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Selby R, Meijer P, Favaloro EJ. D-dimer diagnostics: can I use any D-dimer assay? Bridging the knowledge-to-action gap. Res Pract Thromb Haemost 2024; 8:102335. [PMID: 38433976 PMCID: PMC10905040 DOI: 10.1016/j.rpth.2024.102335] [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: 12/01/2023] [Revised: 01/09/2024] [Accepted: 01/22/2024] [Indexed: 03/05/2024] Open
Abstract
A State of the Art lecture titled "D-dimer Diagnostics: Can I use any D-dimer assay? Bridging the Knowledge-to-Action gap" was presented at the International Society on Thrombosis and Haemostasis Congress in 2023, included in the session on the clinical impact of variability in commonly used coagulation assays. Here, we review the role of D-dimer, primarily in the outpatient diagnosis of patients with venous thromboembolism (VTE) when combined with clinical decision rules. We focus on the recent large management trials that have studied adjustments of VTE exclusion thresholds for D-dimer based on either prior clinical probability of VTE or patient age, and the resultant benefit of reduced imaging for VTE and improved diagnostic efficiency. In this context, we report on the significant variability between D-dimer results and the multiple D-dimer assays in use worldwide using data from international external quality assurance programs. This variability is particularly high at typical VTE exclusion thresholds. We discuss the potential clinical impact of D-dimer assay substitution on accuracy of diagnosis and risk stratification of patients with VTE. Finally, we summarize relevant new data on this topic presented during the 2023 International Society on Thrombosis and Haemostasis Congress and outline future priorities urgently needed to harmonize D-dimer results and reporting that will require international collaboration among multiple stakeholders with an overall goal to close this knowledge-to-action gap.
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Affiliation(s)
- Rita Selby
- Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Piet Meijer
- ECAT Foundation, Voorschoten, the Netherlands
| | - Emmanuel J Favaloro
- Department of Haematology, Institute of Clinical Pathology and Medical Research, Sydney Centers for Thrombosis and Haemostasis, New South Wales Health Pathology, Westmead Hospital, Westmead, New South Wales, Australia
- School of Dentistry and Medical Sciences, Faculty of Science and Health, Charles Sturt University, Wagga Wagga, New South Wales, Australia
- School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Westmead Hospital, Westmead, New South Wales, Australia
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2
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Xiao H, Yu W, Li L, Yin X, Zhai Q, Hu D, Zhang X, Wang F. Trimester-specific reference intervals of hemostasis biomarkers for healthy pregnancy. Scand J Clin Lab Invest 2023; 83:379-383. [PMID: 37491076 DOI: 10.1080/00365513.2023.2233903] [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: 10/06/2020] [Revised: 07/02/2023] [Accepted: 07/02/2023] [Indexed: 07/27/2023]
Abstract
Physiological changes in hemostasis during pregnancy have been reported by several authors. This study aimed at establishing reference intervals for the hemostasis biomarkers thrombin-antithrombin complex (TAT), α2-plasmininhibitor-plasmin complex (PIC), thrombomodulin (TM) and tissue plasminogen activator-inhibitor complex (tPAI-C), in healthy pregnancies. After excluding outliers, a total of 496 healthy pregnant women (128 first-trimester, 142 second-trimester, 107 third-trimester and 119 pre-labor) and 103 healthy nonpregnant women were enrolled from Shenzhen Bao'an Women's and Children's Hospital. Hemostasis biomarkers, TAT, PIC, TM and tPAI-C, were measured by using a quantitative chemiluminescence enzyme immunoassay performed on HISCL automated analysers. The median and reference intervals (the 2.5th and 97.5th percentiles) were calculated to establish trimester-specific reference intervals for healthy pregnant women. The reference intervals for TAT, PIC, TM and tPAI-C in the first trimester were 0.7-7.6 1 µg/L, 0.2-0.9 mg/L, 2.8-11.0 TU/ml, and 1.2-6.5 1 µg/L, respectively. The reference intervals in the second trimester were 1.7-12.0 1 µg/L, 0.2-1.0 mg/L, 3.7-11.6 TU/ml, and 2.8-8.8 1 µg/L, respectively. The reference intervals in the third trimester were 2.7-16.1 1 µg/L, 0.1-1.4 mg/L, 2.9-12.9 TU/ml, and 1.9-8.0 1 µg/L, respectively. At pre-labor, the reference intervals were 4.8-32.9 1 µg/L, 0.2-1.9 mg/L, 4.2-12.6 TU/ml, and 2.8-15.4 1 µg/L, respectively. Gestational reference intervals for TAT, PIC, TM and tPAI-C in healthy pregnancies are provided, but only for TAT with increasing concentrations throughout pregnancy, the reference intervals for non-pregnant were not applicable.
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Affiliation(s)
- Haijun Xiao
- Shenzhen Baoan Women's and Children's Hospital, Guangdong, P.R. China
| | - Weijian Yu
- Shenzhen Baoan Women's and Children's Hospital, Guangdong, P.R. China
| | - Lihua Li
- Shenzhen Baoan Women's and Children's Hospital, Guangdong, P.R. China
| | - Xiaoqin Yin
- Shenzhen Longhua New District People's Hospital, P.R. China
| | - Qingna Zhai
- Shenzhen Baoan Women's and Children's Hospital, Guangdong, P.R. China
| | - Die Hu
- Shenzhen Baoan Women's and Children's Hospital, Guangdong, P.R. China
| | - Xiufa Zhang
- Shenzhen Baoan Women's and Children's Hospital, Guangdong, P.R. China
| | - Feng Wang
- Shenzhen Baoan Women's and Children's Hospital, Guangdong, P.R. China
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Wauthier L, Favresse J, Hardy M, Douxfils J, Le Gal G, Roy P, van Es N, Ay C, ten Cate H, Lecompte T, Lippi G, Mullier F. D-dimer testing: A narrative review. Adv Clin Chem 2023. [DOI: 10.1016/bs.acc.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
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Tramujas L, Judice MM, Becker AB. Evaluation of the diagnostic management of deep vein thrombosis in the emergency department of a tertiary hospital in Santa Catarina, Brazil: a cross-sectional study. J Vasc Bras 2022; 21:e20200217. [PMID: 36259054 PMCID: PMC9543468 DOI: 10.1590/1677-5449.202002171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 07/20/2022] [Indexed: 11/22/2022] Open
Abstract
Background Venous thromboembolism is an entity that encompasses both deep vein thrombosis and pulmonary thromboembolism. Although protocols for the diagnosis of these diseases are well defined, there is evidence of inappropriate use of diagnostic resources. Objectives To define the epidemiological profiles of patients admitted to the emergency department with suspected deep vein thrombosis, to determine rates of inappropriate ordering of D-dimer assays and color venous Doppler echocardiography of the lower limbs, and to identify whether these requests followed the recommendations contained in the 2015 Brazilian Society of Angiology and Vascular Surgery guidelines. Methods We conducted a cross-sectional observational study that retrospectively evaluated 168 patients with suspected deep vein thrombosis for whom D-dimer assays were requested. The most common risk factors were measured and the pretest probability was calculated with the Wells score. The epidemiological profile of these patients and the rates of inappropriate D-dimer testing were assessed using descriptive statistics. Results The D-dimer requests were inadequate in 55 (32.7%) patients. Venous color Doppler ultrasound was used to examine the lower limbs of 14 (8.3%) of the patients with a low probability according to the Wells score and a negative D-dimer result. No additional diagnostic methods were used in 19 (11.3%) of those with a low probability according to the Wells score and a high D-dimer result. There was unnecessary use of CDUS in 35 (20.8%) cases. The overall rate of inappropriate workup was 53.5%. Conclusions Differences were found between clinical practice and the recommendations for diagnostic evaluation of patients with suspected deep vein thrombosis, with inappropriate use of diagnostic tests.
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Affiliation(s)
- Lucas Tramujas
- Hospital Governador Celso Ramos, Florianópolis, SC, Brasil.,Instituto de Pesquisa Hcor, São Paulo, SP, Brasil.
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Tramujas L, Judice MM, Becker AB. Evaluation of the diagnostic management of deep vein thrombosis in the emergency department of a tertiary hospital in Santa Catarina, Brazil: a cross-sectional study. J Vasc Bras 2022. [DOI: 10.1590/1677-5449.202002172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Abstract Background Venous thromboembolism is an entity that encompasses both deep vein thrombosis and pulmonary thromboembolism. Although protocols for the diagnosis of these diseases are well defined, there is evidence of inappropriate use of diagnostic resources. Objectives To define the epidemiological profiles of patients admitted to the emergency department with suspected deep vein thrombosis, to determine rates of inappropriate ordering of D-dimer assays and color venous Doppler echocardiography of the lower limbs, and to identify whether these requests followed the recommendations contained in the 2015 Brazilian Society of Angiology and Vascular Surgery guidelines. Methods We conducted a cross-sectional observational study that retrospectively evaluated 168 patients with suspected deep vein thrombosis for whom D-dimer assays were requested. The most common risk factors were measured and the pretest probability was calculated with the Wells score. The epidemiological profile of these patients and the rates of inappropriate D-dimer testing were assessed using descriptive statistics. Results The D-dimer requests were inadequate in 55 (32.7%) patients. Venous color Doppler ultrasound was used to examine the lower limbs of 14 (8.3%) of the patients with a low probability according to the Wells score and a negative D-dimer result. No additional diagnostic methods were used in 19 (11.3%) of those with a low probability according to the Wells score and a high D-dimer result. There was unnecessary use of CDUS in 35 (20.8%) cases. The overall rate of inappropriate workup was 53.5%. Conclusions Differences were found between clinical practice and the recommendations for diagnostic evaluation of patients with suspected deep vein thrombosis, with inappropriate use of diagnostic tests.
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Affiliation(s)
- Lucas Tramujas
- Hospital Governador Celso Ramos, Brasil; Instituto de Pesquisa Hcor, Brasil
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Safety of a strategy combining D-dimer testing and whole-leg ultrasonography to rule out deep vein thrombosis. Blood Adv 2020; 4:5002-5010. [PMID: 33057634 DOI: 10.1182/bloodadvances.2020002173] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 07/23/2020] [Indexed: 11/20/2022] Open
Abstract
Guidelines for the diagnostic workup of deep vein thrombosis (DVT) recommend assessing the clinical pretest probability before proceeding to D-dimer testing and/or compression ultrasonography (CUS) if the patient has high pretest probability or positive D-dimer. Referring only patients with positive D-dimer for whole-leg CUS irrespective of pretest probability may simplify the workup of DVT. In this prospective management outcome study, we assessed the safety of such a strategy. We included consecutive outpatients referred to the Emergency Department at Østfold Hospital, Norway, with suspected DVT between February 2015 and November 2018. STA-Liatest D-Di Plus D-dimer was analyzed for all patients, and only patients with levels ≥0.5 µg/mL were referred for CUS. All patients with negative D-dimer or negative CUS were followed for 3 months to assess the venous thromboembolic rate. One thousand three hundred ninety-seven patients were included. Median age was 64 years (interquartile range, 52-73 years), and 770 patients (55%) were female. D-dimer was negative in 415 patients (29.7%) and positive in 982 patients (70.3%). DVT was diagnosed in 277 patients (19.8%). Six patients in whom DVT was ruled out at baseline were diagnosed with DVT within 3 months of follow-up for a thromboembolic rate of 0.5% (95% confidence interval, 0.2-1.2). A simple diagnostic approach with initial stand-alone D-dimer followed by a single whole-leg CUS in patients with positive D-dimer safely ruled out DVT. We consider this strategy to be a valuable alternative to the conventional workup of DVT in outpatients. This trial was registered at www.clinicaltrials.gov as #NCT02486445.
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Rudolf JW, Baron JM, Dighe AS. Order Indication Solicitation to Assess Clinical Laboratory Test Utilization: D-Dimer Order Patterns as an Illustrative Case. J Pathol Inform 2019; 10:36. [PMID: 31897353 PMCID: PMC6909549 DOI: 10.4103/jpi.jpi_46_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 10/10/2019] [Indexed: 11/07/2022] Open
Abstract
Background: A common challenge in the development of laboratory clinical decision support (CDS) and laboratory utilization management (UM) initiatives stems from the fact that many laboratory tests have multiple potential indications, limiting the ability to develop context-specific alerts. As a potential solution, we designed a CDS alert that asks the ordering clinician to provide the indication for testing, using D-dimer as an exemplar. Using data collected over a nearly 3-year period, we sought to determine whether the indication capture was a useful feature within the CDS alert and whether it provided actionable intelligence to guide the development of an UM strategy. Methods: We extracted results and ordering data for D-dimer testing performed in our laboratory over a 35-month period. We analyzed order patterns by clinical indication, hospital service, and length of hospitalization. Results: Our final data set included 13,971 result-order combinations and indeed provided actionable intelligence regarding test utilization patterns. For example, pulmonary embolism was the most common emergency department indication (86%), while disseminated intravascular coagulation was the most common inpatient indication (56%). D-dimer positivity rates increased with the duration of hospitalization and our data suggested limited utility for ordering this test in the setting of suspected venous thromboembolic disease in admitted patients. In addition, we found that D-dimer was ordered for unexpected indications including the assessment of stroke, dissection, and extracorporeal membrane oxygenation. Conclusions: Indication capture within a CDS alert and correlation with result data can provide insight into order patterns which can be used to develop future CDS strategies to guide appropriate test use by clinical indication.
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Affiliation(s)
- Joseph W Rudolf
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, Minneapolis, MN, USA.,Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Jason M Baron
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Anand S Dighe
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
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Kamolratanapiboon K, Tantanate C. Inappropriate use of D-dimer and impact on the test characteristics for deep vein thrombosis exclusion. Scandinavian Journal of Clinical and Laboratory Investigation 2019; 79:431-436. [PMID: 31443614 DOI: 10.1080/00365513.2019.1658214] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
This study aimed to investigate the prevalence of the inappropriate use of D-dimer testing for deep vein thrombosis (DVT) exclusion, and to evaluate the diagnostic value of D-dimer testing compared between testing in appropriate and inappropriate conditions. A retrospective chart review of patients with D-dimer requests at Siriraj Hospital, Bangkok, Thailand during January-September 2017 was performed. Data relating to D-dimer requests, Wells score, imaging investigations, and coexisting conditions that cause elevated D-dimer without correlation to DVT were analyzed. From 2196 cases, there were 300 D-dimer requests for DVT diagnosis. Of those, 5 (1.7%) and 158 (53.6%) requests were considered to be absolutely inappropriate D-dimer test requests due to the absence of pre-test Wells score evaluation and testing in DVT-likely patients, respectively. One-hundred and forty-eight (49.3%) requests were considered to be the relatively inappropriate D-dimer test requests due to testing in patients with coexisting conditions that included malignancies, sepsis, surgery, trauma, arterial thrombosis, and pregnancy. Three patients had more than one of these conditions. Comparatively higher negative predictive values (NPVs) of D-dimer assay for DVT exclusion were observed when used in DVT-unlikely (100% versus 80%), and in patients without coexisting conditions (100% versus 66.7%). The present study revealed the rate of inappropriate D-dimer testing for DVT exclusion to be high and this may lead to missed DVT diagnosis, overuse of imaging study, and unnecessary cost of D-dimer testing. Appropriate patient selection before test request can improve the NPV of D-dimer for DVT exclusion.
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Affiliation(s)
- Karnrawee Kamolratanapiboon
- Department of Clinical Pathology, Faculty of Medicine Siriraj Hospital, Mahidol University , Bangkok , Thailand
| | - Chaicharoen Tantanate
- Department of Clinical Pathology, Faculty of Medicine Siriraj Hospital, Mahidol University , Bangkok , Thailand
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9
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Favresse J, Lippi G, Roy PM, Chatelain B, Jacqmin H, Ten Cate H, Mullier F. D-dimer: Preanalytical, analytical, postanalytical variables, and clinical applications. Crit Rev Clin Lab Sci 2019; 55:548-577. [PMID: 30694079 DOI: 10.1080/10408363.2018.1529734] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
D-dimer is a soluble fibrin degradation product deriving from the plasmin-mediated degradation of cross-linked fibrin. D-dimer can hence be considered a biomarker of activation of coagulation and fibrinolysis, and it is routinely used for ruling out venous thromboembolism (VTE). D-dimer is increasingly used to assess the risk of VTE recurrence and to help define the optimal duration of anticoagulation treatment in patients with VTE, for diagnosing disseminated intravascular coagulation, and for screening medical patients at increased risk of VTE. This review is aimed at (1) revising the definition of D-dimer; (2) discussing preanalytical variables affecting the measurement of D-dimer; (3) reviewing and comparing assay performance and some postanalytical variables (e.g. different units and age-adjusted cutoffs); and (4) discussing the use of D-dimer measurement across different clinical settings.
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Affiliation(s)
- Julien Favresse
- a CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Hematology Laboratory , Université Catholique de Louvain , Yvoir , Belgium
| | - Giuseppe Lippi
- b Section of Clinical Biochemistry , University Hospital of Verona , Verona , Italy
| | - Pierre-Marie Roy
- c Département de Médecine d'Urgence, CHU d'Angers, Institut MITOVASC , Université d'Angers , Angers , France
| | - Bernard Chatelain
- a CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Hematology Laboratory , Université Catholique de Louvain , Yvoir , Belgium
| | - Hugues Jacqmin
- a CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Hematology Laboratory , Université Catholique de Louvain , Yvoir , Belgium
| | - Hugo Ten Cate
- d Department of Internal Medicine, Cardiovascular Institute , Maastricht University Medical Center , Maastricht , the Netherlands
| | - François Mullier
- a CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Hematology Laboratory , Université Catholique de Louvain , Yvoir , Belgium
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Cadamuro J, Ibarz M, Cornes M, Nybo M, Haschke-Becher E, von Meyer A, Lippi G, Simundic AM. Managing inappropriate utilization of laboratory resources. ACTA ACUST UNITED AC 2019; 6:5-13. [PMID: 30096052 DOI: 10.1515/dx-2018-0029] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 06/27/2018] [Indexed: 12/29/2022]
Abstract
Background The inappropriate use of laboratory resources, due to excessive number of tests not really necessary for patient care or by failure to order the appropriate diagnostic test, may lead to wrong, missed or delayed diagnosis, thus potentially jeopardizing patient safety. It is estimated that 5-95% of tests are currently used inappropriately, depending on the appropriateness criteria, thus significantly contributing to the potential of generating medical errors, the third leading cause of death in the US. Content In this review, we discuss the reasons as well as the medical and financial consequences of inappropriate utilization of laboratory tests. We then provide demand management (DM) tools as a means for overcoming this issue and also discuss their benefits, challenges, limitations and requirements for successful implementation. Summary and outlook When based on current evidence, adapted to local conditions and developed in close collaboration with clinicians, DM is a reasonable strategy for progressing toward better management of over- and underuse of laboratory resources.
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Affiliation(s)
- Janne Cadamuro
- Department of Laboratory Medicine, Paracelsus Medical University, Müllner Hauptstr. 48, 5020 Salzburg, Austria, Phone: +43-57255-57263, Fax: +43-57255-23199
| | - Mercedes Ibarz
- Laboratory Medicine Department, University Hospital Arnau de Vilanova, IRBLleida, Lleida, Spain
| | - Michael Cornes
- Clinical Chemistry Department, Worcester Acute Hospitals NHS Trust, Worcester, UK
| | - Mads Nybo
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | | | - Alexander von Meyer
- Institute of Laboratory Medicine, Kliniken Nordoberpfalz AG and Klinikum St. Marien, Weiden and Amberg, Germany
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
| | - Ana-Maria Simundic
- Department of Medical Laboratory Diagnostics, University Hospital "Sveti Duh", Zagreb, Croatia
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Francis S, Limkakeng A, Zheng H, Hollander J, Fermann G, Parry BA, Lovecchio F, Werner N, Schellong S, Kabrhel C. Highly Elevated Quantitative D-Dimer Assay Values Increase the Likelihood of Venous Thromboembolism. TH OPEN 2019; 3:e2-e9. [PMID: 31249975 PMCID: PMC6524895 DOI: 10.1055/s-0038-1677029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 11/29/2018] [Indexed: 01/09/2023] Open
Abstract
Objectives
In patients with suspected venous thromboembolism (VTE), the D-dimer assay is commonly utilized as part of the workup. The assay is primarily used to determine whether to proceed with radiographic imaging. We compared D-dimer levels in patients suspected of having VTE. We hypothesized that higher D-dimer values predict a higher likelihood of subsequent VTE diagnosis.
Methods
We conducted a secondary analysis of a multinational, prospective observational study of low- to intermediate-risk adult patients presenting to the emergency department with suspicion of VTE. Demographic and clinical data were collected in a structured manner. Advanced imaging including ultrasound, computed tomography (CT) pulmonary angiography, and ventilation/perfusion scanning was obtained at the discretion of the treating physicians. Imaging was evaluated by board-certified radiologists in real time. D-dimer values' bins were evaluated using a logistic regression model.
Results
We evaluated 1,752 patients for suspected deep vein thrombosis (DVT), with 191 (10.4%) DVT positive. We evaluated 1,834 patients for suspected pulmonary embolism (PE), with 108 (5.9%) PE positive. Higher D-dimer values in both groups were associated with higher likelihood of subsequent VTE diagnosis, with D-dimer values > 3,999 ng/mL in both groups having the highest incidence of VTE. More than 50% of those patients were VTE positive.
Conclusions
Increasing D-dimer values predict increased likelihood of being found VTE positive in this patient population. Among those in the highest D-dimer category, > 3,999 ng/mL, over half of patients were VTE positive. Further research could determine additional nuance in D-dimer as a tool to work up suspected VTE.
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Affiliation(s)
- Samuel Francis
- Division of Emergency Medicine, Duke University Hospital, Durham, North Carolina, United States
| | - Alexander Limkakeng
- Division of Emergency Medicine, Duke University Hospital, Durham, North Carolina, United States
| | - Hui Zheng
- Department of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Judd Hollander
- Department of Emergency Medicine, Jefferson University, Philadelphia, Pennsylvania, United States
| | - Gregory Fermann
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio, United States
| | - Blair Alden Parry
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Frank Lovecchio
- Department of Emergency Medicine, Maricopa Hospital, Phoenix, Arizona, United States
| | - Nikos Werner
- International Center for Cardiovascular Interventions, Heart Center Bonn, Medizinischen Klinik und Poliklinik II, Bonn, Germany
| | | | - Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Boston, Massachusetts, United States
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Sendama W, Musgrave KM. Decision-Making with D-Dimer in the Diagnosis of Pulmonary Embolism. Am J Med 2018; 131:1438-1443. [PMID: 30125536 DOI: 10.1016/j.amjmed.2018.08.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 08/08/2018] [Accepted: 08/09/2018] [Indexed: 01/13/2023]
Abstract
The measurement of D-dimer can provide useful information to aid in the diagnosis of patients with suspected venous thromboembolism. D-dimer measurement in conjunction with adequate estimation of pretest probability can facilitate the safe discharge of patients with suspected pulmonary embolism and limit unnecessary investigation or anticoagulation. We review clinical decision-making strategies in the diagnosis of pulmonary embolism and propose means to minimize diagnostic error that might arise from knowledge of the D-dimer result prior to clinical assessment.
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Affiliation(s)
- Wezi Sendama
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom; Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom.
| | - Kathryn M Musgrave
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom; Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
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Kilpatrick ES, Sandberg S. An overview of EFLM harmonization activities in Europe. Clin Chem Lab Med 2018; 56:1591-1597. [PMID: 29924732 DOI: 10.1515/cclm-2018-0098] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Accepted: 04/03/2018] [Indexed: 01/22/2023]
Abstract
Abstract
The European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) has initiated many harmonization activities in all phases of the examination process. The EFLM is dealing with both the scientific and the educational aspects of harmonization, with the intention of disseminating best practice in laboratory medicine throughout Europe. Priorities have been given (1) to establish a standard for conducting and assessing biological variation studies and to construct an evidence based EFLM webpage on biological variation data, (2) to harmonize preanalytical procedures by producing European guidelines, (3) to improve test ordering and interpretation, (4) to produce other common European guidelines for laboratory medicine and play an active part in development of clinical guidelines, (5) to establish a common basis for communicating laboratory results to patients, (6) to harmonize units of measurement throughout Europe, (7) to harmonize preanalytical procedures in molecular diagnostics and (8) to harmonize and optimize test evaluation procedures. The EFLM is also now launching the 5th version of the European Syllabus to help the education of European Specialists in Laboratory Medicine (EuSpLM), which is being supported by the development of e-learning courses. A register of EuSpLM is already established for members of National Societies in EU countries, and a similar register will be established for specialists in non-EU countries.
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Affiliation(s)
- Eric S Kilpatrick
- Professor of Pathology and Laboratory Medicine, Weill Cornell Medicine, Division Chief, Clinical Biochemistry, Department of Pathology, Sidra Medicine, 2nd Mezzanine Level, PO Box 26999, Doha, Qatar
| | - Sverre Sandberg
- Norwegian Quality Improvement of Laboratory Examinations, Bergen, Norway
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Farm M, Siddiqui AJ, Onelöv L, Järnberg I, Eintrei J, Maskovic F, Kallner A, Holmström M, Antovic JP. Age-adjusted D-dimer cut-off leads to more efficient diagnosis of venous thromboembolism in the emergency department: a comparison of four assays. J Thromb Haemost 2018; 16:866-875. [PMID: 29505695 DOI: 10.1111/jth.13994] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Indexed: 11/29/2022]
Abstract
Essentials Age-adjusted D-dimer cut-offs decrease the false positives in the elderly. Four D-dimer assays were compared in venous thromboembolism outpatients in an emergency ward. Age-adjusted cut-off resulted in improved specificity with maintained sensitivity for all assays. There was a substantial decrease in false positive results, especially in the older population. SUMMARY Background The study compares different D-dimer assays and age-adjusted cut-offs in outpatients with suspected venous thromboembolism (VTE). The plasma concentration of this sensitive biomarker is increased by activated coagulation, but also by several conditions that are linked to an increased risk of VTE. One such condition is old age, which poses a common clinical problem where many prefer not to analyze D-dimer in elderly patients. Age-adjusted cut-offs have been validated for both deep venous thrombosis (DVT) and pulmonary embolism, aiming to increase specificity without notably decreasing sensitivity. Objectives We evaluated four common D-dimer assays in parallel, with and without applying age-adjusted cut offs for VTE. Patients/methods The prospective single-center study was conducted in 940 outpatients attending the emergency department with clinically suspected pulmonary embolism or DVT. Four automated D-dimer assays were compared (Siemens INNOVANCE® , Roche Tina-quant, Medirox MRX and STA® -Liatest® D-Di PLUS). Results All assays performed with areas under the ROC curve (AUC) > 0.9 and maintained their sensitivities after implementation of age-adjusted cut-offs. Specificities increased by 6-7% and number needed to test decreased by < 0.3. The rate of false positive results decreased by 6% overall and by 10-20% for patients ≥ 70. Conclusions Age-adjusted cut-offs resulted in maintained high sensitivity and a modest improvement in specificity and number needed to test for all evaluated D-dimer assays. There was a significant reduction in false positive results, which reflects avoidable unnecessary imaging without any compromise of clinical safety. This suggests a potential to benefit the management of VTE in elderly patients, both clinically and economically.
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Affiliation(s)
- M Farm
- Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Clinical Chemistry, Karolinska University Hospital, Stockholm, Sweden
| | - A J Siddiqui
- Emergency Department, Karolinska University Hospital, Stockholm, Sweden
| | - L Onelöv
- Clinical Chemistry, Karolinska University Hospital, Stockholm, Sweden
| | - I Järnberg
- Clinical Chemistry, Karolinska University Hospital, Stockholm, Sweden
| | - J Eintrei
- Clinical Chemistry, Karolinska University Hospital, Stockholm, Sweden
| | - F Maskovic
- Emergency Department, Karolinska University Hospital, Stockholm, Sweden
| | - A Kallner
- Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Clinical Chemistry, Karolinska University Hospital, Stockholm, Sweden
| | - M Holmström
- Coagulation Unit, Hematology Center Karolinska, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - J P Antovic
- Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Clinical Chemistry, Karolinska University Hospital, Stockholm, Sweden
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15
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Stavelin A, Albe X, Meijer P, Sarkany E, MacKenzie F. An overview of the European Organization for External Quality Assurance Providers in Laboratory Medicine (EQALM). Biochem Med (Zagreb) 2017; 27:30-36. [PMID: 28392724 PMCID: PMC5382863 DOI: 10.11613/bm.2017.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Accepted: 12/24/2016] [Indexed: 11/18/2022] Open
Abstract
The European Organisation for External Quality Assurance Providers in Laboratory Medicine (EQALM) was founded in 1996 and currently has members from 29 European countries and 6 countries from outside Europe. EQALM provides a forum for co-operation and exchange of knowledge on quality-related matters in laboratory medicine, especially with regard to external quality assessment (EQA) programs in Europe. In addition, EQALM represent the EQA providers in laboratory medicine at European level vis-ŕ-vis political, professional, scientific and other bodies, including patients’ organisations. To this end EQALM promotes activities such as organizing meetings with scientific and practical themes for members and other interested parties, issuing scientific publications, developing EQA projects and representing laboratory medicine EQA activities within other organisations and networks. EQALM is active in scientific and educational activity in different fields such as survey frequency, haematology, haemostasis, microbiology, nomenclature, virtual microscopy, traceability, accreditation, and quality assurance of the total testing process. The aim of this paper is to give an overview of the EQALM organisation.
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Affiliation(s)
- Anne Stavelin
- The Norwegian Quality Improvement of Primary Care Laboratories (Noklus), Haraldsplass Deaconess Hospital, Bergen, Norway
| | - Xavier Albe
- Swiss Center for Quality Control (CSCQ), Chęne-Bourg, Switzerland
| | - Piet Meijer
- External quality Control for Assays and Tests with a focus on Thrombosis and Haemostasis (ECAT Foundation), Voorschoten, The Netherlands
| | - Erika Sarkany
- In Vitro Diagnostic Quality Control (QualiCont), Szeged, Hungary
| | - Finlay MacKenzie
- United Kingdom National External Quality Assessment Service (UK NEQAS) for Clinical Chemistry, Institute of Research and Development, University Hospitals Birmingham, UK
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16
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Pre- and post-test probabilities of venous thromboembolism and diagnostic accuracy of D-dimer, estimated by European clinicians working in emergency departments. Thromb Res 2017; 159:19-23. [DOI: 10.1016/j.thromres.2017.09.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 08/24/2017] [Accepted: 09/11/2017] [Indexed: 11/24/2022]
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17
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Schaefer JK, Jacobs B, Wakefield TW, Sood SL. New biomarkers and imaging approaches for the diagnosis of deep venous thrombosis. Curr Opin Hematol 2017; 24:274-281. [PMID: 28306666 DOI: 10.1097/moh.0000000000000339] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE OF REVIEW Symptoms suggestive of deep vein thrombosis (DVT) are extremely common in clinical practice, but unfortunately nonspecific. In both ambulatory and inpatient settings, clinicians are often tasked with evaluating these concerns. Here, we review the most recent advances in biomarkers and imaging to diagnose lower extremity DVT. RECENT FINDINGS The modified Wells score remains the most supported clinical decision rule for risk stratifying patients. In uncomplicated patients, the D-dimer can be utilized with risk stratification to reasonably exclude lower extremity DVT in some patients. Although numerous biomarkers have been explored, soluble P-selectin has the most promise as a novel marker for DVT. Imaging will be required for many patients and ultrasound is the primary modality. Nuclear medicine techniques are under development, and computed tomography (CT) and magnetic resonance venography are reasonable alternatives in select patients. SUMMARY D-dimer is the only clinically applied biomarker for DVT diagnosis, with soluble P-selectin a promising novel biomarker. Recent studies have identified several other potential biomarkers. Ultrasound remains the imaging modality of choice, but CT, MRI, or nuclear medicine tests can be considered in select scenarios.
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Affiliation(s)
- Jordan K Schaefer
- aDivision of Hematology/Oncology bSection of Vascular Surgery, University of Michigan, Ann Arbor, Michigan, USA
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18
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Lippi G, Adcock D, Simundic AM, Tripodi A, Favaloro EJ. Critical laboratory values in hemostasis: toward consensus. Ann Med 2017; 49:455-461. [PMID: 28042729 DOI: 10.1080/07853890.2016.1278303] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The term "critical values" can be defined to entail laboratory test results that significantly lie outside the normal (reference) range and necessitate immediate reporting to safeguard patient health, as well as those displaying a highly and clinically significant variation compared to previous data. The identification and effective communication of "highly pathological" values has engaged the minds of many clinicians, health care and laboratory professionals for decades, since these activities are vital to good laboratory practice. This is especially true in hemostasis, where a timely and efficient communication of critical values strongly impacts patient management. Due to the heterogeneity of available data, this paper is hence aimed to analyze the state of the art and provide an expert opinion about the parameters, measurement units and alert limits pertaining to critical values in hemostasis, thus providing a basic document for future consultation that assists laboratory professionals and clinicians alike. KEY MESSAGES Critical values are laboratory test results significantly lying outside the normal (reference) range and necessitating immediate reporting to safeguard patient health. A broad heterogeneity exists about critical values in hemostasis worldwide. We provide here an expert opinion about the parameters, measurement units and alert limits pertaining to critical values in hemostasis.
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Affiliation(s)
- Giuseppe Lippi
- a Section of Clinical Biochemistry, University of Verona , Verona , Italy
| | - Dorothy Adcock
- b Colorado Coagulation, Laboratory Corporation of America® Holdings , Englewood , CO , USA
| | - Ana-Maria Simundic
- c Department of Medical Laboratory Diagnostics , University Hospital Sveti Duh , Zagreb , Croatia
| | - Armando Tripodi
- d Angelo Bianchi Bonomi, Hemophilia and Thrombosis Center, Department of Clinical Sciences and Community Health , Università degli Studi di Milano and IRCCS Cà Granda Maggiore Hospital Foundation , Milano , Italy
| | - Emmanuel J Favaloro
- e Department of Haematology, Sydney Centres for Thrombosis and Haemostasis , Institute of Clinical Pathology and Medical Research (ICPMR), Westmead Hospital , Westmead , New South Wales , Australia
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19
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Kim SJ, Kim MH, Lee KM, Kim TH, Choi SY, Son MK, Park JW, Serebruany VL. Troponin I and D-Dimer for Discriminating Acute Pulmonary Thromboembolism from Myocardial Infarction. Cardiology 2016; 136:222-227. [PMID: 27816974 DOI: 10.1159/000449404] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 08/03/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Acute pulmonary thromboembolism (APTE) is a life-threatening condition, often manifesting with chest pain, dyspnea, and increased cardiac biomarkers including cardiac troponin I (CTI) and D-dimer. Therefore, APTE is often misdiagnosed with classical non-ST elevation myocardial infarction (NSTEMI), resulting in unnecessary coronary interventions and a delay of therapy. OBJECTIVES Our aim was to distinguish APTE from NSTEMI based on CTI and D-dimer levels. METHODS Complete clinical and laboratory data sets from APTE patients (n = 123) were compared with matched NSTEMI patients (n = 123) who presented with chest pain. The APTE diagnosis was confirmed by chest tomography, angiography, or radionuclide ventilation-perfusion scan, while NSTEMI was established by clinical symptoms, cardiac biomarkers, and coronary angiography. Clinical characteristics, CTI (initial and peak), and D-dimer levels at presentation were retrospectively analyzed. RESULTS The clinical characteristics were not different between APTE and NSTEMI patients. However, significantly lower initial CTI (0.2 ± 0.5 vs. 4.4 ± 9.5 ng/ml) and peak CTI (0.7 ± 2.7 vs. 17.1 ± 20.4 ng/ml), but higher initial D-dimer (9.8 ± 9.4 vs. 1.6 ± 3.6 ng/ml), distinguished APTE from NSTEMI. By receiver operating characteristic curve analysis, the cutoff values for initial CTI, peak CTI, and D-dimer were 0.25, 0.98, and 3.18 ng/ml, respectively. CONCLUSION Patients with APTE exhibited lower initial and peak CTI but higher D-dimer levels than NSTEMI patients. Assessing cardiac biomarkers is useful for differentiating APTE from NSTEMI. Further large randomized biomarker studies are urgently needed to facilitate a better APTE diagnosis since clinical characteristics are not particularly helpful.
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Affiliation(s)
- Soo Jin Kim
- Department of Cardiology, Dong-A University Hospital, Busan, South Korea
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