J van Es1, L F M Beenen2, R A Douma1, P L den Exter3, I C M Mos3, H A H Kaasjager4, M V Huisman3, P W Kamphuisen5, S Middeldorp1, P M M Bossuyt6. 1. Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands. 2. Department of Radiology, Academic Medical Center, Amsterdam, the Netherlands. 3. Section of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands. 4. Department of Internal Medicine, Rijnstate Hospital, Arnhem, the Netherlands. 5. Department of Vascular Medicine, University Medical Center, Groningen, the Netherlands. 6. Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.
Abstract
BACKGROUND: An 'unlikely' clinical decision rule with a negative D-dimer result safely excludes pulmonary embolism (PE) in 30% of presenting patients. We aimed to simplify this diagnostic approach and to increase its efficiency. METHODS: Data for 723 consecutive patients with suspected PE were analyzed (prevalence of PE, 22%). After constructing a logistic regression model with the D-dimer test result and items from the Wells' score, we identified the most prevalent combinations of influential items and selected new D-dimer positivity thresholds. The performance was separately validated with data from 2785 consecutive patients with suspected PE. RESULTS: Three Wells items significantly added incremental value to the D-dimer test: hemoptysis, signs of deep vein thrombosis and 'PE most likely'. Based on the most frequent combinations of these three items, we identified two groups: (i) none of these three items positive (41%); (ii) one or more of these items positive (59%). When applying a 1000 μg/L D-dimer threshold in group 1 and 500 μg/L in group 2, PE could be excluded without CT scanning in 36%, at a false-negative rate of 1.2% (95%, 0.04-3.3%). In the validation set, these proportions were 46% and 1.9% (95% CI, 1.2-2.7%), respectively. Using the conventional Wells score with a normal D-dimer result, these rates were, respectively, 22% and 0.6% (95% CI, 0.10-2.4%). CONCLUSION: Combining Wells items with the D-dimer test resulted in a simplified decision rule, which reduces the need for CT scanning in patients with suspected PE. A prospective validation is required before it can be implemented in clinical practice.
BACKGROUND: An 'unlikely' clinical decision rule with a negative D-dimer result safely excludes pulmonary embolism (PE) in 30% of presenting patients. We aimed to simplify this diagnostic approach and to increase its efficiency. METHODS: Data for 723 consecutive patients with suspected PE were analyzed (prevalence of PE, 22%). After constructing a logistic regression model with the D-dimer test result and items from the Wells' score, we identified the most prevalent combinations of influential items and selected new D-dimer positivity thresholds. The performance was separately validated with data from 2785 consecutive patients with suspected PE. RESULTS: Three Wells items significantly added incremental value to the D-dimer test: hemoptysis, signs of deep vein thrombosis and 'PE most likely'. Based on the most frequent combinations of these three items, we identified two groups: (i) none of these three items positive (41%); (ii) one or more of these items positive (59%). When applying a 1000 μg/L D-dimer threshold in group 1 and 500 μg/L in group 2, PE could be excluded without CT scanning in 36%, at a false-negative rate of 1.2% (95%, 0.04-3.3%). In the validation set, these proportions were 46% and 1.9% (95% CI, 1.2-2.7%), respectively. Using the conventional Wells score with a normal D-dimer result, these rates were, respectively, 22% and 0.6% (95% CI, 0.10-2.4%). CONCLUSION: Combining Wells items with the D-dimer test resulted in a simplified decision rule, which reduces the need for CT scanning in patients with suspected PE. A prospective validation is required before it can be implemented in clinical practice.
Authors: Rosanne van Maanen; Frans H Rutten; Frederikus A Klok; Menno V Huisman; Jeanet W Blom; Karel G M Moons; Geert-Jan Geersing Journal: BMJ Open Date: 2019-10-10 Impact factor: 2.692
Authors: Rosanne van Maanen; Annelieke E C Kingma; Ruud Oudega; Frans H Rutten; Karel Moons; Geert-Jan Geersing Journal: BMJ Open Date: 2020-12-28 Impact factor: 2.692
Authors: Daniël A Korevaar; Ilayda Aydemir; Peter I Bonta; Josien van Es; Maartje W Minnema; Kaoutar Azijli; Ludo F Beenen; Jarom Heijmans; Nick van Es; Mohanad Al Masoudi; Lilian J Meijboom; Saskia Middeldorp; Prabath W Nanayakkara; Rick I Meijer Journal: J Thromb Thrombolysis Date: 2021-06-23 Impact factor: 2.300