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D-Dimer beyond Diagnosis of Pulmonary Embolism: Its Implication for Long-Term Prognosis in Cardio-Oncology Era. J Pers Med 2023; 13:jpm13020226. [PMID: 36836459 PMCID: PMC9962345 DOI: 10.3390/jpm13020226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 01/20/2023] [Accepted: 01/22/2023] [Indexed: 01/31/2023] Open
Abstract
Venous thromboembolism (VTE) is a common comorbidity of cancer, often referred to as cancer-associated thrombosis (CAT). Even though its prevalence has been increasing, its clinical picture has not been thoroughly investigated. In this single-center retrospective observational study, 259 patients who were treated for pulmonary embolism (PE) between January 2015 and December 2020 were available for analysis. The patients were divided by the presence or absence of concomitant malignancy, and those with malignancy (N = 120, 46%) were further classified into active (N = 40, 15%) and inactive groups according to the treatment status of malignancy. In patients with malignancy, PE was more often diagnosed incidentally by computed tomography or D-dimer testing, and the proportion of massive PE was lower. Although D-dimer levels overall decreased after the initiation of anticoagulation therapy, concomitant malignancy was independently associated with higher D-dimer at discharge despite the lower severity of PE at onset. The patients with malignancy had a poor prognosis during post-discharge follow-up. Active malignancy was independently associated with major adverse cardiovascular events (MACE) and major bleeding. D-dimer at discharge was an independent predictor of mortality even after adjustment for malignancy. This study's findings suggest that CAT-PE patients might have hypercoagulable states, which can potentially lead to a poorer prognosis.
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Di Minno MND, Calcaterra I, Papa A, Lupoli R, Di Minno A, Maniscalco M, Ambrosino P. Diagnostic accuracy of D-Dimer testing for recurrent venous thromboembolism: A systematic review with meta-analysis.: VTE recurrence and D-dimer. Eur J Intern Med 2021; 89:39-47. [PMID: 33933338 DOI: 10.1016/j.ejim.2021.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 04/02/2021] [Accepted: 04/07/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Venous thromboembolism (VTE) recurrence is a major concern after a first symptomatic episode, potentially impacting survival and healthcare needs in community, hospital and rehabilitation settings. We evaluated the association of D-Dimer positivity after oral anticoagulant therapy (OAT) discontinuation with VTE recurrence. METHODS PubMed, Web of Science, Scopus and EMBASE databases were systematically searched. Differences were expressed as Odds Ratio (OR) with 95% confidence intervals (95%CI). Pooled sensitivity, specificity, positive (PLR) and negative likelihood ratio (NLR), and summary ROC (sROC) curve were calculated. RESULTS Twenty-six articles on 10,725 VTE patients showed that the absolute risk of recurrence was 16.1% (95%CI: 13.2%-19.5%) among 4,049 patients with a positive D-Dimer and 7.4% (95%CI: 6.0%-9.0%) in 6,676 controls (OR: 2.1, 95%CI: 1.7-2.8, P<0.001), with an attributable risk of 54.0%. sROC curve of the association between positive D-Dimer and recurrence showed a diagnostic AUC of 63.8 (95%CI: 60.3-67.4), with a pooled sensitivity of 54.3% (95%CI: 51.3%-57.3%), specificity of 64.2% (95%CI: 63.2-65.1), PLR of 1.53 (95%CI: 1.37-1.72), and NLR of 0.71 (95%CI: 0.60-0.84). Subgroup and meta-regression analyses suggested that a positive D-Dimer may have a higher discriminatory ability for patients with provoked events, confirmed by better pooled diagnostic indexes for recurrence and a diagnostic AUC of 70.6 (95%CI: 63.8-77.4). Regression models showed that the rate of OAT resumption after the evidence of D-Dimer positivity was inversely associated with VTE recurrence (Z-score: -3.91, P<0.001). CONCLUSIONS D-Dimer positivity after OAT may identify VTE patients at higher risk of recurrence, with a better diagnostic accuracy for provoked events.
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Affiliation(s)
| | - Ilenia Calcaterra
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Antimo Papa
- Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Roberta Lupoli
- Department of Molecular Medicine and Medical Biotechnology Federico II University, Naples, Italy
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Developing and testing of a screening tool to predict people without IgE-mediated allergy: a quantitative analysis of the predictive value of a screening tool. Br J Gen Pract 2017; 67:e293-e299. [PMID: 28246099 DOI: 10.3399/bjgp17x689869] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 08/23/2016] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Consultations in primary care for allergies are common. It can be difficult to differentiate between IgE-mediated (atopic) symptoms - which respond to allergen-specific interventions - and those that are non-atopic, without performing objective tests that are largely unavailable in UK general practice. AIM To develop and test a screening tool that can accurately discriminate between atopic and non-atopic individuals. DESIGN AND SETTING A validation study that took place in 2012 in adult volunteers aged >16 years in Scotland. METHOD A questionnaire screening tool was developed using questions from a large cohort study and through consultation with experts. Participants answered the questions and had skin prick tests for four aeroallergens (house dust mite, cat, dog, and mixed grasses). Participants were classified as atopic if any average wheal diameter was ≥3 mm bigger than the negative control. Sensitivity, specificity, and positive and negative predictive values of individual and combinations of questions were calculated. RESULTS In all, 143 participants completed the questionnaire and underwent skin prick testing. Of these, 81 (56.6%) were atopic. Negative predictive values for the individual questions ranged from 48.2% (55 not atopic out of 114 negative answers) to 72.0% (18/25). An optimum combination of four questions was identified, in which a negative answer to all four questions was reported by 24 participants, 21 (87.5%) of whom were not atopic. CONCLUSION The authors have identified a set of questions that correctly predict negative skin prick tests to common aeroallergens 88% of the time. These may be useful to exclude patients who do not warrant further investigation and who can reliably be advised that allergen avoidance is neither necessary nor helpful.
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Guo DJ, Zhao C, Zou YD, Huang XH, Hu JM, Guo L. Values of the Wells and revised Geneva scores combined with D-dimer in diagnosing elderly pulmonary embolism patients. Chin Med J (Engl) 2015; 128:1052-7. [PMID: 25881599 PMCID: PMC4832945 DOI: 10.4103/0366-6999.155085] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Pulmonary embolism (PE) can be difficult to diagnose in elderly patients because of the coexistent diseases and the combination of drugs that they have taken. We aimed to compare the clinical diagnostic values of the Wells score, the revised Geneva score and each of them combined with D-dimer for suspected PE in elderly patients. METHODS Three hundred and thirty-six patients who were admitted for suspected PE were enrolled retrospectively and divided into two groups based on age (≥65 or <65 years old). The Wells and revised Geneva scores were applied to evaluate the clinical probability of PE, and the positive predictive values of both scores were calculated using computed tomography pulmonary arteriography as a gold standard; overall accuracy was evaluated by the area under the curve (AUC) of receiver operator characteristic curve; the negative predictive values of D-dimer, the Wells score combined with D-dimer, and the revised Geneva score combined with D-dimer were calculated. RESULTS Ninety-six cases (28.6%) were definitely diagnosed as PE among 336 cases, among them 56 cases (58.3%) were ≥65 years old. The positive predictive values of Wells and revised Geneva scores were 65.8% and 32.4%, respectively (P < 0.05) in the elderly patients; the AUC for the Wells score and the revised Geneva score in elderly was 0.682 (95% confidence interval [CI]: 0.612-0.746) and 0.655 (95% CI: 0.584-0.722), respectively (P = 0.389). The negative predictive values of D-dimer, the Wells score combined with D-dimer, and the revised Geneva score combined with D-dimer were 93.7%, 100%, and 100% in the elderly, respectively. CONCLUSIONS The diagnostic value of the Wells score was higher than the revised Geneva score for the elderly cases with suspected PE. The combination of either the Wells score or the revised Geneva score with a normal D-dimer concentration is a safe strategy to rule out PE.
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Affiliation(s)
- Dan-Jie Guo
- Department of Cardiology, Peking University People's Hospital, Beijing 100044, China
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Levin D, Seo JB, Kiely DG, Hatabu H, Gefter W, van Beek EJR, Schiebler ML. Triage for suspected acute Pulmonary Embolism: Think before opening Pandora's Box. Eur J Radiol 2015; 84:1202-11. [PMID: 25864020 DOI: 10.1016/j.ejrad.2015.03.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Revised: 02/26/2015] [Accepted: 03/23/2015] [Indexed: 12/22/2022]
Abstract
This is a review of the current strengths and weaknesses of the various imaging modalities available for the diagnosis of suspected non-massive Pulmonary Embolism (PE). Without careful consideration for the clinical presentation, and the timely application of clinical decision support (CDS) methodology, the current overutilization of imaging resources for this disease will continue. For a patient with a low clinical risk profile and a negative D-dimer there is no reason to consider further workup with imaging; as the negative predictive value in this scenario is the same as imaging. While the current efficacy and effectiveness data support the continued use of Computed Tomographic angiography (CTA) as the imaging golden standard for the diagnosis of PE; this test does have the unintended consequences of radiation exposure, possible overdiagnosis and overuse. There is a persistent lack of appreciation on the part of ordering physicians for the effectiveness of the alternatives to CTA (ventilation-perfusion imaging and contrast enhanced magnetic resonance angiography) in these patients. Careful use of standardized protocols for patient triage and the application of CDS will allow for a better use of imaging resources.
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Affiliation(s)
- David Levin
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Joon Beom Seo
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, M-15, M-Floor, Royal Hallamshire Hospital, Sheffield, UK
| | - Hiroto Hatabu
- Department of Radiology, Brigham and Women's Hospital and Harvard Medical School Boston, MA, USA
| | - Warren Gefter
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Mark L Schiebler
- Department of Radiology, UW-Madison School of Medicine and Public Health, 600 Highland Avenue, Madison, WI 53792-3252, USA.
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Mousa AY, Broce M, Gill G, Kali M, Yacoub M, AbuRahma AF. Appropriate use of D-dimer testing can minimize over-utilization of venous duplex ultrasound in a contemporary high-volume hospital. Ann Vasc Surg 2014; 29:311-7. [PMID: 25286110 DOI: 10.1016/j.avsg.2014.07.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Revised: 06/27/2014] [Accepted: 07/30/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND The sensitivity of d-dimer (DD) in detecting deep venous thrombosis (DVT) is remarkably high; however, many institutions send patients immediately for a venous duplex ultrasound (VDU). This study was designed to examine the appropriate utilization of DD and VDU in a high-volume hospital. METHODS A retrospective study was conducted on consecutive patients who presented to a high-volume emergency department (ED) with lower extremity limb swelling/pain over a 30-day period, who were sent for VDU during an evaluation for DVT. VDU data were merged with electronic DD laboratory results. The enzyme-linked immunosorbent assay method was used to provide DD values and thresholds. Values above 0.60 mg/fibrinogen equivalent unit (FEU) were considered abnormal. RESULTS We reviewed the medical records of 517 ED patients in the month of June 2013. After applying the Wells criteria, 157 patients (30.4%) were excluded because of a history of DVT or pulmonary embolism, having been screened for shortness of breath, or sent for surveillance-leaving 360 for analysis. The average age was 59.3 ± 16.5 years with more women (210, 58.3%) and the majority reported limb pain or swelling (73.9%). DD was performed on 51 patients with an average value of 3.6 ± 5.4 mg/FEU, of which 43 (84.3%) were positive. DD identified all positive and negative DVT patients (100% sensitivity and negative predictive value), but also included 40 false positives (16.7% specificity). On the other hand, 309 patients were sent directly to VDU without DD; of those, 43 (13.9%) were positive for DVT. However, 266 (86.1%) patients were negative for DVT by VDU without DD and these were deemed improper by our current study protocol. Potential charge savings were calculated as VDU for all (360 × $1000 = $360,000), DD for all (360 × $145 = $52,200), and VDU for both true and false positives (estimated to be about 25% of the cases; 90 × $1000 = $90,000); this equals a charge savings of $217,800 and would avoid unnecessary VDUs. CONCLUSIONS Based on the results of our study, we suggest that the DD test be utilized during the initial work-up for patients with limb swelling/pain in the emergency room. Appropriate utilization of DD, as well as other clinical criteria, may limit the over-utilization and added cost of VDU, without a negative impact on patient care. The results of DD tests should be utilized to limit the number of patients sent for VDU to only those patients with a positive DD or other significant underlying concerns.
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Affiliation(s)
- Albeir Y Mousa
- Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, WV.
| | - Mike Broce
- CAMC Health Education and Research Institute, Charleston, WV
| | - Gurpreet Gill
- Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, WV
| | - Maher Kali
- CAMC Health Education and Research Institute, Charleston, WV
| | - Michael Yacoub
- Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, WV
| | - Ali F AbuRahma
- Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, WV
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Smithburger PL, Campbell S, Kane-Gill SL. Alteplase treatment of acute pulmonary embolism in the intensive care unit. Crit Care Nurse 2014; 33:17-27. [PMID: 23547122 DOI: 10.4037/ccn2013626] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Acute pulmonary embolism accounts for 50 000 to 100 000 deaths each year in the United States. Because of the wide spectrum of clinical manifestations, ranging from massive pulmonary embolism to small peripheral emboli, stratifying and treating patients according to their signs and symptoms is important when an acute embolism is suspected. Patients' clinical findings can range from no signs or symptoms to unstable hemodynamic status and shock. The 3-month mortality is 10% to 15%, but can be as high as 60% in patients with hemodynamic shock. This article reviews the classifications of acute peripheral emboli, explains the treatment of acute peripheral emboli, reviews the pharmacology of alteplase, and presents an assessment of the literature evaluating alteplase for the treatment of acute peripheral emboli. Clinical pearls for the administration, monitoring, and care of a patient receiving alteplase in an intensive care unit also are discussed.
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Affiliation(s)
- Pamela L Smithburger
- University of Pittsburgh School of Pharmacy, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh PA 15213, USA.
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Palareti G. Recurrent venous thromboembolism: what is the risk and how to prevent it. SCIENTIFICA 2012; 2012:391734. [PMID: 24278687 PMCID: PMC3820456 DOI: 10.6064/2012/391734] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Accepted: 09/10/2012] [Indexed: 05/07/2023]
Abstract
Venous thromboembolism (VTE) that includes deep vein thrombosis and/or pulmonary embolism is a frequent, severe, and potentially lethal disease. After a first episode, VTE has a strong tendency to recur. While VTE is an acute disease, it may have variable outcomes in early and late phases after initial presentation. Furthermore, the incidence of late, clinically important consequences (postthrombotic syndrome and/or chronic thromboembolic pulmonary hypertension) increases in case of recurrent events. The aims of the present review are (i) to analyze the incidence and risk factors for recurrence of VTE (either those related to the type of first thrombotic event or to the patients), the risks associated with occurrence of recurrent events, and the problems linked to the diagnosis, not always easy, of recurrent events; (ii) to discuss whether or not it is possible to predict the individual risk of recurrence after a first event, by stratifying patients at high or low risk of recurrence, and how this can influence their treatment; (iii) to comment what the current guidelines and guidance suggest/recommend about anticoagulant treatment after a first VTE event and, finally, to propose practical indications on how to manage individual patients affected by VTE.
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Affiliation(s)
- Gualtiero Palareti
- Department of Angiology and Blood Coagulation, Via Albertoni 15, 40138 Bologna (BO), Italy
- *Gualtiero Palareti:
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