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Naum AG, Jari I, Moisii L, Ursu AM, Moisii P. Imaging and Biomarkers: The Assesment of Pulmonary Embolism Risk and Early Mortality. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1489. [PMID: 39336530 PMCID: PMC11433879 DOI: 10.3390/medicina60091489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2024] [Revised: 08/13/2024] [Accepted: 08/29/2024] [Indexed: 09/30/2024]
Abstract
Background and Objectives: Pulmonary embolism (PE) incidence has been increasing in the last 10 years. Computed thoracic pulmonary angiography (CTPA) had a major role in PE diagnosis and prognosis. The main purpose of this study was as follows: the prognostic value of a CTPA parameter, pulmonary artery obstruction index (PAOI), in PE risk assessment and the predictive accuracy of biomarkers, D-dimer and cardiac Troponin T (c-TnT), in 7-day mortality. A second objective of the research was to investigate the relationship between imaging by PAOI and these biomarkers in different etiologies of PE. Materials and Methods: This study comprised 109 patients with PE, hospitalized and treated between February 2021 and August 2022. They had different etiologies of PE: deep vein thrombosis (DVT); persistent atrial fibrillation (AF); chronic obstructive pulmonary disease (COPD) exacerbation; COVID-19; and cancers. The investigations were as follows: clinical examination; D-dimer testing, as a mandatory method for PE suspicion (values ≥500 µg/L were highly suggestive for PE); c-TnT, as a marker of myocardial injury (values ≥14 ng/L were abnormal); CTPA, with right ventricle dysfunction (RVD) signs and PAOI. Treatments were according to PE risk: systemic thrombolysis in high-risk PE; low weight molecular heparins (LWMH) in high-risk PE, after systemic thrombolysis or from the beginning, when systemic thrombolysis was contraindicated; and direct oral anticoagulants (DOAC) in low- and intermediate-risk PE. Results: PAOI had a high predictive accuracy for high-risk PE (area under curve, AUC = 0.993). D-dimer and cTnT had a statistically significant relationship with 7-day mortality for the entire sample, p < 0.001, and for AF, p = 0.0036; COVID-19, p = 0.003; and cancer patients, p = 0.005. PAOI had statistical significance for 7-day mortality only in COVID-19, p = 0.045, and cancer patients, p = 0.038. The relationship PAOI-D-dimer and PAOI-c-TnT had very strong statistical correlation for the entire sample and for DVT, AF, COPD, and COVID-19 subgroups (Rho = 0.815-0.982). Conclusions: PAOI was an important tool for PE risk assessment. D-dimer and c-TnT were valuable predictors for 7-day mortality in PE. PAOI (imaging parameter for PE extent) and D-dimer (biomarker for PE severity) as well as PAOI and c-TnT (biomarker for myocardial injury) were strongly correlated for the entire PE sample and for DVT, AF, COPD, and COVID-19 patients.
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Affiliation(s)
- Alexandru Gratian Naum
- 2nd Morphofunctional Sciences Department, Biophysics and Medical Physics, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania;
- “Neolife” Medical Center, 52 Carol I Avenue, 700503 Iasi, Romania
| | - Irina Jari
- 2nd Surgical Department, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania;
- St. Spiridon Emergency Hospital, Radiology and Medical Imaging Clinique, 1st Independentei Avenue, 700111 Iasi, Romania;
| | - Liliana Moisii
- 2nd Surgical Department, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania;
- St. Spiridon Emergency Hospital, Radiology and Medical Imaging Clinique, 1st Independentei Avenue, 700111 Iasi, Romania;
| | - Andra Mara Ursu
- St. Spiridon Emergency Hospital, Radiology and Medical Imaging Clinique, 1st Independentei Avenue, 700111 Iasi, Romania;
| | - Paloma Moisii
- 1st Medical Department “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
- Promedicanon “Cardiology Office”, 15 Prisacii Valley, 707410 Valea Lupului, Romania
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Falster C, Mørkenborg MD, Thrane M, Clausen J, Arvig M, Brockhattingen K, Biesenbach P, Paludan L, Nielsen RW, Nhi Huynh TA, Poulsen MK, Brabrand M, Møller JE, Posth S, Laursen CB. Utility of ultrasound in the diagnostic work-up of suspected pulmonary embolism: an open-label multicentre randomized controlled trial (the PRIME study). THE LANCET REGIONAL HEALTH. EUROPE 2024; 42:100941. [PMID: 39070742 PMCID: PMC11281927 DOI: 10.1016/j.lanepe.2024.100941] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 05/09/2024] [Accepted: 05/10/2024] [Indexed: 07/30/2024]
Abstract
Background Prevalence of pulmonary embolism (PE) in patients referred to diagnostic imaging is decreasing, indicating a need for improving patient selection. The aim of this study was to assess reduction in referral to diagnostic imaging by integrating a bespoke ultrasound protocol and describe associated failure rate and adverse events in patients with suspected PE. Methods In a randomized open-label multicentre trial spanning June 18, 2021, through Feb 1, 2023, adult patients with suspected PE and 1) a Wells score of 0-6 and elevated age-adjusted D-dimer or 2) Wells score >6 were randomly assigned 1:1 to direct diagnostic imaging (controls) or focused lung, cardiac, and deep venous ultrasound by unblinded investigators. Ultrasound could: 1) dismiss PE if no signs of PE and low clinical suspicion or an alternate diagnosis, 2) confirm PE in case of visible venous thrombus, ≥2 subpleural infarctions, McConnell's, or D-sign, or 3) refer to diagnostic imaging if neither category was fulfilled or a patient with confirmed PE by ultrasound required admission. Primary endpoint was proportion of patients referred to diagnostic imaging. Outcome assessors were not blinded to group assignment. All included participants were included in safety analyses. The trial was registered at clinicaltrials.gov (NCT04882579). Findings A total of 150 patients were recruited, of whom 73 were randomized to ultrasound. Among 77 controls referred to diagnostic imaging, 26 patients had PE confirmed. In the ultrasound group, 40 patients were referred to diagnostic imaging of whom 20 had PE, reducing referral for diagnostic imaging by 45.2% (95% CI: 34.3-56.6, p < 0.0001). Three further PEs were diagnosed by presence of a DVT. During 3-month follow-up, the number of patients who did not receive anticoagulation but was diagnosed with PE was two (4%; 95% CI: 1.1-13.5) and none (0%; 95% CI: 0.0-7.0) in the ultrasound and control group, respectively. Interpretation Ultrasound substantially reduced referral to diagnostic imaging in suspected PE. Albeit with an unacceptable failure rate. Funding University of Southern Denmark, Odense University Hospital, Master Carpenter Sophus Jacobsen and wife's foundation, Engineer K. A. Rhode and wife foundation.
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Affiliation(s)
- Casper Falster
- Odense Respiratory Research Unit (ODIN), University of Southern Denmark, Odense, Denmark
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
- Open Patient Data Explorative Network (OPEN), Odense University Hospital, Region of Southern Denmark
| | | | - Mikkel Thrane
- Department of Geriatrics, Odense University Hospital, Odense, Denmark
| | - Jesper Clausen
- Department of Internal Medicine, Svendborg Hospital, Svendborg, Denmark
| | - Michael Arvig
- Emergency Department, Slagelse Hospital, Slagelse, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Kristoffer Brockhattingen
- Department of Geriatrics, Odense University Hospital, Odense, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Peter Biesenbach
- Department of Emergency Medicine, Esbjerg Hospital, Esbjerg, Denmark
| | - Lasse Paludan
- Department of Emergency Medicine, Kolding Hospital, Kolding, Denmark
| | - Rune Wiig Nielsen
- Odense Respiratory Research Unit (ODIN), University of Southern Denmark, Odense, Denmark
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
| | - Thi Anh Nhi Huynh
- Department of Emergency Medicine, Gødstrup Hospital, Herning, Denmark
| | - Mikael K. Poulsen
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Mikkel Brabrand
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - Jacob E. Møller
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Stefan Posth
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - Christian B. Laursen
- Odense Respiratory Research Unit (ODIN), University of Southern Denmark, Odense, Denmark
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
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Jůza T, Válek V, Vlk D, Dostál M, Andrašina T. Roles of spectral dual-layer CT, D-dimer concentration, and COVID-19 pneumonia in diagnosis of pulmonary embolism. Eur J Radiol Open 2024; 12:100575. [PMID: 38882633 PMCID: PMC11179566 DOI: 10.1016/j.ejro.2024.100575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 05/22/2024] [Accepted: 05/29/2024] [Indexed: 06/18/2024] Open
Abstract
Purpose To demonstrate advantages of spectral dual-layer computed tomography (CT) in diagnosing pulmonary embolism (PE). To compare D-dimer values in patients with PE and concomitant COVID-19 pneumonia to those in patients without PE and COVID-19 pneumonia. To compare D-dimer values in cases of minor versus extensive PE. Methods A monocentric retrospective study of 1500 CT pulmonary angiographies (CTPAs). Three groups of 500 consecutive examinations: 1) using conventional multidetector CT (CTC), 2) using spectral dual-layer CT (CTS), and 3) of COVID-19 pneumonia patients using spectral dual-layer CT (COV). Only patients with known D-dimer levels were enrolled in the study. Results Prevalence of inconclusive PE findings differed significantly between CTS and CTC (0.8 % vs. 5.4 %, p < 0.001). In all groups, D-dimer levels were significantly higher in PE positive patients than in patients without PE (CTC, 8.04 vs. 3.05 mg/L; CTS, 6.92 vs. 2.57 mg/L; COV, 10.26 vs. 2.72 mg/L, p < 0.001). There were also statistically significant differences in D-dimer values between minor and extensive PE in the groups negative for COVID-19 (CTC, 5.16 vs. 8.98 mg/L; CTS 3.52 vs. 9.27 mg/L, p < 0.001). The lowest recorded D-dimer value for proven PE in patients with COVID-19 pneumonia was 1.19 mg/L. Conclusion CTPAs using spectral dual-layer CT reduce the number of inconclusive PE findings. Plasma D-dimer concentration increases with extent of PE. Cut-off value of D-dimer with 100 % sensitivity for patients with COVID-19 pneumonia could be doubled to 1.0 mg/L. This threshold would have saved 110 (22 %) examinations in our cohort.
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Affiliation(s)
- Tomáš Jůza
- Department of Radiology and Nuclear Medicine, Faculty of Medicine, University Hospital Brno, Masaryk University, Jihlavská 340/20, Brno 625 00, Czech Republic
- Department of Biophysics, Faculty of Medicine, Masaryk University, Kamenice 126/3, Brno 625 00, Czech Republic
| | - Vlastimil Válek
- Department of Radiology and Nuclear Medicine, Faculty of Medicine, University Hospital Brno, Masaryk University, Jihlavská 340/20, Brno 625 00, Czech Republic
| | - Daniel Vlk
- Department of Biophysics, Faculty of Medicine, Masaryk University, Kamenice 126/3, Brno 625 00, Czech Republic
| | - Marek Dostál
- Department of Radiology and Nuclear Medicine, Faculty of Medicine, University Hospital Brno, Masaryk University, Jihlavská 340/20, Brno 625 00, Czech Republic
- Department of Biophysics, Faculty of Medicine, Masaryk University, Kamenice 126/3, Brno 625 00, Czech Republic
| | - Tomáš Andrašina
- Department of Radiology and Nuclear Medicine, Faculty of Medicine, University Hospital Brno, Masaryk University, Jihlavská 340/20, Brno 625 00, Czech Republic
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Keragala CB, McFadyen JD, Ho H, McCutcheon FM, Liu Z, Stevens H, Monagle P, Chunilal S, Medcalf RL, Tran H. Plasma from patients with vaccine-induced immune thrombotic thrombocytopenia displays increased fibrinolytic potential and enhances tissue-type plasminogen activator but not urokinase-mediated plasminogen activation. J Thromb Haemost 2024; 22:785-793. [PMID: 37944898 DOI: 10.1016/j.jtha.2023.10.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 10/24/2023] [Accepted: 10/28/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a rare complication of adenovirus vector-based COVID-19 vaccines. VITT is associated with markedly raised levels of D-dimer; yet, how VITT modulates the fibrinolytic system is unknown. OBJECTIVES We aimed to compare changes in fibrinolytic activity in plasma from patients with VITT, patients diagnosed with venous thromboembolism (VTE) after vaccination but without VITT (VTE-no VITT), and healthy vaccinated controls. METHODS Plasma levels of plasmin-antiplasmin (PAP) complexes, plasminogen, and alpha-2-antiplasmin (α2AP) from 10 patients with VITT, 10 patients with VTE-no VITT, and 14 healthy vaccinated controls were evaluated by enzyme-linked immunosorbent assay and/or Western blotting. Fibrinolytic capacity was evaluated by quantitating PAP levels at baseline and after ex vivo plasma stimulation with 50-nM tissue-type plasminogen activator (tPA) or urokinase for 5 minutes. RESULTS Baseline PAP complex levels in control and VTE-no VITT individuals were similar but were ∼7-fold higher in plasma from patients with VITT (P < .0001). VITT samples also revealed consumption of α2AP and fibrinogenolysis consistent with a hyperfibrinolytic state. Of interest, VITT plasma produced significantly higher PAP levels after ex vivo treatment with tPA, but not urokinase, compared to the other groups, indicative of increased fibrinolytic potential. This was not due to D-dimer as addition of D-dimer to VTE-no VITT plasma failed to potentiate tPA-induced PAP levels. CONCLUSION A marked hyperfibrinolytic state occurs in patients with VITT, evidenced by marked elevations in PAP, α2AP consumption, and fibrinogenolysis. An unidentified plasma cofactor that selectively potentiates tPA-mediated plasminogen activation also appears to exist in the plasma of patients with VITT.
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Affiliation(s)
- Charithani B Keragala
- Australian Centre for Blood Diseases, the Central Clinical School, Monash University, Melbourne, Victoria, Australia; Department of Hematology, Monash Health, Clayton, Victoria, Australia; School of Clinical Sciences, Monash Health, Monash University, Clayton, Victoria, Australia
| | - James D McFadyen
- Australian Centre for Blood Diseases, the Central Clinical School, Monash University, Melbourne, Victoria, Australia; Atherothrombosis and Vascular Biology Program, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Department of Hematology, Alfred Hospital, Melbourne, Victoria, Australia; Baker Department of Cardiometabolic Health, the University of Melbourne, Parkville, Victoria, Australia
| | - Heidi Ho
- Australian Centre for Blood Diseases, the Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Fiona M McCutcheon
- Australian Centre for Blood Diseases, the Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Zikou Liu
- Australian Centre for Blood Diseases, the Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Hannah Stevens
- Australian Centre for Blood Diseases, the Central Clinical School, Monash University, Melbourne, Victoria, Australia; Atherothrombosis and Vascular Biology Program, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Department of Hematology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Paul Monagle
- Department of Pediatrics, University of Melbourne, Melbourne, Victoria, Australia; Hematology Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Clinical Hematology, Royal Children's Hospital, Parkville, Victoria, Australia; Kids Cancer Centre, Sydney Children's Hospital, Randwick, New South Wales, Australia
| | - Sanjeev Chunilal
- Department of Hematology, Monash Health, Clayton, Victoria, Australia; School of Clinical Sciences, Monash Health, Monash University, Clayton, Victoria, Australia
| | - Robert L Medcalf
- Australian Centre for Blood Diseases, the Central Clinical School, Monash University, Melbourne, Victoria, Australia.
| | - Huyen Tran
- Australian Centre for Blood Diseases, the Central Clinical School, Monash University, Melbourne, Victoria, Australia; Department of Hematology, Alfred Hospital, Melbourne, Victoria, Australia.
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Maraziti G, Cimini LA, Becattini C. Risk stratification to optimize the management of acute pulmonary embolism. Expert Rev Cardiovasc Ther 2022; 20:377-387. [PMID: 35544707 DOI: 10.1080/14779072.2022.2077194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Pulmonary embolism (PE) is a life-threatening disease. Risk stratification in patients with acute PE can guide clinical decisions. Clinical assessment, including hemodynamics, respiratory parameters, patient history, and right ventricle evaluation, has a pivotal role in this scope. AREAS COVERED This review aims to describe: i) the role of individual tools for prognostic stratification, from simple clinical parameters to the models suggested by international guidelines; ii) the implications of risk stratification in terms of patient disposition and treatment. The bleeding risk assessment in acute PE was also reviewed. The literature search was performed in PubMed and Embase to address these issues. EXPERT OPINION Prognostic assessment is essential to proceed with life-saving treatments in hemodynamically unstable patients and consider home treatment or short hospital stay in patients at low risk for death. In hemodynamically stable patients, risk stratification allows the implementation of personalized treatment pathways to reduce the risk of death, early PE recurrence, and bleeding. With the aim of optimizing healthcare resources, risk stratification may suggest appropriate patient disposition.
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Affiliation(s)
- Giorgio Maraziti
- Internal and Cardiovascular Medicine - Stroke Unit, Ospedale Santa Maria della Misericordia -University of Perugia, Perugia, Italy
| | - Ludovica Anna Cimini
- Internal and Cardiovascular Medicine - Stroke Unit, Ospedale Santa Maria della Misericordia -University of Perugia, Perugia, Italy
| | - Cecilia Becattini
- Internal and Cardiovascular Medicine - Stroke Unit, Ospedale Santa Maria della Misericordia -University of Perugia, Perugia, Italy
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Cau R, Pacielli A, Fatemeh H, Vaudano P, Arru C, Crivelli P, Stranieri G, Suri JS, Mannelli L, Conti M, Mahammedi A, Kalra M, Saba L. Complications in COVID-19 patients: Characteristics of pulmonary embolism. Clin Imaging 2021; 77:244-249. [PMID: 34029929 PMCID: PMC8130594 DOI: 10.1016/j.clinimag.2021.05.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/09/2021] [Accepted: 05/16/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The purpose of this study is to evaluate chest CT imaging features, clinical characteristics, laboratory values of COVID-19 patients who underwent CTA for suspected pulmonary embolism. We also examined whether clinical, laboratory or radiological characteristics could be associated with a higher rate of PE. MATERIALS AND METHODS This retrospective study included 84 consecutive patients with laboratory-confirmed SARS-CoV-2 who underwent CTA for suspected PE. The presence and localization of PE as well as the type and extent of pulmonary opacities on chest CT exams were examined and correlated with the information on comorbidities and laboratory values for all patients. RESULTS Of the 84 patients, pulmonary embolism was discovered in 24 patients. We observed that 87% of PE was found to be in lung parenchyma affected by COVID-19 pneumonia. Compared with no-PE patients, PE patients showed an overall greater lung involvement by consolidation (p = 0.02) and GGO (p < 0.01) and a higher level of D-Dimer (p < 0,01). Moreover, the PE group showed a lower level of saturation (p = 0,01) and required more hospitalization (p < 0,01). CONCLUSION Our study showed a high incidence of PE in COVID-19 pneumonia. In 87% of patients, PE was found in lung parenchyma affected by COVID-19 pneumonia with a worse CT severity score and a greater number of lung lobar involvement compared with non-PE patients. CT severity, lower level of saturation, and a rise in D-dimer levels could be an indication for a CTPA. ADVANCES IN KNOWLEDGE Certain findings of non-contrast chest CT could be an indication for a CTPA.
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Affiliation(s)
- Riccardo Cau
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari - Polo di Monserrato s.s. 554, Monserrato (Cagliari) 09045, Italy
| | - Alberto Pacielli
- Department of Radiology, Ospedale S. Giovanni Bosco, 10154 Turin, Italy
| | - Homayounieh Fatemeh
- Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA
| | - Paolo Vaudano
- Department of Radiology, Ospedale S. Giovanni Bosco, 10154 Turin, Italy
| | - Chiara Arru
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari - Polo di Monserrato s.s. 554, Monserrato (Cagliari) 09045, Italy
| | - Paola Crivelli
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Sassari - Sassari, Italy
| | | | - Jasjit S Suri
- Stroke Monitoring and Diagnostic Division, AtheroPoint™, Roseville, CA, USA
| | | | - Maurizio Conti
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Sassari - Sassari, Italy
| | - Abdelkader Mahammedi
- Department of Neuroradiology, University of Cincinnati Medical Center, OH 45267, USA
| | - Mannudeep Kalra
- Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari - Polo di Monserrato s.s. 554, Monserrato (Cagliari) 09045, Italy.
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Gawlitza J, Ziegelmayer S, Wilkens H, Jagoda P, Raczeck P, Buecker A, Stroeder J. Beyond the d-dimer - Machine-learning assisted pre-test probability evaluation in patients with suspected pulmonary embolism and elevated d-dimers. Thromb Res 2021; 205:11-16. [PMID: 34237678 DOI: 10.1016/j.thromres.2021.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 06/14/2021] [Accepted: 07/01/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Acute pulmonary embolism (PE) is a leading cardiovascular cause of death, resembling a common indication for emergency computed tomography (CT). Nonetheless, in clinical routine most CTs performed for suspicion of PE excluded the suspected diagnosis. As patients with low to intermediate risk for PE are triaged according to the d-dimer, its relatively low specifity and widespread elevation among elderly might be an underlying issue. Aim of this study was to find potential predictors based on initial emergency blood tests in patients with elevated d-dimers and suspected PE to further increase pre-test probability. METHODS In this retrospective study all patients at the local university hospital's emergency room from 2009 to 2019 with suspected PE, emergency blood testing and CT were included. Cluster analysis was performed to separate groups with distinct laboratory parameter profiles and PE frequencies were compared. Machine learning algorithms were trained on the groups to predict individual PE probability based on emergency laboratory parameters. RESULTS Overall, PE frequency among the 2045 analyzed patients was 41%. Three clusters with significant differences (p ≤ 0.05) in PE frequency were identified: C1 showed a PE frequency of 43%, C2 40% and C3 33%. Laboratory parameter profiles (e.g. creatinine) differed significantly between clusters (p ≤ 0.0001). Both logistic regression and support-vector machines were able to predict clusters with an accuracy of over 90%. DISCUSSION Initial blood parameters seem to enable further differentiation of patients with suspected PE and elevated d-dimers to raise pre-test probability of PE. Machine-learning-based prediction models might help to further narrow down CT indications in the future.
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Affiliation(s)
- Joshua Gawlitza
- Clinic of Diagnostic and Interventional Radiology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Straße 22, 81675 Munich, Germany.
| | - Sebastian Ziegelmayer
- Clinic of Diagnostic and Interventional Radiology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Straße 22, 81675 Munich, Germany
| | - Heinrike Wilkens
- Cardiology, Angiology, Pulmonary and Intensive Care, Saarland University Medical Center, Kirrberger Strasse 100, 66424 Homburg, Germany
| | - Philippe Jagoda
- Clinic for Diagnostic and Interventional Radiology, Saarland University Medical Center, Kirrberger Strasse 100 (Building 41), 66424 Homburg, Germany
| | - Paul Raczeck
- Clinic for Diagnostic and Interventional Radiology, Saarland University Medical Center, Kirrberger Strasse 100 (Building 41), 66424 Homburg, Germany
| | - Arno Buecker
- Clinic for Diagnostic and Interventional Radiology, Saarland University Medical Center, Kirrberger Strasse 100 (Building 41), 66424 Homburg, Germany
| | - Jonas Stroeder
- Clinic for Diagnostic and Interventional Radiology, Saarland University Medical Center, Kirrberger Strasse 100 (Building 41), 66424 Homburg, Germany
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Song ZK, Wu H, Xu X, Cao H, Wei Q, Wang J, Wang X, Zhang X, Tang M, Yang S, Liu Y, Qin L. Association Between D-Dimer Level and In-Hospital Death of Pulmonary Embolism Patients. Dose Response 2020; 18:1559325820968430. [PMID: 33335457 PMCID: PMC7724417 DOI: 10.1177/1559325820968430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 06/01/2020] [Accepted: 06/05/2020] [Indexed: 11/15/2022] Open
Abstract
To investigate whether D-dimer level could predict pulmonary embolism (PE) severity and in-hospital death, a total of 272 patients with PE were divided into a survival group (n = 249) and a death group (n = 23). Comparisons of patient characteristics between the 2 groups were performed using Mann-Whitney U test. Significant variables in univariate analysis were entered into multivariate logistic regression analysis. Receiver operating characteristic (ROC) curve analysis was performed to determine the predictive value of D-dimer level alone or together with the simplified Pulmonary Embolism Severity Index (sPESI) for in-hospital death. Results showed that patients in the death group were significantly more likely to have hypotension (P = 0.008), tachycardia (P = 0.000), elevated D-dimer level (P = 0.003), and a higher sPESI (P = 0.002) than those in the survival group. Multivariable logistic regression analysis showed that D-dimer level was an independent predictor of in-hospital death (OR = 1.07; 95% CI, 1.003-1.143; P = 0.041). ROC curve analysis showed that when D-dimer level was 3.175 ng/ml, predicted death sensitivity and specificity were 0.913 and 0.357, respectively; and when combined with sPESI, specificity (0.838) and area under the curve (0.740) were increased. Thus, D-dimer level is associated with in-hospital death due to PE; and the combination with sPESI can improve the prediction level.
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Affiliation(s)
- Zi-Kai Song
- Department of Cardiology, the First Hospital of Jilin
University, Changchun, China
| | - Haidi Wu
- Department of Cardiology, the First Hospital of Jilin
University, Changchun, China
| | - Xiaoyan Xu
- Department of Cardiology, the First Hospital of Jilin
University, Changchun, China
| | - Hongyan Cao
- Department of Cardiology, the First Hospital of Jilin
University, Changchun, China
| | - Qi Wei
- Department of Cardiology, the First Hospital of Jilin
University, Changchun, China
| | - Junfeng Wang
- Department of Cardiology, the First Hospital of Jilin
University, Changchun, China
| | - Xingwen Wang
- Department of Cardiology, the First Hospital of Jilin
University, Changchun, China
| | - Xue Zhang
- Department of Cardiology, the First Hospital of Jilin
University, Changchun, China
| | - Minglong Tang
- Department of Cardiology, the First Hospital of Jilin
University, Changchun, China
| | - Shuo Yang
- Department of Cardiology, the First Hospital of Jilin
University, Changchun, China
| | - Yang Liu
- Department of Cardiology, the First Hospital of Jilin
University, Changchun, China
| | - Ling Qin
- Department of Cardiology, the First Hospital of Jilin
University, Changchun, China
- Ling Qin, PhD, Department of Cardiology, the
First Hospital of Jilin University, 71 Xinmin St., Changchun, Jilin, 130000,
China.
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Keller K, Hobohm L, Engelhardt M. Impact of atrial fibrillation/flutter on the in-hospital mortality of surgical patients - Results from the German nationwide cohort. Thromb Res 2020; 196:526-535. [PMID: 33126050 DOI: 10.1016/j.thromres.2020.10.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 09/16/2020] [Accepted: 10/08/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND To investigate the impact of atrial fibrillation/flutter (AF) on adverse in-hospital outcomes in hospitalized surgical patients. METHODS The nationwide German inpatient sample of the years 2005-2018 was used for this analysis. Surgical patients were stratified by AF and compared. Logistic regression models were used to investigate the impact of AF on in-hospital outcomes. RESULTS In total, 96,589,627 hospitalizations with surgery were included in the present analysis in Germany (2005-2018). Among these, 6,680,261 were additionally coded with AF (6.9%). In-hospital death rate was substantially higher in surgical patients with AF (6.3%) than without (1.1%). Proportion of surgical patients with AF increased from 4.8% in 2005 to 8.9% in 2018, whereas in-hospital mortality decreased from 7.6% to 5.6%. For further analysis of the year 2014, 7,043,514 hospitalized surgical patients (54.5% females, 31.6% aged ≥0 years) were included in the analysis. Of these, 546,019 patients (7.8%) were diagnosed with AF. Overall, 1.4% of the surgical patients and 5.8% of the surgical patients with AF died in-hospital. Surgical patients with coded AF were in median 20 years older (57.0 [37.0-72.0] vs. 77.0 [72.0-83.0] years, P < 0.001), had more often comorbidities such as heart failure (31.3% vs. 3.8%, P < 0.001). All-cause death (RR 6.14 (95%CI 6.05-6.22), P < 0.001) occurred more often in patients with AF than without. AF was an important predictor for in-hospital death (OR 1.58 [95%CI 1.56-1.61], P < 0.001) independent of age, sex and comorbidities. CONCLUSIONS The proportion of AF increased from 2005 to 2018 in surgical patients. AF was an independent risk factor for in-hospital death in these patients.
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Affiliation(s)
- Karsten Keller
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; Team Doctor of the German Bundesliga Club 1, FSV Mainz 05 in the Soccer Season 2014/2015, Mainz, Germany.
| | - Lukas Hobohm
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | - Martin Engelhardt
- Department for Orthopedics, Trauma Surgery and Hand Surgery, Klinikum Osnabrück, Osnabrück, Germany; Institute for Applied Training Science Leipzig, Leipzig, Germany
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10
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Impact of concomitant deep or superficial venous thrombosis of the legs on survival of patients with pulmonary embolism. Int J Cardiol 2020; 315:92-98. [DOI: 10.1016/j.ijcard.2020.05.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 04/04/2020] [Accepted: 05/13/2020] [Indexed: 11/21/2022]
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11
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Whyte MB, Kelly PA, Gonzalez E, Arya R, Roberts LN. Pulmonary embolism in hospitalised patients with COVID-19. Thromb Res 2020; 195:95-99. [PMID: 32682004 PMCID: PMC7351054 DOI: 10.1016/j.thromres.2020.07.025] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 06/25/2020] [Accepted: 07/08/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) is characterised by dyspnoea and abnormal coagulation parameters, including raised D-dimer. Data suggests a high incidence of pulmonary embolism (PE) in ventilated patients with COVID-19. OBJECTIVES To determine the incidence of PE in hospitalised patients with COVID-19 and the diagnostic yield of Computer Tomography Pulmonary Angiography (CTPA) for PE. We also examined the utility of D-dimer and conventional pre-test probability for diagnosis of PE in COVID-19. PATIENTS/METHODS Retrospective review of single-centre data of all CTPA studies in patients with suspected or confirmed COVID-19 identified from Electronic Patient Records (EPR). RESULTS There were 1477 patients admitted with COVID-19 and 214 CTPA scans performed, of which n = 180 (84%) were requested outside of critical care. The diagnostic yield for PE was 37%. The overall proportion of PE in patients with COVID-19 was 5.4%. The proportions with Wells score of ≥4 ('PE likely') was 33/134 (25%) without PE vs 20/80 (25%) with PE (P = 0.951). The median National Early Warning-2 (NEWS2) score (illness severity) was 5 (interquartile range [IQR] 3-9) in PE group vs 4 (IQR 2-7) in those without PE (P = 0.133). D-dimer was higher in PE (median 8000 ng/mL; IQR 4665-8000 ng/mL) than non-PE (2060 ng/mL, IQR 1210-4410 ng/mL, P < 0.001). In the 'low probability' group, D-dimer was higher (P < 0.001) in those with PE but had a limited role in excluding PE. CONCLUSIONS Even outside of the critical care environment, PE in hospitalised patients with COVID-19 is common. Of note, approaching half of PE events were diagnosed on hospital admission. More data are needed to identify an optimal diagnostic pathway in patients with COVID-19. Randomised controlled trials of intensified thromboprophylaxis are urgently needed.
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Affiliation(s)
- Martin B Whyte
- Dept of Medicine, King's College NHS Foundation Trust, London, UK; Dept Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Philip A Kelly
- Dept of Medicine, King's College NHS Foundation Trust, London, UK
| | - Elisa Gonzalez
- Dept of Medicine, King's College NHS Foundation Trust, London, UK
| | - Roopen Arya
- King's Thrombosis Centre, Department of Haematological Medicine, King's College NHS Foundation Trust, London, UK
| | - Lara N Roberts
- King's Thrombosis Centre, Department of Haematological Medicine, King's College NHS Foundation Trust, London, UK.
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12
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Abstract
Anticoagulation is the cornerstone of acute pulmonary embolism (PE) therapy. Intermediate-risk (submassive) or high-risk (massive) PE patients have higher mortality than low-risk patients. It is generally accepted that high-risk PE patients should be considered for more aggressive therapy. Intermediate-risk patients can be subdivided, although more than simply categorizing the patient is required to guide therapy. Therapeutic approaches depend on a prompt, detailed evaluation, and PE response teams may help with rapid assessment and initiation of therapy. More clinical trial data are needed to guide clinicians in the management of acute intermediate- and high-risk PE patients.
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Affiliation(s)
- Victor F Tapson
- Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center, Thalians Building Room w155, 8730 Alden Drive, Los Angeles, CA 90048, USA.
| | - Aaron S Weinberg
- Cedars-Sinai Medical Center, Thalians Building, 8730 Alden Drive, Los Angeles, CA 90048, USA
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13
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Gong X, Lei X, Huang Z, Song Y, Wang Q, Qian J, Ge J. D-Dimer Level Predicts Angiographic No-Reflow Phenomenon After Percutaneous Coronary Intervention Within 2-7 Days of Symptom Onset in Patients with ST-Segment Elevation Myocardial Infarction. J Cardiovasc Transl Res 2020; 14:728-734. [PMID: 32212039 DOI: 10.1007/s12265-020-09991-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 03/11/2020] [Indexed: 10/24/2022]
Abstract
It remains uncertain whether plasma D-dimer level can predict no-reflow in patients with STEMI who had pPCI after 48 h of symptom onset. This study retrospectively enrolled 229 consecutive patients who had pPCI for acute STEMI within 2-7 days of symptom onset between January 2008 and December 2018. Patients were divided into no-reflow group (TIMI flow grade 0-2) and reflow group (TIMI flow grade 3). Predictors of no-reflow were assessed by univariate and multivariate binary logistic regression analyses. Plasma D-dimer level can independently predict no-reflow in patients with STEMI who had pPCI within 2-7 days of symptom onset (OR 2.52 per 1 mg/L increase, 95% CI 1.16-5.47, p = 0.019). This finding indicated that pPCI may be safe and feasible for STEMI patients within 2-7 days of symptom onset with low D-dimer level. Graphical Abstract Plasma D-dimer level can independently predict no-reflow in patients with STEMI who had pPCI within 2-7 days of symptom onset. pPCI may be safe and feasible for STEMI patients within 2-7 days of symptom onset with low D-dimer level.
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Affiliation(s)
- Xue Gong
- Department of Cardiology, DeltaHealth Hospital, Shanghai, China.,Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Xiaoting Lei
- Department of Cardiology, No. 1 Hospital of Tianshui City, Tianshui, Gansu Province, China
| | - Zheyong Huang
- Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China.
| | - Yanan Song
- Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Qibing Wang
- Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Juying Qian
- Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Junbo Ge
- Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China.
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14
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Prevalence and Predictor of Pulmonary Embolism in a Cohort of Chinese Patients with Acute Proximal Deep Vein Thrombosis. Ann Vasc Surg 2020; 63:293-297. [DOI: 10.1016/j.avsg.2019.06.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 06/08/2019] [Accepted: 06/30/2019] [Indexed: 11/18/2022]
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15
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Geissenberger F, Schwarz F, Probst M, Haberl S, Gruetzner S, Kroencke T, von Scheidt W, Berghaus TM. D-Dimer Predicts Disease Severity but Not Long-Term Prognosis in Acute Pulmonary Embolism. Clin Appl Thromb Hemost 2020; 25:1076029619863495. [PMID: 31298057 PMCID: PMC6714905 DOI: 10.1177/1076029619863495] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
D-dimer might be correlated with prognosis in pulmonary embolism (PE). The predictive value of plasma D-dimer for disease severity and survival was investigated in the lowest and highest D-dimer quartile among 200 patients with PE. Patients with high D-dimers were significantly more often hypotensive (P = .001), tachycardic (P = .016), or hypoxemic (P = .001). Pulmonary arterial obstruction index (PAOI) values were significantly higher in the high D-dimer quartile (P < .001). Elevated troponin I (TNI) levels (P < .001), simplified PE severity indices ≥1 (P < .001), right-to-left ventricular (RV/LV) diameter ratios ≥1 (P < .001), and thrombolysis (P = .001) were more frequent in the high D-dimer quartile. D-dimer was associated with RV/LV ratios ≥1 (P = .021), elevated PAOI (P < .001) or TNI levels (P < .001), hypotension (P < .001), tachycardia (P = .003), and hypoxemia (P < .001), but not with long-term all-cause mortality. D-dimer predicts disease severity but not long-term prognosis in acute PE, possibly due to a more aggressive treatment strategy in severely affected patients.
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Affiliation(s)
- Fabian Geissenberger
- 1 Department of Cardiology, Respiratory Medicine and Intensive Care, University Hospital Augsburg, Augsburg, Germany
| | - Florian Schwarz
- 2 Department of Radiology, University Hospital Augsburg, Augsburg, Germany.,3 Ludwig-Maximilians-University Munich, Munich, Germany
| | - Michael Probst
- 2 Department of Radiology, University Hospital Augsburg, Augsburg, Germany
| | - Sabine Haberl
- 1 Department of Cardiology, Respiratory Medicine and Intensive Care, University Hospital Augsburg, Augsburg, Germany
| | - Stefanie Gruetzner
- 4 Department of Transfusion Medicine and Hemostaseology, University hospital Augsburg, Augsburg, Germany
| | - Thomas Kroencke
- 2 Department of Radiology, University Hospital Augsburg, Augsburg, Germany
| | - Wolfgang von Scheidt
- 1 Department of Cardiology, Respiratory Medicine and Intensive Care, University Hospital Augsburg, Augsburg, Germany.,3 Ludwig-Maximilians-University Munich, Munich, Germany
| | - Thomas M Berghaus
- 1 Department of Cardiology, Respiratory Medicine and Intensive Care, University Hospital Augsburg, Augsburg, Germany.,3 Ludwig-Maximilians-University Munich, Munich, Germany
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16
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Sikora-Skrabaka M, Skrabaka D, Ruggeri P, Caramori G, Skoczyński S, Barczyk A. D-dimer value in the diagnosis of pulmonary embolism-may it exclude only? J Thorac Dis 2019; 11:664-672. [PMID: 31019753 DOI: 10.21037/jtd.2019.02.88] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Pulmonary embolism (PE) is the third most common cause of death for cardiovascular diseases in Europe. Quick PE diagnosis is therefore crucial for prognosis improvement. It is critical to have suitable screening tests both to exclude PE as well to select patient with highest likelihood of PE occurrence. Currently D-dimer test is accepted as important tool useful to exclude PE in low risk patients. Our goal was to assess the D-dimer test positive prognostic value. Methods A retrospective study based on medical record analysis of consecutively admitted patients to 9 wards of The University Clinical Center in Katowice who were hospitalized during four consecutive years was performed. Three hundred and seventy patients met the inclusion criteria for the study, which involved the D-dimer tests and computed tomographic pulmonary angiography (CTPA) performed during hospitalization. Assessed patients were divided into two groups: PE confirmed and PE excluded by CTPA. Results We have found that patients with D-dimer levels higher than 2,152 ng/mL had significantly increased risk of PE [area under curve (AUC) of 0.69; 95% CI, 0.64-0.75; P<0.05]. Positive predictive value (PPV) reached the level of 53%, whereas negative predictive value (NPV) reached 82%. We also found that patients with the history of neoplasm and at >65 years of age had D-dimer cut-off point moved to the level of 2,652 ng/mL (AUC of 0.67; 95% CI, 0.52-0.81; P<0.05). Conclusions Whereas the NPV of the D-dimer test is generally accepted our results suggest that, in selected cases, an increased plasmatic D-dimer levels may have PPV in PE diagnosis. Patients with the history of neoplasm have higher cut-off D-dimer points above which we should consider increased PE likelihood. CTPA should be considered even for patients with low probability of PE when D-dimer values exceed four times the normal level.
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Affiliation(s)
- Magdalena Sikora-Skrabaka
- Department of Pneumonology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland.,Department of Clinical Oncology, Provincial Specialist Hospital No. 4 in Bytom, Bytom, Poland
| | - Damian Skrabaka
- Department of Pneumonology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland.,Department of General and Vascular Surgery, City Hospital, Ruda Slaska, Poland
| | - Paolo Ruggeri
- Unità Operativa Complessa di Pneumologia, Dipartimento di Scienze Biomediche, Odontoiatriche e delle Immagini Morfologiche e Funzionali (BIOMORF), University of Messina, Messina, Italy
| | - Gaetano Caramori
- Unità Operativa Complessa di Pneumologia, Dipartimento di Scienze Biomediche, Odontoiatriche e delle Immagini Morfologiche e Funzionali (BIOMORF), University of Messina, Messina, Italy
| | - Szymon Skoczyński
- Department of Pneumonology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Adam Barczyk
- Department of Pneumonology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
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17
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Itagaki R, Kimura N, Mieno M, Hori D, Itoh S, Akiyoshi K, Yuri K, Tanno K, Kawahito K, Yamaguchi A. Characteristics and Treatment Outcomes of Acute Type A Aortic Dissection With Elevated D-Dimer Concentration. J Am Heart Assoc 2018; 7:JAHA.118.009144. [PMID: 29987123 PMCID: PMC6064831 DOI: 10.1161/jaha.118.009144] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background Clinical characteristics and treatment outcomes of acute type A aortic dissection with D‐dimer elevation have not been clarified. Methods and Results D‐dimer was measured preoperatively within 24 hours of symptom onset in 262 patients with acute type A aortic dissection. The median (and interquartile range) admission D‐dimer concentration in our total patient group was 26.7 (8.3–85.9) μg/mL. Median (interquartile range) D‐dimer concentrations were 5.0 (2.6–18.0) μg/mL for complete false lumen thrombosis (n=33), 60.9 (19.4–160.4) μg/mL for partial thrombosis (n=81), 26.5 (10.0–70.6) μg/mL for a patent false lumen (n=131), and 8.7 (3.2–26.9) μg/mL for ulcerlike projection (n=17) (P<0.01). With a D‐dimer concentration of ≤8.3 μg/mL representing the lower quartile, we then investigated predictors of a low D‐dimer level. Multivariate analysis showed dissection limited to the ascending aorta (P<0.01; odds ratio, 9.81) or descending aorta (P<0.01; odds ratio, 7.68), a completely thrombosed false lumen (P<0.01; odds ratio, 4.02), and absence of brain ischemia (P=0.013; odds ratio, 4.74) to be predictors of the lower D‐dimer concentration. Compared with patients with a low D‐dimer concentration (≤8.3 μg/mL, n=66), patients with a D‐dimer concentration >8.3 μg/mL (n=196) had a reduced preoperative platelet count and increased operation time and transfusion volume. In‐hospital mortality was elevated in this group (1.5% versus 11.2%; P=0.031), although 7‐year survival did not differ for hospital survivors (lower versus higher, 93.1% versus 79.1%; P=0.21). Conclusions D‐dimer concentrations are strongly influenced by the extent of dissection and false lumen status. Operative risks are increased in patients with a relatively high D‐dimer concentration.
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Affiliation(s)
- Ryo Itagaki
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Naoyuki Kimura
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Makiko Mieno
- Department of Medical Informatics, Center for Information, Jichi Medical University, Tochigi, Japan
| | - Daijiro Hori
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Satoshi Itoh
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Kei Akiyoshi
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Koichi Yuri
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Keisuke Tanno
- Department of Radiology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Koji Kawahito
- Division of Cardiovascular Surgery, Department of Surgery, Jichi Medical University, Shimotsuke, Japan
| | - Atsushi Yamaguchi
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
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Keller K, Beule J, Balzer JO, Dippold W. Reply to the letter to the editor. Am J Emerg Med 2018; 36:1100-1102. [DOI: 10.1016/j.ajem.2018.02.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 02/24/2018] [Indexed: 10/17/2022] Open
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Singer AJ, Zheng H, Francis S, Fermann GJ, Chang AM, Parry BA, Giordano N, Kabrhel C. D-dimer levels in VTE patients with distal and proximal clots. Am J Emerg Med 2018; 37:33-37. [PMID: 29703562 DOI: 10.1016/j.ajem.2018.04.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 04/18/2018] [Accepted: 04/19/2018] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES There is growing evidence that venous thromboembolism (VTE) patients with distal clots (distal calf deep vein thrombosis [DVT] and sub-segmental pulmonary embolism [PE]) may not routinely benefit from anticoagulation. We compared the D-dimer levels in VTE patients with distal and proximal clots. METHODS We conducted a multinational, prospective observational study of low-to-intermediate risk adult patients presenting to the emergency department (ED) with suspected VTE. Patients were classified as distal (calf DVT or sub-segmental PE) or proximal (proximal DVT or non-sub-segmental PE) clot groups and compared with univariate and multivariate analyses. RESULTS Of 1752 patients with suspected DVT, 1561 (89.1%) had no DVT, 78 (4.4%) had a distal calf DVT, and 113 (6.4%) had a proximal DVT. DVT patients with proximal clots had higher D-dimer levels (3760 vs. 1670 mg/dL) than with distal clots. Sensitivity and negative predictive value (NPV) for proximal DVT at an optimal D-dimer cutoff of 5770 mg/dL were 40.7% and 52.1% respectively. Of 1834 patients with suspected PE, 1726 (94.1%) had no PE, 7 (0.4%) had isolated sub-segmental PE, and 101 (5.5%) had non-sub-segmental PE. PE patients with proximal clots had higher D-dimer levels (4170 vs. 2520 mg/dL) than those with distal clots. Sensitivity and NPV for proximal PE at an optimal D-dimer cutoff of 3499 mg/dL were 57.4% and 10.4% respectively. CONCLUSIONS VTE patients with proximal clots had higher D-dimer levels than patients with distal clots. However, D-dimer levels cannot be used alone to discriminate between VTE patients with distal or proximal clots.
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Affiliation(s)
- Adam J Singer
- Department of Emergency Medicine, Stony Brook University, Stony Brook, NY, United States.
| | - Hui Zheng
- Department of Biostatistics, Massachusetts General Hospital, Boston, MA, United States
| | - Samuel Francis
- Department of Emergency Medicine, Duke University, Durham, NC, United States
| | - Gregory J Fermann
- Department of Emergency Medicine, University of Cincinnati, United States
| | - Anne Marie Chang
- Department of Emergency Medicine, Jefferson University, Philadelphia, PA, United States
| | - Blair A Parry
- Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Nick Giordano
- Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Christopher Kabrhel
- Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States
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20
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Keller K, Beule J, Balzer JO, Dippold W. D-Dimer and thrombus burden in acute pulmonary embolism. Am J Emerg Med 2018; 36:1613-1618. [PMID: 29371044 DOI: 10.1016/j.ajem.2018.01.048] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Revised: 01/12/2018] [Accepted: 01/13/2018] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Thrombus burden in pulmonary embolism (PE) is associated with higher D-Dimer-levels and poorer prognosis. We aimed to investigate i) the influence of right ventricular dysfunction (RVD), deep venous thrombosis (DVT), and high-risk PE-status on D-Dimer-levels and ii) effectiveness of D-Dimer to predict RVD in normotensive PE patients. METHODS Overall, 161 PE patients were analyzed retrospectively, classified in 5 subgroups of thrombus burden according to clinical indications and compared regarding D-Dimer-levels. Linear regression models were computed to investigate the association between D-Dimer and the groups. In hemodynamically stable PE patients, a ROC curve was calculated to assess the effectiveness of D-Dimer for predicting RVD. RESULTS Overall, 161 patients (60.9% females, 54.0% aged >70 years) were included in this analysis. The D-Dimer-level was associated with group-category in a univariate linear regression model (β 0.050 (95%CI 0.002-0.099), P = .043). After adjustment for age, sex, cancer, and pneumonia in a multivariate model we observed an association between D-Dimer and group-category with borderline significance (β 0.047 (95%CI 0.002-0.096), P = .058). The Kruskal-Wallis test demonstrated that D-Dimer increased significantly with higher group-category. In 129 normotensive patients, patients with RVD had significantly higher D-Dimer values compared to those without (1.73 (1.11/3.48) vs 1.17 (0.65/2.90) mg/l, P = .049). A ROC curve showed an AUC of 0.61, gender non-specific, with calculated optimal cut-off of 1.18 mg/l. Multi-variate logistic regression model confirmed an association between D-Dimer >1.18 mg/l and RVD (OR2.721 (95%CI 1.196-6.190), P = .017). CONCLUSIONS Thrombus burden in PE is related to elevated D-Dimer levels, and D-Dimer values >1.18 mg/l were predictive for RVD in normotensive patients. D-Dimer levels were influenced by DVT, but not by cancer, pneumonia, age, or renal impairment.
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Affiliation(s)
- Karsten Keller
- Center for thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Johannes Gutenberg-University Mainz, Germany; Cardiology I, Center of Cardiology, University Medical Center Mainz, Mainz, Johannes Gutenberg-University Mainz, Germany.
| | - Johannes Beule
- Department of Internal Medicine, St. Vincenz and Elisabeth Hospital Mainz (KKM), Mainz, Germany
| | - Jörn Oliver Balzer
- Department of Radiology and Nuclear Medicine, Catholic Clinic Mainz (KKM), Mainz, Germany; Department of Diagnostic and Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt (Main), Frankfurt, Germany
| | - Wolfgang Dippold
- Department of Internal Medicine, St. Vincenz and Elisabeth Hospital Mainz (KKM), Mainz, Germany
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Marschner C, Kristensen A, Rozanski E, McEvoy F, Kühnel L, Taeymans O, de Laforcade A, Sato A, Wiinberg B. Diagnosis of canine pulmonary thromboembolism by computed tomography and mathematical modelling using haemostatic and inflammatory variables. Vet J 2017; 229:6-12. [DOI: 10.1016/j.tvjl.2017.10.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 06/19/2017] [Accepted: 10/17/2017] [Indexed: 10/18/2022]
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Bai Z, Huang Y, Song C, Liu H, Chen Y, Zhang H, Lu X, Song Y, Zhang X. Clinical application of the Innovance D-dimer assay in the diagnosis of acute pulmonary thromboembolism. Exp Ther Med 2017; 13:3543-3548. [PMID: 28587438 DOI: 10.3892/etm.2017.4400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 01/26/2017] [Indexed: 11/06/2022] Open
Abstract
Patients with acute pulmonary thromboembolism (APTE) have a high short-term mortality rate. The current study aimed to investigate the use of D-dimer in the diagnosis of APTE in suspected APTE patients. All suspected APTE patients were classified into diagnosis or control groups according to the results of a computed tomography pulmonary angiogram. Mann-Whitney U and Kruskal-Wallis H tests were used to evaluate the association between D-dimer values and APTE. Area under the curve (AUC) values and the Youden Index were used to determine D-dimer cut-off levels for the prediction of APTE. The data of 112 suspected APTE patients (54.8% women; mean age, 70.5 years) were analyzed prospectively. There were no significant differences in age (74.5 vs. 73.5 years, P=0.538) or gender distribution (female ratio 56.5 vs. 53.0%, P=0.847) between the diagnosis and control groups. The incidence of symptoms including dyspnea (67.4 vs. 33.3%; P<0.01), chest distress (47.8 vs. 25.8%; P<0.05) and elevated D-dimer (8.49 vs. 0.97 mg/l; P<0.001) were significantly higher in patients with APTE compared with the control group. D-dimer values >3.32 mg/l fibrinogen equivalent units (FEU) were indicative of APTE and the Youden Index was 0.69. The maximum AUC was 0.87 (95% CI: 0.79-0.92), the sensitivity and specificity were 89.13 and 80.30%, respectively, the positive and negative likelihood ratios were 4.53 and 0.14, respectively, and the positive and negative predictive values were 75.90 and 91.40%, respectively. A D-dimer value <0.60 mg/l FEU was the optimal threshold for excluding APTE diagnosis, with a sensitivity of 100.0% and a specificity of 28.79%. The positive and negative likelihood ratios were 1.40 and 0.00, respectively, and the positive and negative predictive values were 49.50 and 100.00%, respectively. Thus, D-dimer levels, combined with clinical assessment, yield high sensitivity and specificity in diagnosing APTE.
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Affiliation(s)
- Zhuxiao Bai
- Clinical Laboratory, the First Affiliated Hospital of the Medical College, Shihezi University, Shihezi, Xinjiang 832000, P.R. China.,Clinical Laboratory, Hospital of Xinjiang Production and Construction Corps, Urumqi, Xinjiang 830002, P.R. China
| | - Yurong Huang
- Department of Respiratory Medicine, Hospital of Xinjiang Production and Construction Corps, Urumqi, Xinjiang 830002, P.R. China
| | - Chenghua Song
- Department of Respiratory Medicine, Hospital of Xinjiang Production and Construction Corps, Urumqi, Xinjiang 830002, P.R. China
| | - Huimin Liu
- Clinical Laboratory, Hospital of Xinjiang Production and Construction Corps, Urumqi, Xinjiang 830002, P.R. China
| | - Yihui Chen
- Department of Respiratory Medicine, Hospital of Xinjiang Production and Construction Corps, Urumqi, Xinjiang 830002, P.R. China
| | - Haitao Zhang
- Department of Respiratory Medicine, Hospital of Xinjiang Production and Construction Corps, Urumqi, Xinjiang 830002, P.R. China
| | - Xinhong Lu
- Clinical Laboratory, Hospital of Xinjiang Production and Construction Corps, Urumqi, Xinjiang 830002, P.R. China
| | - Yingbo Song
- Clinical Laboratory, Hospital of Xinjiang Production and Construction Corps, Urumqi, Xinjiang 830002, P.R. China
| | - Xin Zhang
- Clinical Laboratory, Hospital of Xinjiang Production and Construction Corps, Urumqi, Xinjiang 830002, P.R. China
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Yazıcı S, Kırış T, Ceylan US, Akyüz Ş, Uzun AO, Hacı R, Terzi S, Doğan A, Emre A, Yeşilçimen K. The accuracy of combined use of troponin and red cell distribution width in predicting mortality of patients with acute pulmonary embolism. Wien Klin Wochenschr 2016; 128:596-603. [PMID: 27647364 DOI: 10.1007/s00508-016-1081-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 08/17/2016] [Indexed: 01/04/2023]
Abstract
BACKGROUND Cardiac troponins and red cell distribution width (RDW) are associated with increased mortality in acute pulmonary embolism (PE). In this study, we aimed to investigate the accuracy of the combined use of troponin and RDW in predicting short-term mortality in acute PE patients. METHODS The data of 201 patients with the diagnosis of acute PE were retrospectively analyzed. We obtained troponin-RDW scores (TR scores) using a combination of troponin and RDW values, and then evaluated this score's accuracy in predicting mortality in patients with acute PE. RESULTS The mean participant age was 68 ± 16 years, and 52 % of patients were female. Fifteen (7.4 %) patients died during the first month. Patients classified as high-risk according to TR scores were older (72 ± 15 vs. 66 ± 15 years, p = 0.005), and they had higher heart rates (101 ± 20 vs. 90 ± 15 beat/min, p < 0.001) and respiratory rates (23 ± 4 vs. 21 ± 3 breath/min, p = 0.001). In multivariate analysis, TR (odds ratio [OR] 4.93, 95 % confidence interval [CI] 1.13-21.38, p = 0.033) and simplified pulmonary embolism severity index (sPESI) scores (OR 3.78, 95 % CI 1.71-8.37, p = 0.002) were independent predictors of 30-day mortality. For 30-day mortality, the TR score had a slightly lower sensitivity (87 % vs. 93 %), but a higher specificity (69 % vs. 52 %) compared to the sPESI score. CONCLUSION The TR score is easy to calculate, and it may be used to predict early mortality in patients with acute PE.
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Affiliation(s)
- Selçuk Yazıcı
- Cardiology Clinic, Dr.Siyami Ersek Thoracic and Cardiovascular Surgery Center, İstanbul, Turkey.
- , Cihadiye Street, No: 61/10 A-Blok, 34840, Altıntepe, Maltepe-İstanbul, Turkey.
| | - Tuncay Kırış
- Atatürk Training and Research Hospital, Cardiology Clinic, Katip Celebi University, İzmir, Turkey
| | - Ufuk S Ceylan
- Cardiology Clinic, Dr.Siyami Ersek Thoracic and Cardiovascular Surgery Center, İstanbul, Turkey
| | - Şükrü Akyüz
- Cardiology Clinic, Dr.Siyami Ersek Thoracic and Cardiovascular Surgery Center, İstanbul, Turkey
| | - Ahmet O Uzun
- Cardiology Clinic, Dr.Siyami Ersek Thoracic and Cardiovascular Surgery Center, İstanbul, Turkey
| | - Recep Hacı
- Cardiology Clinic, Dr.Siyami Ersek Thoracic and Cardiovascular Surgery Center, İstanbul, Turkey
| | - Sait Terzi
- Cardiology Clinic, Dr.Siyami Ersek Thoracic and Cardiovascular Surgery Center, İstanbul, Turkey
| | - Abdullah Doğan
- Medical School, İzmir Katip Celebi University, İzmir, Turkey
| | - Ayşe Emre
- Cardiology Clinic, Dr.Siyami Ersek Thoracic and Cardiovascular Surgery Center, İstanbul, Turkey
| | - Kemal Yeşilçimen
- Cardiology Clinic, Dr.Siyami Ersek Thoracic and Cardiovascular Surgery Center, İstanbul, Turkey
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Abstract
The diagnosis of pulmonary embolism (PE) remains challenging despite the evolution of well-validated clinical algorithms over the past few decades, largely because of nonspecific clinical features altering clinician suspicion. D-dimer is a simple noninvasive test that is an essential part of the diagnostic algorithm but is often deemed to be of little value in patients who are elderly or have other comorbidities. We describe a case of an elderly man who presented with clinical features and initial imaging consistent with pneumonia and a positive D-dimer test. Adherence to the suggested diagnostic algorithm and obtaining chest imaging, however, prevented what could have been a catastrophic missed diagnosis of PE. We review existing evidence on the importance of suspecting PE in the presence of alternative diagnosis and explore the literature on the association between the magnitude of D-dimer and the diagnosis of PE.
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Soylu K, Gedikli Ö, Ekşi A, Avcıoğlu Y, Soylu Aİ, Yüksel S, Aksan G, Gülel O, Yılmaz Ö. Neutrophil-to-lymphocyte ratio for the assessment of hospital mortality in patients with acute pulmonary embolism. Arch Med Sci 2016; 12:95-100. [PMID: 26925123 PMCID: PMC4754370 DOI: 10.5114/aoms.2016.57585] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 05/25/2014] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Neutrophil-to-lymphocyte ratio (NLR), which is an essential marker of inflammation, has been shown to be associated with adverse outcomes in various cardiovascular diseases in the literature. In this study we sought to evaluate the association between NLR and prognosis of acute pulmonary embolism (APE). MATERIAL AND METHODS We retrospectively evaluated blood counts and clinical data of 142 patients with the diagnosis of pulmonary embolism (PE) from Ondokuz Mayis University Hospital between January 2006 and December 2012. The patients were divided into two groups according to NLR: NLR < 4.4 (low NLR group, n = 71) and NLR ≥ 4.4 (high NLR group, n = 71). RESULTS Massive embolism (66.2% vs. 36.6%, p < 0.001) and in-hospital mortality (21.1%, 1.4%, p < 0.001) were higher in the high NLR group. In multivariate regression analysis NLR ≥ 5.7, systolic blood pressure (BP) < 90 mm Hg, serum glucose > 126 mg/dl, heart rate > 110 beats/min, and PCO2 < 35 or > 50 mm Hg were predictors of in-hospital mortality. The optimal NLR cutoff value was 5.7 for mortality in receiver operating characteristic (ROC) analysis. Having an NLR value above 5.7 was found to be associated with a 10.8 times higher mortality rate than an NLR value below 5.7. CONCLUSIONS In patients presenting with APE, NLR value is an independent predictor of in-hospital mortality and may be used for clinical risk classification.
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Affiliation(s)
- Korhan Soylu
- Department of Cardiology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Ömer Gedikli
- Department of Cardiology, Artvin State Hospital, Artvin, Turkey
| | - Alay Ekşi
- Department of Cardiology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Yonca Avcıoğlu
- Department of Cardiology, Düzen Laboratories Group, Ankara, Turkey
| | - Ayşegül İdil Soylu
- Department of Radiology, Samsun Training and Research Hospital, Samsun, Turkey
| | - Serkan Yüksel
- Department of Cardiology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Gökhan Aksan
- Department of Cardiology, Gazi State Hospital, Samsun, Turkey
| | - Okan Gülel
- Department of Cardiology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Özcan Yılmaz
- Department of Cardiology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
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Keller K, Beule J, Schulz A, Coldewey M, Dippold W, Balzer JO. D-dimer for risk stratification in haemodynamically stable patients with acute pulmonary embolism. Adv Med Sci 2015; 60:204-10. [PMID: 25847178 DOI: 10.1016/j.advms.2015.02.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Revised: 01/30/2015] [Accepted: 02/20/2015] [Indexed: 12/19/2022]
Abstract
PURPOSE Patients with submassive pulmonary embolism (PE) have a higher short-term mortality than those with low-risk PE. Rapid identification of submassive PE is important for adequate treatment of non-massive PE. We aimed to investigate the utility of D-dimer for the prediction of submassive PE stadium in normotensive PE patients. PATIENTS AND METHODS Normotensive PE patients were classified into submassive or low-risk PE groups. In addition to the comparison of the groups, area under the curve (AUC) and D-dimer cut-off for the prediction of submassive PE stadium, multi-variate logistic regression for association between D-dimer values above this cut-off and submassive PE stadium were also calculated. RESULTS The data of 129 normotensive PE patients (59.7% women, mean age 70.0 years (60.7/81.0)) were analysed retrospectively. Patients with submassive PE were older (75.0 years (61.7/81.0) vs. 66.5 years (55.7/74.2), P=0.026) and more frequently female (63.6% vs. 53.8%, P=0.35). Heart rate (100.0beats/min (85.0/108.0) vs. 80.0beats/min (70.0/96.2), P<0.0001), systolic pulmonary-artery pressure (41.55±16.79mmHg vs. 22.62±14.81mmHg, P<0.0001), and D-dimer (2.00mg/l (1.09/3.98) vs. 1.21mg/l (0.75/1.99), P=0.011) were higher in patients with submassive PE. D-dimer values >1.32mg/l were indicative of submassive PE and shock-index ≥0.7. The effectiveness (AUC) of the test was 0.63 for submassive PE and 0.64 for shock-index ≥0.7. D-dimer values >1.32mg/l were associated with submassive PE stadium (OR 3.81 (95% CI: 1.74-8.35), P=0.00083) as well as with systolic blood pressure (OR 0.98 (95% CI: 0.97-0.99), P=0.033), heart rate (OR 1.02 (95% CI: 1.00-1.04), P=0.023) and shock-index value (OR 15.89 (95% CI: 1.94-130.08), P=0.0099). CONCLUSIONS D-dimer values >1.32mg/l are indicative of submassive PE stadium and shock-index ≥0.7. Efficacy of D-dimer for predicting submassive PE stadium was only weak to moderate.
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Sunnetcioglu A, Sertogullarindan B, Ozbay B, Asker S, Ekin S. Assessments of the associations of thrombus localization with accompanying disorders, risk factors, D-dimer levels, and the red cell distribution width in pulmonary embolism. Clinics (Sao Paulo) 2015; 70:441-5. [PMID: 26106964 PMCID: PMC4462567 DOI: 10.6061/clinics/2015(06)10] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Accepted: 03/31/2015] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE Pulmonary embolisms occur as a wide spectrum ranging from clinically asymptomatic thrombi to massive thrombi that lead to cardiogenic shock. The purpose of this study was to determine the associations of thrombus localization with risk factors, accompanying disorders, D-dimer levels and the red blood cell distribution width in patients with pulmonary embolism. MATERIAL AND METHODS In 148 patients diagnosed with pulmonary embolism, the presence and anatomical localization of the thrombus were assessed via computed tomographic pulmonary angiography. The accompanying disorders, risk factors, serum D-dimer levels, and red blood cell distribution width of the patients were retrospectively evaluated. ClinicalTrials.gov: NCT02388841. RESULTS The mean age of the patients was 54±16.0 years, and 48 patients were ≥65 years of age. The most frequent accompanying disorders were chronic obstructive pulmonary disease (22%) and malignancy (10.1%), and the most frequent risk factors were recent operation (14.1%) and immobilization (18.2%). Thrombi were most frequently observed in the right pulmonary artery (37.8%). In 31% of the patients, the thrombus was localized to the main pulmonary arteries. Immobile patients exhibited a higher proportion of thrombi in the main pulmonary arteries than mobile patients. The mean D-dimer level and the mean red blood cell distribution width in the patients with thrombi in the main pulmonary arteries were higher than those in the patients with thrombi in more distal pulmonary arterial branches. CONCLUSION Significant associations of proximally localized thrombi with immobilization, the D-dimer levels, and the red blood cell distribution width were observed.
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Affiliation(s)
- Aysel Sunnetcioglu
- Yuzuncu Yil University Medical Faculty, Department of Pulmonary, Van/, Turkey
- Aysel SunnetciogluCorresponding author: E-mail:
| | | | - Bulent Ozbay
- Muğla Sitki Koçman University Medical Faculty, Department of Pulmonary, Muğla/TurkeyMuğla/Turkey
| | - Selvi Asker
- Yuzuncu Yil University Medical Faculty, Department of Pulmonary, Van/, Turkey
| | - Salemi Ekin
- Yuzuncu Yil University Medical Faculty, Department of Pulmonary, Van/, Turkey
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Spring JL, Winkler A, Levy JH. The influence of various patient characteristics on D-dimer concentration in critically ill patients and its role as a prognostic indicator in the intensive care unit setting. Clin Lab Med 2015; 34:675-86. [PMID: 25168950 DOI: 10.1016/j.cll.2014.06.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
This study examines the relationship between D-dimer concentration and patient age, gender, race, and renal function, and the role of D-dimer concentration as a predictor of in-hospital mortality, in a critically ill patient population. The results demonstrate there is a correlation between increased D-dimer concentration and renal impairment in critically ill patients, with patients in renal failure having the highest D-dimer concentrations. Peak D-dimer levels were higher among female patients than in male patients, but there was no association between peak D-dimer levels and other patient characteristics. D-dimer concentration was also not predictive of in-hospital mortality.
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Affiliation(s)
- Jenna L Spring
- Department of Medicine, University of Toronto, Suite RFE 3-805, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada
| | - Anne Winkler
- Department of Pathology, Emory University, 1364 Clifton Road, NE, Atlanta, GA 30322, USA
| | - Jerrold H Levy
- Duke University School of Medicine, Divisions of Cardiothoracic Anesthesiology and Critical Care, Duke University Hospital, 2301 Erwin Road, Durham, NC 27710, USA.
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García-Sanz M, Pena-Álvarez C, López-Landeiro P, Bermo-Domínguez A, Fontúrbel T, González-Barcala F. Symptoms, location and prognosis of pulmonary embolism. REVISTA PORTUGUESA DE PNEUMOLOGIA 2014; 20:194-9. [DOI: 10.1016/j.rppneu.2013.09.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 09/05/2013] [Accepted: 09/21/2013] [Indexed: 10/25/2022] Open
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Wexels F, Dahl OE, Pripp AH, Seljeflot I, Borris LC, Haslund A, Gudmundsen TE, Lauritzen T, Lassen MR. Prothrombin fragment 1+2 in urine as a marker on coagulation activity in patients with suspected pulmonary embolism. Thromb Res 2014; 134:68-71. [DOI: 10.1016/j.thromres.2014.04.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 04/10/2014] [Accepted: 04/17/2014] [Indexed: 11/29/2022]
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Clinical features of patients inappropriately undiagnosed of pulmonary embolism. Am J Emerg Med 2013; 31:1646-50. [PMID: 24060320 DOI: 10.1016/j.ajem.2013.08.037] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 08/10/2013] [Accepted: 08/16/2013] [Indexed: 11/24/2022] Open
Abstract
PURPOSES The objective of this study was to identify clinical factors associated with delayed diagnosis of acute pulmonary embolism (PE) in the emergency department (ED). BASIC PROCEDURES A retrospective observational study was performed at three University affiliated Hospitals; 436 consecutive patients who presented to the ED with an acute PE confirmed by chest computed tomography from 2008 to 2011 were included. Patients were divided into 3 groups: group 1, PE was diagnosed while the patient was still in the ED; group 2, PE was diagnosed during hospitalization; group 3, patients who were sent home with a wrong alternative diagnosis and returned to the ED and were diagnosed of PE. MAIN FINDINGS One hundred forty-six patients (33.5%) had a delayed diagnosis of PE--21.5% belong to group 2 and 11.9% to Group 3. Chronic coexisting medical conditions like asthma or chronic obstructive pulmonary disease were independent predictors of a delayed diagnosis in patients who were admitted to hospital whereas non-specific and less severe symptoms like the presence of pleuro-mechanic thoracic pain, fever, hemoptysis, or the presence of a pulmonary infiltrate in chest x-ray were independent predictors of a delayed diagnosis in patients who were sent home. PRINCIPAL CONCLUSIONS Delay in diagnosis of acute PE is frequent despite current diagnostic strategies. Patients are sent home or admitted to hospital with a wrong diagnosis depending on clinical presentation or coexisting medical conditions.
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Tong C, Zhang Z. Evaluation factors of pulmonary embolism severity and prognosis. Clin Appl Thromb Hemost 2013; 21:273-84. [PMID: 24023267 DOI: 10.1177/1076029613501540] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Management of pulmonary embolism (PE) is still unclear. We summarized 16 kinds of evaluation factors of PE severity and prognosis, and we analyzed the single and joint value for short-term and long-term prognosis. Among them, biomarkers such as brain natriuretic peptide or N-terminal probrain natriuretic peptide, troponin, and heart-type fatty acid-binding protein are the best indicators of PE severity and short-term prognosis. They might replace imaging detections in evaluating PE severity. But the positive predictive value of all the biomarkers is low, and we need to improve each value through joint detection. The PE severity index and simplified PE severity index are more suitable for evaluating the overall risk and long-term prognosis. They could be used as complements of indicators of the PE severity, especially in identifying low-risk group. Integrated risk stratification and strategies of management should be established based on the 2 aspects mentioned previously.
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Affiliation(s)
- ChunRan Tong
- Department of Respiratory Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, China
| | - ZhongHe Zhang
- Department of Respiratory Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, China
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Razzouk L, Fusaro M, Esquitin R. Novel biomarkers for risk stratification and identification of life-threatening cardiovascular disease: troponin and beyond. Curr Cardiol Rev 2013; 8:109-15. [PMID: 22708908 PMCID: PMC3406270 DOI: 10.2174/157340312801784943] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2011] [Revised: 08/15/2011] [Accepted: 09/01/2011] [Indexed: 01/10/2023] Open
Abstract
Chest pain and other symptoms that may represent acute coronary syndromes (ACS) are common reasons for emergency department (ED) presentations, accounting for over six million visits annually in the United States [1]. Chest pain is the second most common ED presentation in the United States. Delays in diagnosis and inaccurate risk stratification of chest pain can result in serious morbidity and mortality from ACS, pulmonary embolism (PE), aortic dissection and other serious pathology. Because of the high morbidity, mortality, and liability issues associated with both recognized and unrecognized cardiovascular pathology, an aggressive approach to the evaluation of this patient group has become the standard of care. Clinical history, physical examination and electrocardiography have a limited diagnostic and prognostic role in the evaluation of possible ACS, PE, and aortic dissection, so clinicians continue to seek more accurate means of risk stratification. Recent advances in diagnostic imaging techniques particularly computed-tomography of the coronary arteries and aorta, have significantly improved our ability to diagnose life-threatening cardiovascular disease. In an era where health care utilization and cost are major considerations in how disease is managed, it is crucial to risk-stratify patients quickly and efficiently. Historically, biomarkers have played a significant role in the diagnosis and risk stratification of several cardiovascular disease states including myocardial infarction, congestive heart failure, and pulmonary embolus. Multiple biomarkers have shown early promise in answering questions of risk stratification and early diagnosis of cardiovascular pathology however many do not yet have wide clinical availability. The goal of this review will be to discuss these novel biomarkers and describe their potential role in direct patient care.
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Affiliation(s)
- Louai Razzouk
- Division of Cardiology, Department of Medicine- NYU Langone Medical Center, NY, USA.
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Expedited Management of Deep Vein Thrombosis and Acute Pulmonary Embolism. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2013. [DOI: 10.1007/s40138-013-0015-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Vedovati MC, Becattini C, Agnelli G, Kamphuisen PW, Masotti L, Pruszczyk P, Casazza F, Salvi A, Grifoni S, Carugati A, Konstantinides S, Schreuder M, Golebiowski M, Duranti M. Multidetector CT scan for acute pulmonary embolism: embolic burden and clinical outcome. Chest 2013; 142:1417-1424. [PMID: 22628491 DOI: 10.1378/chest.11-2739] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND In patients with acute pulmonary embolism (PE), the correlation between the embolic burden assessed by multidetector CT (MDCT) scan and clinical outcomes remains unclear. Patients with symptomatic acute PE diagnosed based on MDCT angiography were included in a multicenter study aimed at assessing the prognostic role of the embolic burden evaluated with MDCT scan. METHODS Embolic burden was assessed as (1) localization of the emboli as central (saddle or at least one main pulmonary artery), lobar, or distal (segmental or subsegmental arteries) and (2) the obstruction index by the scoring system of Qanadli. The primary outcome was 30-day all-cause death or clinical deterioration. Predictors of all-cause death or clinical deterioration were identified by Cox regression statistics. RESULTS Overall, 579 patients were included in the study; 60 (10.4%) died or had clinical deterioration at 30 days. Central localization of emboli was not associated with all-cause death or clinical deterioration (hazard ratio [HR], 2.42; 95% CI, 0.77-7.59; P 5 .13). However, in 516 hemodynamically stable patients, central localization of emboli (HR, 8.3; 95% CI, 1.0-67; P 5 .047) was an independent predictor of all-cause death or clinical deterioration, whereas distal emboli were inversely associated with these outcome events (HR, 0.12; 95% CI, 0.015-0.97; P 5 .047). No correlation was found between obstruction index (evaluated in 448 patients) and all-cause death or clinical deterioration in the overall study population and in the hemodynamically stable patients. CONCLUSIONS In hemodynamically stable patients with acute PE, central emboli are associated with an increased risk for all-cause death or clinical deterioration. This risk is low in patients with segmental or subsegmental PE.
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Affiliation(s)
- Maria Cristina Vedovati
- Internal and Cardiovascular Medicine-Stroke Unit, S Maria della Misericordia Hospital, Perugia, Italy.
| | - Cecilia Becattini
- Internal and Cardiovascular Medicine-Stroke Unit, S Maria della Misericordia Hospital, Perugia, Italy
| | - Giancarlo Agnelli
- Internal and Cardiovascular Medicine-Stroke Unit, S Maria della Misericordia Hospital, Perugia, Italy
| | - Pieter W Kamphuisen
- Department of Vascular Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Luca Masotti
- Department of Internal Medicine, Cecina Hospital, Cecina, Italy
| | - Piotr Pruszczyk
- Department of Internal Medicine and Cardiology, Warsaw, Poland
| | - Franco Casazza
- Department of Cardiology, San Carlo Borromeo Hospital, Milan, Italy
| | - Aldo Salvi
- Department of Emergency Medicine, Ancona Hospital, Ancona, Italy
| | - Stefano Grifoni
- Department of Emergency Medicine, Careggi Hospital, Florence, Italy
| | - Anna Carugati
- Department of Internal Medicine, Valduce Hospital, Como, Italy
| | | | - Marthe Schreuder
- Department of Vascular Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Michele Duranti
- University of Perugia, and Department of Radiology, S Maria della Misericordia Hospital, Perugia, Italy
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Lucassen WA, Beenen LF, Büller HR, Erkens PM, Schaefer-Prokop CM, van den Berk IA, van Weert HC. Concerns in using multi-detector computed tomography for diagnosing pulmonary embolism in daily practice. A cross-sectional analysis using expert opinion as reference standard. Thromb Res 2013; 131:145-9. [DOI: 10.1016/j.thromres.2012.11.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Revised: 11/19/2012] [Accepted: 11/27/2012] [Indexed: 10/27/2022]
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Rydman R, Söderberg M, Larsen F, Alam M, Caidahl K. d-Dimer and simplified pulmonary embolism severity index in relation to right ventricular function. Am J Emerg Med 2012; 31:482-6. [PMID: 23154103 DOI: 10.1016/j.ajem.2012.09.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2012] [Revised: 09/11/2012] [Accepted: 09/11/2012] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Right ventricular (RV) involvement in pulmonary embolism (PE) is an ominous sign. The aim of this study was to investigate the extent to which the d-dimer level or simplified PE severity index (sPESI) indicates RV dysfunction in patients with preserved systemic arterial pressure. METHODS Right ventricular function was studied in 34 consecutive patients with acute nonmassive PE by echocardiography including Doppler tissue imaging within 24 hours after arrival to the hospital. d-Dimer and sPESI were assessed upon arrival. RESULTS d-Dimer correlated with RV pressure (Rs, 0.60; P < .001) and pulmonary vascular resistance (PVR; Rs, 0.68; P < .0001) and tended to be related to myocardial performance index (MPI; Rs, 0.31; P = .067). Compared to a level less than 3.0 mg/L, patients with d-dimer 3.0 mg/L or higher had lower systolic tricuspid annular velocity (11.3 ± 2.7 vs 13.5 ± 2.7 cm/s; P < .05), a prolonged MPI (0.8 ± 0.3 vs 0.5 ± 0.2; P < .01), increased RV pressure (58 ± 13 vs 37 ± 12 mm Hg; P < .001), and increased PVR (3.3 ± 1.1 vs 1.8 ± 0.4 Woods units; P < .001). Patients in the high-risk sPESI group had higher filling pressure than those in the low risk sPESI group. CONCLUSIONS In the acute stage of PE, a d-dimer level 3 mg/L or higher may identify nonmassive PE patients with RV dysfunction and thereby help to determine their risk profile. We found no additional value for sPESI in this context.
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Affiliation(s)
- Riikka Rydman
- Section of Clinical Physiology, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
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Nafie R, Shaker A, Gazzar AE, Hawary AE. Can brain natriuretic peptide predict the outcome in patients with acute pulmonary embolism? EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2012. [DOI: 10.1016/j.ejcdt.2012.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Huang CM, Lin YC, Lin YJ, Chang SL, Lo LW, Hu YF, Chiang CE, Wang KL, Chen SA. Risk stratification and clinical outcomes in patients with acute pulmonary embolism. Clin Biochem 2011; 44:1110-1115. [PMID: 21723271 DOI: 10.1016/j.clinbiochem.2011.06.077] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Revised: 06/13/2011] [Accepted: 06/15/2011] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Pulmonary embolism is a common disease associated with a high mortality rate. The risk assessment and appropriate treatment selection of patients with acute pulmonary embolism remains a challenge. DESIGN AND METHODS This single center cohort study included a total of 150 patients (96 male, age = 71 ± 15 years) with acute pulmonary embolism confirmed by spiral-computed tomography or magnetic resonance image. The prognostic performance of the clinical characteristics and laboratory values were investigated to predict the in-hospital hemodynamically instable events and 30-day all-cause mortality. RESULTS The rate of in-hospital hemodynamic instability and 30-day all-cause mortality was 21% and 12%, respectively. A multivariate Cox regression analysis demonstrated that a heart rate ≥ 110 bpm (odd ratio 4.26 [95% CI 1.42-12.77]), chronic pulmonary disease (6.47 [1.99-21.04]), WBC ≥ 11,000 mm(3) (3.78 [1.32-10.82]), and D-dimer level ≥ 4.0 μg/mL (3.68 [1.01-13.43]) independently predicted the 30-day fatal outcome. A Kaplan-Meier survival analysis showed that the categorization based on the number of risk factors was significantly associated with the likelihood of 30-day all-cause mortality (P<0.0001). CONCLUSIONS The initial presentation of tachycardia, presence of chronic pulmonary disease, elevated WBC and D-dimer on admission can be used to identify the risk for a short-term fatal outcome within 30 days in patients with acute pulmonary embolism.
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Affiliation(s)
- Chi-Ming Huang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yen-Chung Lin
- Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Yenn-Jiang Lin
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.
| | - Shih-Lin Chang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Li-Wei Lo
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Yu-Feng Hu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Chern-En Chiang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Kang-Ling Wang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Shih-Ann Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
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Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ, Jenkins JS, Kline JA, Michaels AD, Thistlethwaite P, Vedantham S, White RJ, Zierler BK. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation 2011; 123:1788-830. [PMID: 21422387 DOI: 10.1161/cir.0b013e318214914f] [Citation(s) in RCA: 1500] [Impact Index Per Article: 115.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Venous thromboembolism (VTE) is responsible for the hospitalization of >250 000 Americans annually and represents a significant risk for morbidity and mortality. Despite the publication of evidence-based clinical practice guidelines to aid in the management of VTE in its acute and chronic forms, the clinician is frequently confronted with manifestations of VTE for which data are sparse and optimal management is unclear. In particular, the optimal use of advanced therapies for acute VTE, including thrombolysis and catheter-based therapies, remains uncertain. This report addresses the management of massive and submassive pulmonary embolism (PE), iliofemoral deep vein thrombosis (IFDVT),and chronic thromboembolic pulmonary hypertension (CTEPH). The goal is to provide practical advice to enable the busy clinician to optimize the management of patients with these severe manifestations of VTE. Although this document makes recommendations for management, optimal medical decisions must incorporate other factors, including patient wishes, quality of life, and life expectancy based on age and comorbidities. The appropriateness of these recommendations for a specific patient may vary depending on these factors and will be best judged by the bedside clinician.
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Stein PD, Janjua M, Matta F, Alrifai A, Jaweesh F, Chughtai HL. Prognostic value of D-dimer in stable patients with pulmonary embolism. Clin Appl Thromb Hemost 2011; 17:E183-5. [PMID: 21288930 DOI: 10.1177/1076029610395129] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Prognosis of pulmonary embolism (PE) based on levels of D-dimer has shown mixed results, and data on in-hospital prognosis of stable patients are sparse. We assessed in-hospital prognosis in 292 stable patients with PE based on retrospective chart review using an arbitrarily selected value of D-dimer ≥5000 ng/mL as cut-off level. In-hospital mortality from PE was 0% (0 of 222) with D-dimer <5000 ng/mL compared with 2.9% (2 of 70) with D-dimer ≥5000 ng/mL (P = .06). In-hospital all-cause mortality was 2.3% (5 of 222) with D-dimer <5000 ng/mL compared with 2.9% (2 of 70) with D-dimer ≥5000 ng/mL (NS). Markedly elevated levels of D-dimer, therefore, did not indicate a high mortality from PE or all-cause mortality during hospitalization.
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Affiliation(s)
- Paul D Stein
- Department of Internal Medicine, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA.
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Singanayagam A, Scally C, Al-Khairalla MZ, Leitch L, Hill LE, Chalmers JD, Hill AT. Are biomarkers additive to pulmonary embolism severity index for severity assessment in normotensive patients with acute pulmonary embolism? QJM 2011; 104:125-31. [PMID: 20871127 DOI: 10.1093/qjmed/hcq168] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Biomarkers and clinical prediction rules have been proposed for severity assessment in acute pulmonary embolism (PE). AIM The aim of this study was to compare biomarkers with the PE Severity Index (PESI), a validated scoring system for predicting 30-day mortality and to determine if addition of biomarkers to PESI would improve its predictive accuracy. STUDY DESIGN AND METHODS We conducted a retrospective analysis of normotensive patients admitted with PE confirmed by CT pulmonary angiogram, to three teaching hospitals between January 2005 and July 2007. All patients had admission levels of D-dimer and Troponin I and calculation of PESI score on admission. The outcome of interest was 30-day mortality. RESULTS There were 411 patients included in the study. Patients who died had higher levels of D-dimer (median 2947 ng/ml vs. 1464 ng/ml; P=0.02), Troponin (57.1% positive vs. 13.8%; P<0.0001) and higher PESI scores [median 109 vs. 83; P<0.0001], compared to survivors. PESI had superior accuracy for predicting 30-day mortality than a combination of Troponin and D-dimer (AUC 0.80 vs. 0.75). Addition of Troponin to PESI further improved the predictive value of the score (AUC 0.85 for vs. AUC 0.80 for PESI alone). CONCLUSION Biomarkers and clinical prediction rules predict outcome in acute PE. Addition of troponin to the PESI scoring system improves the predictive value for 30-day mortality and may be useful for guiding initial management of patients presenting with PE.
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Affiliation(s)
- A Singanayagam
- Department of Respiratory Medicine, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, UK.
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Jiménez D, Aujesky D, Yusen RD. Risk stratification of normotensive patients with acute symptomatic pulmonary embolism. Br J Haematol 2010; 151:415-24. [PMID: 20955409 DOI: 10.1111/j.1365-2141.2010.08406.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Treatment guidelines recommend strong consideration of thrombolysis in patients with acute symptomatic pulmonary embolism (PE) that present with arterial hypotension or shock because of the high risk of death in this setting. For haemodynamically stable patients with PE, the categorization of risk for subgroups may assist with decision-making regarding PE therapy. Clinical models [e.g. Pulmonary Embolism Severity Index (PESI)] may accurately identify those at low risk of overall death in the first 3 months after the diagnosis of PE, and such patients might benefit from an abbreviated hospital stay or outpatient therapy. Though some evidence suggests that a subset of high-risk normotensive patients with PE may have a reasonable risk to benefit ratio for thrombolytic therapy, single markers of right ventricular dysfunction (e.g. echocardiography, spiral computed tomography, or brain natriuretic peptide testing) and myocardial injury (e.g. cardiac troponin T or I testing) have an insufficient positive predictive value for PE-specific mortality to drive decision-making toward such therapy. Recommendations for outpatient treatment or thrombolytic therapy for patients with PE necessitate further development of prognostic models and conduct of clinical trials that assess various treatment strategies.
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Affiliation(s)
- David Jiménez
- Respiratory Department and Medicine Department, Ramón y Cajal Hospital and Alcalá de Henares University, IRYCIS, Madrid, Spain.
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45
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Kurklinsky AK, Kalsi H, Wysokinski WE, Mauck KF, Bhagra A, Havyer RD, Thompson CA, Hayes SN, McBane RD. Fibrin D-Dimer Concentration, Deep Vein Thrombosis Symptom Duration, and Venous Thrombus Volume. Angiology 2010; 62:253-6. [DOI: 10.1177/0003319710382416] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction: To determine the relationship between fibrin D-dimer levels, symptom duration, and thrombus volume, consecutive patients with incident deep venous thrombosis (DVT) were evaluated. Methods: In a cross-sectional study design, patient symptom onset was determined by careful patient questioning. Venous thrombosis was confirmed by compression duplex ultrasonography. Thrombus volume was estimated based on patient’s femur length using a forensic anthropology method. Fibrin D-dimer was measured by latex immunoassay. Results: 72 consecutive patients with confirmed leg DVT agreed to participate. The median symptom duration at the time of diagnosis was 10 days. The median D-dimer concentration was 1050 ng/dL. The median thrombus volume was 12.92 cm3. D-Dimer levels correlated with estimated thrombus volume (P < .0006 CI 0.12-0.41; R2adjusted = .15) but not symptom duration, patient’s age, or gender. Conclusions: Despite varying symptom duration prior to diagnosis, fibrin D-dimer remains a sensitive measure of venous thrombosis and correlates with thrombus volume.
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Affiliation(s)
| | - Henna Kalsi
- Division of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Karen F. Mauck
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Anjali Bhagra
- Division of Primary Care Internal Medicine, Rochester, MN, USA
| | | | | | - Sharonne N. Hayes
- Division of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Robert D. McBane
- Division of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA,
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Gutte H, Mortensen J, Jensen CV, Von Der Recke P, Petersen CL, Kristoffersen US, Kjaer A. ANP, BNP and D-dimer predict right ventricular dysfunction in patients with acute pulmonary embolism. Clin Physiol Funct Imaging 2010; 30:466-72. [DOI: 10.1111/j.1475-097x.2010.00967.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Dalzell JR. Biomarkers in pulmonary embolism. QJM 2010; 103:360. [PMID: 20139100 DOI: 10.1093/qjmed/hcq005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Jeebun V, Doe SJ, Singh L, Worthy SA, Forrest IA. Are clinical parameters and biomarkers predictive of severity of acute pulmonary emboli on CTPA? QJM 2010; 103:91-7. [PMID: 20040533 DOI: 10.1093/qjmed/hcp162] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Previous studies have shown that findings of computed tomography pulmonary angiography (CTPA) relate to outcome in pulmonary embolus (PE). These include clot burden as quantified using an obstruction index and markers of pressure overload such as right ventricle to left ventricle size ratio (RV/LV ratio). Little data exists correlating these findings with clinical presentation and biomarkers. AIM To explore the link between clinical presentation and biomarkers with CTPA findings. METHODS Retrospective case note analysis of consecutive cases presenting to a large teaching hospital. An independent radiologist reviewed CTPAs and clot burden quantified using an obstruction index. RESULTS One hundred and seventy cases were identified and notes retrieved in 137 cases. (i) CLINICAL PRESENTATION correlation was seen between clot burden and systolic blood pressure (BP) (r = -0.299, P = 0.0006) and heart rate (r = 0.240, P = 0.0056). Median obstruction index was significantly higher in those with a presenting BP <90 mmHg [41.25% (95% CI 30-50) vs. 15% (95% CI 12.5-25), (P = 0.0004)]. Clot burden was significantly higher in patients with temperature of >37.5 degrees C [30% (95% CI 25.0-42.5) vs. 15% (95% CI 12.5-28.3), P = 0.02)] and (ii)Biomarkers: significant correlation between clot burden and D-dimer was seen (r = 0.36, P = 0.0001). Location of thrombus was associated with significant differences in D-dimer level. A subgroup of patients had cardiac biomarkers measured (n = 24). There was a statistically significant correlation between troponin I and clot burden (r = 0.412, P = 0.048) and RV/LV ratio (r = 0.699, P = 0.0013). DISCUSSION These findings suggest that clinical parameters and biomarkers have a role in predicting the radiological severity of PE. These data support the need for further studies of risk stratification in patients presenting with acute PE.
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Affiliation(s)
- V Jeebun
- Department of Respiratory Medicine, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, UK.
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49
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Yoon JC, Kim WY, Choi SS, Jung SK, Sohn CH, Kim W, Lim KS, Jeong TO, Jin YH, Lee JB. D-dimer as a Prognostic Tool in Patients with Normotensive Pulmonary Embolism. Tuberc Respir Dis (Seoul) 2010. [DOI: 10.4046/trd.2010.68.2.87] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Jae Chol Yoon
- Department of Emergency Medicine, Chonbuk National University Hospital, Jeonju, Korea
| | - Won Young Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sang Sik Choi
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sang Ku Jung
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Chang Hwan Sohn
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Won Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Kyoung Soo Lim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Tae O Jeong
- Department of Emergency Medicine, Chonbuk National University Hospital, Jeonju, Korea
| | - Young Ho Jin
- Department of Emergency Medicine, Chonbuk National University Hospital, Jeonju, Korea
| | - Jae Baek Lee
- Department of Emergency Medicine, Chonbuk National University Hospital, Jeonju, Korea
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50
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Lobo JL, Zorrilla V, Aizpuru F, Grau E, Jiménez D, Palareti G, Monreal M. D-dimer levels and 15-day outcome in acute pulmonary embolism. Findings from the RIETE Registry. J Thromb Haemost 2009; 7:1795-801. [PMID: 19691481 DOI: 10.1111/j.1538-7836.2009.03576.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND A number of variables have been evaluated for risk stratification in patients with acute pulmonary embolism (PE). Whereas increased D-dimer levels have been associated with mortality at 3 months, its role in predicting short-term outcome (the period of time during which any therapeutic decision has to be taken) remains unclear. METHODS RIETE is an ongoing, prospective registry of consecutive patients with acute venous thromboembolism. We assessed the prognostic value of D-dimer levels at baseline, measured with an automated latex agglutination test (IL Test D-dimer), on the 15-day outcome in patients with acute PE. Overall mortality, fatal PE and major bleeding rates were compared by quartile. RESULTS As of February 2008, 1707 patients with acute PE underwent D-dimer testing. Of these, 72 patients (4.2%) died during the first 15 days, 11 (0.6%) had recurrent PE, and 29 (1.7%) had major bleeding. Overall mortality increased with increasing D-dimer levels, from 2.7% in the first quartile (< 1050 ng mL(-1)) to 7.0% in the fourth quartile (>or= 4200 ng mL(-1)). The rates of fatal PE and major bleeding also increased. On multivariate analysis, patients with D-dimer levels in the fourth quartile had an increased risk for overall death (odds ratio, 1.8; 95% CI, 1.1-3.2), fatal PE (odds ratio, 2.0; 95% CI, 1.0-3.8) or major bleeding (odds ratio, 3.2; 95% CI, 1.5-7.0). CONCLUSIONS PE patients with D-dimer levels in the fourth quartile had an increased incidence of overall death, fatal PE and major bleeding within 15 days both before and after multivariate adjustment.
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Affiliation(s)
- J L Lobo
- Servicio de Neumología, Hospital Txagorritxu, Vitoria, Spain
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