Fibrinogen Degradation Products - metabolism
Health risk assessment
Hemoptysis
Humans
Male
Medical imaging
Middle Aged
Prospective Studies
Pulmonary arteries
Pulmonary Embolism - blood
Pulmonary Embolism - diagnosis
Pulmonary Embolism - diagnostic imaging
Pulmonary embolisms
Software Design
Thromboembolism
Thrombosis
venous thromboembolism
computed tomography
D-dimer
clinical decision rule
diagnosis
venous thromboembolism
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Summary:Essentials Imaging is warranted in the majority of patients to confirm or rule out pulmonary embolism (PE). The age‐adjusted D‐dimer (ADJUST) reduced the number of required imaging tests in patients ≥ 50 years. The YEARS algorithm was designed to improve the efficiency in patients with suspected PE. There was no added value of implementing ADJUST in the YEARS algorithm in our cohort. Summary Background The YEARS algorithm was designed to simplify the diagnostic work‐up of pulmonary embolism (PE) and to reduce the number of necessary computed tomography pulmonary angiography (CTPA) scans. An alternative strategy to reduce the number of CTPAs is the age‐adjusted D‐dimer cut‐off (ADJUST) in patients aged 50 years or older. We aimed to investigate whether a combination of both diagnostic strategies might save additional CTPAs. Methods The YEARS algorithm consists of three items (clinical signs of deep venous thrombosis, hemoptysis, ‘PE most likely diagnosis’) with simultaneous D‐dimer testing using a pre‐test dependent threshold. We performed a post hoc analysis in 3465 patients managed according to YEARS to compare the number of patients managed without CTPA scans and associated diagnostic failures in hypothetical scenarios with different YEARS‐ADJUST combinations. Results Following the YEARS algorithm, 1651 patients (48%) were managed without CTPA; PE was diagnosed in 456 (13%) patients at baseline and 18 patients with initial normal testing suffered venous thromboembolism (VTE) during 3‐month follow‐up (failure rate 0.61%; 95% confidence interval [CI], 0.36–0.96). If ADJUST had been fully integrated in YEARS, 1627 patients (47%) would have been managed without CTPA (absolute decrease of 0.69%; 95% CI −1.7 to 3.0), at cost of four additional missed PE diagnoses at baseline, for a projected 3‐month VTE failure rate of 0.75% (95% CI, 0.49–1.13). None of the other studied scenarios showed relevant improvements in efficiency as well, but all led to more missed diagnoses. Conclusion In our cohort, there was no added value of implementing ADJUST in the YEARS algorithm.
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ISSN:1538-7933
1538-7836
1538-7836
DOI:10.1111/jth.13852