An Age-Adjusted D-dimer Threshold for

Emergency Department Patients With

Suspected Pulmonary Embolus: Accuracy and
Clinical Implications

Dr Vishnu v k
JR , Emergency Medicine
2nd yr ,AIIMS
Introduction
• Pulmonary embolism can be a difficult condition to diagnose because
clinical presentation is highly variable.
• Use of D dimer testing along with clinical decision rules are recommended
for patients with low to moderate risk of PE.
• High sensitivity of D dimer allows less number of missed PE cases and
false negetives.
• Low specificity results in increased number of advanced imaging.
• Increase in D dimer values with age further increases the false positivity
rates.
Introduction
• Increased incidence of imaging related complications like contrast induced
nephropathy ,acute renal failure with older age.
• Imaging related complications vs missed PTE.
• Age adjusted threshold value and raising the cut off of D dimer.
• False positive D dimer – liver disease , malignancy , Rheumatoid factor ,
trauma ,pregnancy , recent surgery.
• False negative – anticoagulation , delayed testing or too early sample.
Review of literature
• Wohler SC ,Adams et al study (2014)
• Sample size of 923

threshold sensitivity specificity FN

500 ng/dl & D 100% 12.4% 0.55%

dimer +ve
500 ng/dl & D 0%
dimer -ve
Age adjusted 97% 32.4% 0.35%
D dimer +ve
Age adjusted 1.5%
D dimer -ve
Review of literature
• Contrast induced nephropathy & renal failure in CECT
• Mitchel AM & Jones A E et al
• CIN – 11%
• Renal failure – 1%
• Deaths related to CIN – 2%
• CIN occurs in >10% of patients with CECT and is associated with a
significant risk of severe renal failure and death.
Aims & objectives
Primary objective
• Evaluate the sensitivity and specificity of
an age-adjusted D-dimer threshold in
detecting pulmonary embolism among
patients older than 50 years.
Secondary objective
• Compare an age-adjusted limit to the current
standard threshold (500 ng/dL), as well as a higher
fixed limit (1,000 ng/dL)
• To describe the frequency of pulmonary embolism
among patients receiving advanced imaging,
• The proportion of patients receiving low value
imaging with a negative D-dimer test result
• Percentage of those who did not receive imaging
after a positive D-dimer test result,
• Number of “missed” pulmonary embolisms
identified within 30 days of initial ED visit.
Materials & methods
Inclusion criteria Exclusion criteria
• Age > 50 years • Age < 50 years
• Patient presenting with chief complaint • Pulmonary embolism diagnosis in
related to possible pulmonary embolism previous 90 days
• Ultrasonographic imaging for deep vein
thrombosis

• Study design – retrospective study

• Place – 14 ED’s of southern California (2008 – 2013)
Materials & methods
• The primary outcome of analysis was an encounter diagnosis of acute
pulmonary embolism.
• Individualized D-dimer cutoff was made by multiplying the patient’s age
in years by 10.
• Dichotomous D-dimer limits were aggregated to calculate sensitivity,
specificity, positive predictive value, and negative predictive value for the
age-adjusted threshold.
• Current D-dimer limit (500 ng/dL) and a higher fixed cutoff (1,000 ng/dL)
were used to calculate and compare sensitivities, specificities, positive
predictive values, and negative predictive values
Materials & methods
Materials & methods
• Patients who received advanced imaging within 24 hrs of presentation to
ED were included.
• Patients were stratified to D dimer values <500 receiving imaging & more
than cut off values with out imaging.
• To identify any missed pulmonary embolism diagnosis, review of patients
who neither received a pulmonary embolism diagnosis nor underwent
imaging at the initial ED encounter, but subsequently received a
pulmonary embolism diagnosis within 30 days of the index ED encounter
was performed.
Materials & methods
• Estimation of results of CIN, episodes of renal failure & deaths related to
CIN according to the sensitivity and specificity of the different D-dimer
thresholds were made based on the previously published values
(11% ,0.9% ,0.6%)
• Patients who had AKI or unspecified renal failure diagnosis within 30 days
of ED encounter were grouped to patients with imaging and without
imaging.
• These results were used to create estimates for events per 10,000 suspected
pulmonary embolism encounters
Materials &
methods
31094 patients had D dimer tests
PE diagnosis in 507
NO PE in 30587
Missed PE within 30 days - 12
Results
threshold sensitivity specificity PPV NPV FN

Age adjusted 92.9% 63.9% 4.1% 99.8% 7.1

threshold

500 ng/dl 98.0% 54.4% 3.4% 99.9% 2.0

1000 ng/dl 84.2% 75.4% 5.4% 99.7% 15.8

Results
Results
• Age-adjusted D-dimer threshold was more specific but less sensitive than
a conventional threshold of 500 ng/dL and resulted in approximately 20%
fewer false-positive test results requiring follow-up imaging.
• Approximately 40% of ED patients with suspected pulmonary embolism
received advanced chest imaging, including 11% who had a D-dimer value
below the conventional threshold.
• Among patients who did not receive chest imaging, 17.6% had a D-dimer
concentration above the threshold for a positive test result
• Missed pulmonary embolisms were rare (2.3%).
• The cutoff of 1,000 ng/dL had the best specificity (75.4%) but low
sensitivity (84.2%) to justify use in current clinical practice.
Results
• Among patients who underwent imaging there was an excess of 0.74%
cases of acute kidney injury or unspecified renal failure compared with
that for patients who did not undergo CT pulmonary angiography.
Results
Limitations
• Retrospective study.
• Missed PE within 30 days of ED encounter was documented.
• PE wells score was not included in the criteria.
• Type of missed PE cases ?
THANK YOU