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Kearon C, de Wit K, Parpia S, Schulman S, Afilalo M, Hirsch A, Spencer FA, Sharma S, D'Aragon F, Deshaies JF, Le Gal G, Lazo-Langner A, Wu C, Rudd-Scott L, Bates SM, Julian JA. Diagnosis of Pulmonary Embolism with d-Dimer Adjusted to Clinical Probability. N Engl J Med 2019; 381:2125-2134. [PMID: 31774957 DOI: 10.1056/nejmoa1909159] [Citation(s) in RCA: 183] [Impact Index Per Article: 36.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Retrospective analyses suggest that pulmonary embolism is ruled out by a d-dimer level of less than 1000 ng per milliliter in patients with a low clinical pretest probability (C-PTP) and by a d-dimer level of less than 500 ng per milliliter in patients with a moderate C-PTP. METHODS We performed a prospective study in which pulmonary embolism was considered to be ruled out without further testing in outpatients with a low C-PTP and a d-dimer level of less than 1000 ng per milliliter or with a moderate C-PTP and a d-dimer level of less than 500 ng per milliliter. All other patients underwent chest imaging (usually computed tomographic pulmonary angiography). If pulmonary embolism was not diagnosed, patients did not receive anticoagulant therapy. All patients were followed for 3 months to detect venous thromboembolism. RESULTS A total of 2017 patients were enrolled and evaluated, of whom 7.4% had pulmonary embolism on initial diagnostic testing. Of the 1325 patients who had a low C-PTP (1285 patients) or moderate C-PTP (40 patients) and a negative d-dimer test (i.e., <1000 or <500 ng per milliliter, respectively), none had venous thromboembolism during follow-up (95% confidence interval [CI], 0.00 to 0.29%). These included 315 patients who had a low C-PTP and a d-dimer level of 500 to 999 ng per milliliter (95% CI, 0.00 to 1.20%). Of all 1863 patients who did not receive a diagnosis of pulmonary embolism initially and did not receive anticoagulant therapy, 1 patient (0.05%; 95% CI, 0.01 to 0.30) had venous thromboembolism. Our diagnostic strategy resulted in the use of chest imaging in 34.3% of patients, whereas a strategy in which pulmonary embolism is considered to be ruled out with a low C-PTP and a d-dimer level of less than 500 ng per milliliter would result in the use of chest imaging in 51.9% (difference, -17.6 percentage points; 95% CI, -19.2 to -15.9). CONCLUSIONS A combination of a low C-PTP and a d-dimer level of less than 1000 ng per milliliter identified a group of patients at low risk for pulmonary embolism during follow-up. (Funded by the Canadian Institutes of Health Research and others; PEGeD ClinicalTrials.gov number, NCT02483442.).
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Affiliation(s)
- Clive Kearon
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Kerstin de Wit
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Sameer Parpia
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Sam Schulman
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Marc Afilalo
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Andrew Hirsch
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Frederick A Spencer
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Sangita Sharma
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Frédérick D'Aragon
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Jean-François Deshaies
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Gregoire Le Gal
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Alejandro Lazo-Langner
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Cynthia Wu
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Lisa Rudd-Scott
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Shannon M Bates
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
| | - Jim A Julian
- From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada
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