Prognostic value of D-dimer in patients with pulmonary embolism

Relationship between baseline D-dimer and prognosis in Japanese patients with venous thromboembolism: Insights from the J'xactly study

Background

D-dimer is a biomarker of fibrin production and degradation, and changes in D-dimer concentration suggest fibrin clot formation, which is associated with thromboembolism and hypercoagulable states. Thus, an elevated D-dimer concentration could be a useful prognostic predictor for patients with venous thromboembolism (VTE).

Methods and results

In this subanalysis of the J'xactly study, a prospective multicenter study conducted in Japan, we examined the clinical outcomes of 949 patients with VTE stratified by baseline D-dimer concentration. The median D-dimer concentration was 7.6 μg/ml (low D-dimer group: <7.6 μg/ml [n = 473, 49.8%]; high D-dimer group: ≥7.6 μg/ml [n = 476, 50.2%]). The mean age of the patients was 68 years, and 386 patients (40.7%) were male. Compared with the low D-dimer group, the high D-dimer group had more frequent pulmonary embolism with or without deep vein thrombosis (DVT), proximal DVT, atrial fibrillation, or diabetes mellitus, and underwent intensive treatment with 30 mg/day rivaroxaban. The incidence of composite clinically relevant events (recurrence or exacerbation of symptomatic VTE, acute coronary syndrome [ACS], ischemic stroke, death from any cause, or major bleeding) was higher in the high D-dimer group than in the low D-dimer group (11.1% vs. 7.5% per patient-year; hazard ratio, 1.46; 95% confidence interval, 1.05-2.04; p = 0.025). There was no significant difference between the high and low D-dimer groups in the incidence of VTE (2.8% vs. 2.5% per patient-year, respectively; p = 0.788), ACS (0.4% per patient-year vs. not observed, respectively; p = 0.078), or major bleeding (4.0% vs. 2.1% per patient-year, respectively; p = 0.087), but there was a significant difference in the incidence of ischemic stroke (1.0% per patient-year vs. not observed, respectively; p = 0.004).

Conclusion

Elevated D-dimer concentration may be an important prognostic predictor in Japanese patients with VTE.Clinical Trial Registration: UMIN CTR, UMIN000025072 (https://www.umin.ac.jp/ctr/index.htm).

Risk stratification to optimize the management of acute pulmonary embolism

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.

Combination of D-dimer and simplified pulmonary embolism severity index to improve prediction of hospital death in patients with acute pulmonary embolism

Objective

To investigate whether the combination of D-dimer and simplified pulmonary embolism severity index (sPESI) could improve prediction of in-hospital death from pulmonary embolism (PE).

Methods

Patients with PE (n = 272) were divided into a surviving group (n = 249) and an in-hospital death group (n = 23).

Results

Compared with surviving patients, patients who died in hospital had significantly higher rates of hypotension and tachycardia, reduced SaO₂ levels, elevated D-dimer and troponin T levels, higher sPESI scores, and were more likely to be classified as high risk. Elevated D-dimer levels and high sPESI scores were significantly associated with in-hospital death. Using thresholds for D-dimer and sPESI of 3.175 ng/mL and 1.5, respectively, the specificity for prediction of in-hospital death was 0.357 and 0.414, respectively, and the area under the receiver operating characteristic curve (AUC) was 0.665 and 0.668, respectively. When D-dimer and sPESI were considered together, the specificity for prediction of in-hospital death increased to 0.838 and the AUC increased to 0.74.

Conclusions

D-dimer and sPESI were associated with in-hospital death from PE. Considering D-dimer levels together with sPESI can significantly improve the specificity of predicting in-hospital death for patients with PE.

Impact of atrial fibrillation/flutter on the in-hospital mortality of surgical patients - Results from the German nationwide cohort

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.

Lipocalin-type prostaglandin D synthase levels are associated with the severity of pulmonary embolism

Pulmonary thromboembolism (PTE) is an acute emergency with high mortality and morbidity rates. This study aimed to investigate the importance of Lipocalin-type prostaglandin D synthase (L-PGDS) in predicting mortality and prognosis in PTE. The study prospectively included 90 patients who were admitted to the emergency department and in whom PTE was confirmed by computed tomographic pulmonary angiography as well as 40 healthy volunteers with no disease. L-PGDS levels in the venous blood were measured and compared. Pulmonary embolism severity index (PESI) prognosis scores of all patients and 1-month mortality rate were calculated. There was a statistically significant difference between the L-PGDS levels of the patient and control groups (P = 0.024), and 1-month mortality of patients diagnosed with PTE was 20% (n = 18). Furthermore, the patients were divided into two groups: patients deceased within 1 month following the diagnosis and survivors. L-PGDS levels of the deceased patients were significantly higher than those of the survivors (P < 0.001). Age, systolic blood pressure, pulse, shock index, lactate, and PESI scores were significantly different between the survivors and deceased patients. The cut-off value for L-PGDS obtained using receiver operating characteristic (ROC) curve analysis for 1-month mortality was 815.26 ng/mL (sensitivity: 83.33%; specificity: 79.17%; area under the curve: 0.851; 95% confidence interval 0.760-0.917; P < 0.001). Based on this cut-off value, logistic regression analysis revealed that increased L-PGDS, together with PESI, was an independent indicator of 1-month mortality. L-PGDS is associated with short-term mortality in patients with PTE; therefore, it can be used to predict mortality risk in patients with PTE.

Advances in the diagnosis of acute pulmonary embolism

Venous thromboembolism is a common disease which remains underdiagnosed because of nonspecific presentations which can range from asymptomatic incidental imaging findings to sudden death. Symptoms can overlap with comorbid cardiopulmonary disease, and risk factors that offer clues to the clinician are not always present. The diagnostic approach can vary depending on the specific clinical presentation, but ruling in the diagnosis nearly always depends on lung imaging. Overuse of diagnostic testing is another recognized problem; a cautious, evidence-based approach is required, although physician gestalt must be acknowledged. The following review offers an approach to the diagnosis of acute pulmonary embolism based on the assessment of symptoms, signs, risk factors, laboratory findings, and imaging studies.

The predictive value of PaO2/FIO2 and additional parameters for in-hospital mortality in patients with acute pulmonary embolism: an 8-year prospective observational single-center cohort study

BACKGROUND

Rapid stratification and appropriate treatment on admission are critical to saving lives of patients with acute pulmonary embolism (PE). None of the clinical prediction tools perform well when applied to all patients with acute PE. It may be important to integrate respiratory features into the 2014 European Society of Cardiology model. First, we aimed to assess the relationship between the arterial partial pressure of oxygen/fraction of inspired oxygen (PaO₂/FIO₂) ratio and in-hospital mortality, determine the optimal cutoff value of PaO₂/FIO₂, and determine if this value, which is quick and easy to obtain on admission, is a predictor of in-hospital mortality in this population. Second, we aimed to evaluate the potential additional determinants including laboratory parameters that may affect the in-hospital mortality. We hypothesized that the PaO2/FiO2 ratio would be a clinical prediction tool for in-hospital mortality in patients with acute PE.

METHODS

A prospective single-center observational cohort study was conducted in Beijing Hospital from January 2010 to November 2017. Arterial blood gas analysis data captured on admission, clinical characteristics, risk factors, laboratory data, imaging findings, and in-hospital mortality were compared between survivors and non-survivors. The area under the receiver operating characteristic curve (AUC) for in-hospital mortality based on the PaO₂/FiO₂ value was determined, and the association between the parameters and in-hospital mortality was analyzed by using logistic regression analysis.

RESULTS

Body mass index, history of cancer, PaO₂/FiO₂ value, pulse rate, cardiac troponin I level, lactate dehydrogenase level, white blood cell count, D-dimer level, and risk stratification measurements differed between survivors and non-survivors. The optimal cutoff value of PaO₂/FiO₂ for predicting mortality was 265 (AUC = 0.765, P < 0.001). Only a PaO₂/FiO₂ ratio < 265 (95% confidence interval [CI] 1.823-21.483, P = 0.004), history of cancer (95% CI 1.161-15.927, P = 0.029), and risk stratification (95% CI 1.047-16.957, P = 0.043) continued to be associated with an increased risk of in-hospital mortality of acute PE.

CONCLUSION

A simple determination of the PaO₂/FiO₂ ratio at <265 may provide important information on admission about patients' in-hospital prognosis, and PaO₂/FiO₂ ratio < 265, history of cancer, and risk stratification are predictors of in-hospital mortality of acute PE.

Comorbidity burden conditions the prognostic performance of D-dimer in elderly patients with acute pulmonary embolism

INTRODUCTION

The prognostic accuracy of D-dimer for risk assessment in acute Pulmonary Embolism (APE) patients may be hampered by comorbidities. We investigated the impact of comorbidity burden (CB) by using the Charlson Comorbidity Index (CCI), on the prognostic ability of D-dimer to predict 30 and 90-day mortality in hemodynamically stable elderly patients with APE.

METHODS

All patients aged >65 years with normotensive APE, consecutively evaluated in the Emergency Department since 2010 through 2014 were included in this retrospective cohort study. Area under the curve (AUC) and ½ Net Reclassification Improvement (NRI) were calculated.

RESULTS

Study population: 162 patients, median age: 79.2 years. The optimal cut-off value of CCI score for predicting mortality was ≤1 (Low CB) and >1 (High CB), AUC = 0.786. Higher levels of D-dimer were associated with an increased risk death at 30 (HR = 1.039, 95%CI:1.000-1.080, p = 0.049) and 90 days (HR = 1.039, 95%CI:1.009-1.070, p = 0.012). When added to simplified Pulmonary Embolism Severity Index (sPESI) score, D-dimer increased significantly the AUC for predicting 30-day mortality in Low CB (AUC = 0.778, 95%CI:0.620-0.937, ½NRI = 0.535, p = 0.015), but not in High CB patients (AUC = 0.634, 95%CI:0.460-0.807, ½ NRI = 0.248, p = 0.294). Similarly, for 90-day mortality D-dimer increased significantly the AUC in Low CB (AUC = 0.786, 95%CI:0.643-0.929, ½NRI = 0.424, p-value = 0.025), but not in High CB patients (AUC = 0.659, 95%CI:0.541-0.778, ½NRI = 0.354, p-value = 0.165).

CONCLUSION

In elderly patients with normotensive APE, comorbidities condition the prognostic performance of D-dimer, which was found to be a better predictor of death in subjects with low CB. These results support multimarker strategies for risk assessment in this population.

D-dimer levels in VTE patients with distal and proximal clots

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.

D-Dimer and thrombus burden in acute pulmonary embolism

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.

Update on the risk stratification of acute symptomatic pulmonary thromboembolism

Early mortality in patients with pulmonary thromboembolism (PTE) varies from 2% in normotensive patients to 30% in patients with cardiogenic shock. The current risk stratification for symptomatic PTE includes 4 patient groups, and the recommended therapeutic strategies are based on this stratification. Patients who have haemodynamic instability are considered at high risk. Fibrinolytic treatment is recommended for these patients. In normotensive patients, risk stratification helps differentiate between those of low risk, intermediate-low risk and intermediate-high risk. There is currently insufficient evidence on the benefit of intensive monitoring and fibrinolytic treatment in patients with intermediate-high risk. For low-risk patients, standard anticoagulation is indicated. Early discharge with outpatient management may be considered, although its benefit has still not been firmly established.

The accuracy of combined use of troponin and red cell distribution width in predicting mortality of patients with acute pulmonary embolism

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.

Role of D-dimer Assays in the Diagnostic Evaluation of Pulmonary Embolism

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.

D-dimer for risk stratification in haemodynamically stable patients with acute pulmonary embolism

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.

Predictive value of biomarkers for the prognosis of acute pulmonary embolism in Japanese patients: Results of the Tokyo CCU Network registry

BACKGROUND

Several studies from Western countries have reported associations between cardiac troponin and B-type natriuretic peptide (BNP) levels and acute pulmonary embolism prognosis; however, the number of such reports from Asian countries, including Japan, is limited. Thus, we evaluated the relationship between blood biochemical findings and acute-phase pulmonary embolism prognosis in Japanese patients.

METHODS

The subjects included 441 patients with acute pulmonary embolism (191 men, 250 women; average age, 65.8±16.0 years) treated at Tokyo CCU Network Institutions from 2009 to 2011 and registered via survey forms. The association between blood biochemical findings at admission and 30-day mortality was investigated.

RESULTS

The median BNP value was 186.5pg/mL (25th to 75th interquartile range: 49.8-500pg/mL) of 210 cases. No deaths were recorded among those with BNP levels <90pg/mL (n=70), whereas significantly higher mortality (10 deaths/140 cases, 7.1%; p=0.033) was observed among those with BNP levels ≥90pg/mL. A qualitative cardiac troponin test was positive in 58 of the 204 cases (28.4%), with a significantly higher mortality incidence (p=0.017) among the troponin-positive cases [6 (10.3%) versus 3 (2.1%) deaths among the 146 troponin-negative cases]. The overall mean blood glucose level at admission of 331 cases was 152.0±74.0mg/dL, and 30-day mortality significantly increased with blood glucose values (p=0.048).

CONCLUSIONS

Troponin, BNP, and blood glucose levels are useful prognostic biomarkers for acute pulmonary embolism in Japanese patients.

D-dimer levels and 90-day outcome in patients with acute pulmonary embolism with or without cancer

BACKGROUND

The prognostic value of D-dimer testing in patients with acute pulmonary embolism (PE) has not been thoroughly studied.

METHODS

We used the RIETE Registry data to assess the 90-day prognostic value of increased IL Test D-dimer levels at baseline in patients with PE, according to the presence or absence of cancer.

RESULTS

As of May 2013, 3,283 patients with acute PE underwent D-dimer testing using IL Test D-dimer. Among 2,588 patients without cancer, those with D-dimer levels in the highest quartile had a higher rate of fatal PE (2.6% vs. 0.9%; p=0.002), fatal bleeding (1.1% vs. 0.3%; p=0.017) and all-cause death (9.1% vs. 4.4%; p<0.001) at 90 days compared with those with levels in the lowest quartiles. Among 695 patients with cancer, those with levels in the highest quartile had a similar rate of fatal PE or fatal bleeding but higher mortality (35% vs. 24%; p<0.01). On multivariate analysis, non-cancer patients with D-dimer levels in the highest quartile had an increased risk for fatal PE (odds ratio [OR]: 3.3; 95% CI: 1.6-6.6), fatal bleeding (OR: 4.3; 95% CI: 1.4-13.7) and all-cause death (OR: 2.1; 95% CI: 1.4-3.1) compared with patients with levels in the lowest quartiles.

CONCLUSIONS

Non-cancer patients with acute PE and IL Test D-dimer levels in the highest quartile had an independently higher risk for fatal PE, fatal bleeding and all-cause death at 90 days than those with levels in the lowest quartiles. In patients with cancer, D-dimer levels failed to predict fatal PE or fatal bleeding.

[Update on diagnosis and treatment of high-risk pulmonary embolism]

INTRODUCTION

High-risk pulmonary embolism (PE) is associated with a significant early mortality, approaching 25%, and is defined by the presence of cardiogenic shock.

STATE OF THE ART

The high early mortality rate for patients with shock requires a rapid diagnostic approach with bedside tests. Right ventricular dilatation assessed by echocardiography in patients with a high clinical probability for PE confirms the diagnosis without the need for additional testing. Spiral CT pulmonary angiography remains the first line investigation for patients without shock. Anticoagulant treatment should be started as soon as pulmonary embolism is suspected. Fibrinolytic therapy is recommended for patients with high-risk pulmonary embolism. The prognostic value of cardiac biomarkers, such as B natriuretic peptide, troponins and right ventricular dilatation for early mortality has been demonstrated. These markers permit the identification of an intermediate risk group of patients with normotensive pulmonary embolism and prognostic scores have been developed.

PERSPECTIVES

It remains to be established whether fibrinolysis can have a clinical benefit or reduce mortality in patients with intermediate risk pulmonary embolism. A large randomised placebo-controlled study is currently under way to answer this question. Further studies will more clearly define the role of various predictive rules to identify patients requiring hospital care or those who should be considered for outpatient management.

Risk stratification and clinical outcomes in patients with acute pulmonary embolism

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.

No firm association between N-terminal pro-brain natriuretic peptide and percentage of pulmonary vascular obstruction in patients with acute pulmonary embolism

INTRODUCTION

High concentrations of N-terminal-pro-brain natriuretic peptide (NT-proBNP) are found in patients with right ventricular overload. Right ventricular overload may be the result of large perfusion defects in patients with pulmonary embolism (PE). NT-proBNP levels are associated with poorer outcome in patients with acute PE. Likewise, the percentage of pulmonary vascular obstruction (PVO) has shown to be a prognostic parameter for outcome in PE-patients. We postulated that NT-proBNP is associated with the amount of perfusion defects, expressed as the PVO, on perfusion scintigraphy.

METHODS

We included 85 consecutive patients in whom the diagnosis PE was confirmed by ventilation-perfusion scintigraphy. PVO was calculated in all patients. NT-proBNP concentrations were measured at presentation. We plotted the logarithm of NT-proBNP versus the PVO. The strength of the estimated association between NT-proBNP and the PVO was expressed by R2.

RESULTS

Eighteen percent of the variation in PVO could be explained by NT-proBNP. A positive association becomes apparent for NT-proBNP values above 200 pg/mL, with an increase in PVO of 6.3% (95% Confidence Interval 2.0 to 10.6), with every doubling of NT-proBNP.

CONCLUSION

There is an association between NT-proBNP concentrations and PVO, although this relation is quite weak. Some patients with low NT-proBNP values can have a high PVO, which might be relevant for outcome. Therefore, we advise caution in risk stratification and not to focus on NT-proBNP, without involving the clinical condition.

Risk stratification of normotensive patients with acute symptomatic pulmonary embolism

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.

D-dimer levels and 15-day outcome in acute pulmonary embolism. Findings from the RIETE Registry

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.

Risk stratification and outcomes in hemodynamically stable patients with acute pulmonary embolism: a prospective, multicentre, cohort study with three months of follow-up

BACKGROUND

The role of risk stratification in normotensive patients with acute pulmonary embolism (PE) is still unclear.

OBJECTIVES

We evaluated, in these patients, the usefulness of six prognostic markers for predicting in-hospital adverse events related to PE and 3-month mortality.

PATIENTS/METHODS

Two hundred and one consecutive patients with confirmed acute PE and normal blood pressure, who were administered conventional anticoagulation, were recruited in a multicentre prospective cohort study with 3 months of follow-up. At baseline, they received a comprehensive risk-evaluation including echocardiographic assessment of right ventricular dysfunction, determination of troponin I, brain natriuretic peptide and D-dimer, arterial blood gas analysis and a clinical score. Primary outcome of the study was PE-related in-hospital death or clinical deterioration. Secondary outcomes were in-hospital and 3-month all-cause mortality.

RESULTS

The primary outcome occurred in one patient (0.5%), who died from PE during hospitalization. The in-hospital and 3-month all-cause mortality were 2% and 9%, respectively. None of the prognostic markers was predictive of the primary outcome. Clinical score, troponin I and hypoxemia predicted in-hospital all-cause mortality (P = 0.02, 0.01 and < 0.01, respectively). Clinical score (HR, 4.7; 95% CI, 1.9-12.0), D-dimer (4.8; 1.4-16.3), hypoxemia (5.7; 2.1-15.1) and troponin I (7.5; 2.5-22.7) were predictors of 3-month all-cause mortality on univariate analysis. On multivariate analysis clinical score and troponin I remained independently predictive.

CONCLUSIONS

We did not find prognostic markers useful as predictors of in-hospital PE-related adverse events. Clinical score, troponin I and hypoxemia predicted in-hospital all-cause mortality. Clinical score and troponin I independently predicted 3-month all-cause mortality.

Elevated D-dimer levels predict recurrence in patients with idiopathic venous thromboembolism: a meta-analysis

BACKGROUND

The evidence on the optimal duration of treatment in patients with an idiopathic venous thromboembolic event (VTE) is inconclusive. d-dimer testing to predict recurrent VTE has been evaluated in several studies.

OBJECTIVES

We performed a meta-analysis of studies of patients with idiopathic VTE treated with oral anticoagulation therapy (OAT) to assess the prognostic value of elevated D-dimer levels 1 month after discontinuation of OAT for VTE recurrence.

PATIENTS/METHODS

The MEDLINE, EMBASE and Cochrane databases were searched to identify relevant studies. Studies were eligible for inclusion if they included patients with idiopathic VTE and in addition reported results for this group separately, had measured D-dimer approximately 1 month after discontinuation of OAT and had reported on recurrence of VTE. A random-effects model was used to pool study results.

RESULTS

Data from four studies (1539 patients) were included in the current analysis. All studies reported on the number of recurrent events in the normal and elevated D-dimer groups. Overall, 125 of 751 patients (16.6%) with elevated D-dimer levels experienced recurrent VTE during the period of follow-up compared with 57 of 788 patients (7.2%) with normal D-dimer levels. Elevated D-dimer levels were significantly associated with recurrent VTE (odds ratio , 2.36; 95% CI, 1.65 to 3.36).

CONCLUSIONS

Elevated d-dimer levels measured 1 month after discontinuation of OAT identify patients with idiopathic VTE at higher risk of recurrence.

Cardiac biomarkers for risk stratification in non-massive pulmonary embolism: a multicenter prospective study

BACKGROUND

Troponins (cTnI and cTnT), N-terminal pro-Brain Natriuretic Peptide (NT-proBNP), myoglobin, heart-type fatty acid-binding protein (H-FABP) and fibrin D-Dimer are emergent candidates for risk stratification in pulmonary embolism (PE).

OBJECTIVE

To compare the respective prognostic values of biomarker with non-massive PE to predict an adverse outcome at 3 months.

PATIENTS/METHODS

One hundred and forty-six consecutive patients with non-massive PE were included in this multicenter prospective study. The combined outcome consisted of intensive care monitoring on admission, death or hospitalization attributable to either a PE-related complication [defined by PE/deep vein thrombosis (DVT) relapse or major bleeding under anticoagulation] or to dyspnoea with or without chest pain during follow-up.

RESULTS

The outcome was met in 12% of patients. In univariate analysis, a NT-proBNP level above 300 pg/ml was the strongest predictor of unfavorable outcome with an odds ratio (OR) of 15.8 [95% confidence interval (CI): 2.05-122). ORs for the other variables were: 8.0 for D-dimer >2000 ng/ml (95% CI: 1.1-64), 4.7 for H-FABP >6 ng/ml (95% CI:1.5-14.8), 3.5 for cTnI >0.09 ng/ml (95% CI:1.2-9.7), 3.4 for myoglobin >70 ng/ml (95% CI:0.9-12.2). Receiver operating curve (ROC) analysis indicated that NT-proBNP was the best predictor [area under the curve (AUC) 0.84; 95%CI: 0.76-0.92; P < 0.0001] with a negative predictive value of 100% (95% CI: 91-100) at 300 pg/ml. At that cut-off, the true negative rate for NT-proBNP was 40%. In multivariate analysis, NT-proBNP was the only significant independent predictors.

CONCLUSIONS

NT-proBNP appears to be a good risk stratification marker in identifying low-risk patients with non-massive PE who could be treated in an outpatient setting.

Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)

Non-thrombotic PE does not represent a distinct clinical syndrome. It may be due to a variety of embolic materials and result in a wide spectrum of clinical presentations, making the diagnosis difficult. With the exception of severe air and fat embolism, the haemodynamic consequences of non-thrombotic emboli are usually mild. Treatment is mostly supportive but may differ according to the type of embolic material and clinical severity.

D-Dimer for venous thromboembolism diagnosis: 20 years later

Twenty years after its first use in the diagnostic workup of suspected venous thromboembolism (VTE), fibrin D-dimer (DD) testing has gained wide acceptance for ruling out this disease. The test is particularly useful in the outpatient population referred to the emergency department because of suspected deep vein thrombosis (DVT) or pulmonary embolism (PE), in which the ruling out capacity concerns every third patient clinically suspected of having the disease. This usefulness is based on the high sensitivity of the test to the presence of VTE, at least for some assays. Due to its poor specificity precluding its use for ruling in VTE, DD testing must be integrated in comprehensive, sequential diagnostic strategies that include clinical probability assessment and imaging techniques such as lower limb venous compression ultrasonography for suspected DVT or multi-slice helical computed tomography for suspected PE. The present narrative review updates the data available on the use of the various commercially available DD assays in the diagnostic approach of clinically suspected VTE in distinct patient populations or situations, including outpatients and inpatients, patients with cancer, older age, pregnancy, a suspected recurrent event, limited thrombus burden, and patients already on anticoagulant treatment.

Help me, Doctor! My D-dimer is raised

Although optimal strategy for management of patients with suspected venous thromboembolism depends on local expertise and cost, diagnostic algorithms including clinical assessment and D-dimer have been validated in several trials. However, a new paradigm shift is emerging, giving an extended role of D-dimer measurement in clinical practice. D-dimer is a useful biomarker to help determine initial anticoagulant therapy in patients with thrombosis. Emerging evidence also endorses a 'predictive' role for raised D-dimer levels, since its measurement provides prognostic indications for a variety of conditions, including venous thromboembolism, disseminated intravascular coagulation, cardiovascular disease, infectious diseases, and cancer. Additional investigation is needed to clarify whether raised D-dimer is an epiphenomenon or it is actively involved in pathophysiology. Further studies are also required to establish whether D-dimer testing, alone or combined with other prognostic indicators, can be used to identify patient candidates for further triage and treatment. Nevertheless, the hazard(s) associated with raised D-dimer in plasma requires re-emphasis in the teaching of post-graduates, junior doctors and medical students, including the most effective treatments to inhibit clot spread and decrease the probability of further significant thrombotic incidents even in the absence of any 'detectable' thrombosis.

High D-dimer level is associated with increased 15-d and 3 months mortality through a more central localization of pulmonary emboli and serious comorbidity

High D-dimer levels are predictors of death in patients with pulmonary embolism (PE), as are more proximally located, larger emboli. The direct link between these three has not yet been described. A cohort of 674 consecutive patients with confirmed PE was studied. Patients were followed up for 3 months. D-dimer levels were measured only in patients with an unlikely clinical probability (n = 262). The odds ratio (OR) for death of all variables was calculated. Multivariate analysis was performed to identify independent risk factors for mortality. The best predictive D-dimer cut-off point for mortality was a concentration >3000 ng/ml FEU (OR 7.29). High D-dimer levels were correlated with active malignancy and age over 65 years, both being indicators of 3-month mortality. High D-dimer levels were also correlated with centrally located pulmonary emboli and 15-d mortality. The combination of high D-dimer levels and central emboli increased early mortality risk by 2.2. High D-dimer levels in patients with an unlikely clinical probability were associated with fatal outcome after PE. Centrally located pulmonary emboli were associated with higher D-dimer levels and worse 15-d mortality. Active malignancy, being an inpatient at time of diagnosis and age over 65 years were associated with higher D-dimer levels and worse 3-month survival.