L M van der Pol1,2, T van der Hulle1, Y W Cheung3, A T A Mairuhu3, C G Schaar4, L M Faber5, M Ten Wolde6, H M A Hofstee7, M M C Hovens8, M Nijkeuter9, R C J van Klink10, M J H A Kruip11, S Middeldorp3, M V Huisman1, F A Klok1. 1. Department Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands. 2. Department of Medicine, Haga Teaching Hospital, The Hague, the Netherlands. 3. Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands. 4. Department of Medicinee, Gelre Hospital, Apeldoorn, the Netherlands. 5. Department of Medicine, Red Cross Hospital, Beverwijk, the Netherlands. 6. Department of Medicine, Flevo Hospital, Almere, the Netherlands. 7. Department of Internal Medicine, Haaglanden Medical Center, The Hague, the Netherlands. 8. Department of Medicine, Rijnstate Hospital, Arnhem, the Netherlands. 9. Department of Medicine, University Medical Center Utrecht, Utrecht, the Netherlands. 10. Department of Pulmonology, Alrijne Hospital, Leiden, the Netherlands. 11. Department of Hematology, Erasmus Medical Center, Rotterdam, the Netherlands.
Abstract
Essentials Imaging is warranted in the majority of patients to confirm or rule out pulmonary embolism (PE). The age-adjusted D-dimer (ADJUST) reduced the number of required imaging tests in patients ≥ 50 years. The YEARS algorithm was designed to improve the efficiency in patients with suspected PE. There was no added value of implementing ADJUST in the YEARS algorithm in our cohort. SUMMARY: Background The YEARS algorithm was designed to simplify the diagnostic work-up of pulmonary embolism (PE) and to reduce the number of necessary computed tomography pulmonary angiography (CTPA) scans. An alternative strategy to reduce the number of CTPAs is the age-adjusted D-dimer cut-off (ADJUST) in patients aged 50 years or older. We aimed to investigate whether a combination of both diagnostic strategies might save additional CTPAs. Methods The YEARS algorithm consists of three items (clinical signs of deep venous thrombosis, hemoptysis, 'PE most likely diagnosis') with simultaneous D-dimer testing using a pre-test dependent threshold. We performed a post hoc analysis in 3465 patients managed according to YEARS to compare the number of patients managed without CTPA scans and associated diagnostic failures in hypothetical scenarios with different YEARS-ADJUST combinations. Results Following the YEARS algorithm, 1651 patients (48%) were managed without CTPA; PE was diagnosed in 456 (13%) patients at baseline and 18 patients with initial normal testing suffered venous thromboembolism (VTE) during 3-month follow-up (failure rate 0.61%; 95% confidence interval [CI], 0.36-0.96). If ADJUST had been fully integrated in YEARS, 1627 patients (47%) would have been managed without CTPA (absolute decrease of 0.69%; 95% CI -1.7 to 3.0), at cost of four additional missed PE diagnoses at baseline, for a projected 3-month VTE failure rate of 0.75% (95% CI, 0.49-1.13). None of the other studied scenarios showed relevant improvements in efficiency as well, but all led to more missed diagnoses. Conclusion In our cohort, there was no added value of implementing ADJUST in the YEARS algorithm.
Essentials Imaging is warranted in the majority of patients to confirm or rule out pulmonary embolism (PE). The age-adjusted D-dimer (ADJUST) reduced the number of required imaging tests in patients ≥ 50 years. The YEARS algorithm was designed to improve the efficiency in patients with suspected PE. There was no added value of implementing ADJUST in the YEARS algorithm in our cohort. SUMMARY: Background The YEARS algorithm was designed to simplify the diagnostic work-up of pulmonary embolism (PE) and to reduce the number of necessary computed tomography pulmonary angiography (CTPA) scans. An alternative strategy to reduce the number of CTPAs is the age-adjusted D-dimer cut-off (ADJUST) in patients aged 50 years or older. We aimed to investigate whether a combination of both diagnostic strategies might save additional CTPAs. Methods The YEARS algorithm consists of three items (clinical signs of deep venous thrombosis, hemoptysis, 'PE most likely diagnosis') with simultaneous D-dimer testing using a pre-test dependent threshold. We performed a post hoc analysis in 3465 patients managed according to YEARS to compare the number of patients managed without CTPA scans and associated diagnostic failures in hypothetical scenarios with different YEARS-ADJUST combinations. Results Following the YEARS algorithm, 1651 patients (48%) were managed without CTPA; PE was diagnosed in 456 (13%) patients at baseline and 18 patients with initial normal testing suffered venous thromboembolism (VTE) during 3-month follow-up (failure rate 0.61%; 95% confidence interval [CI], 0.36-0.96). If ADJUST had been fully integrated in YEARS, 1627 patients (47%) would have been managed without CTPA (absolute decrease of 0.69%; 95% CI -1.7 to 3.0), at cost of four additional missed PE diagnoses at baseline, for a projected 3-month VTE failure rate of 0.75% (95% CI, 0.49-1.13). None of the other studied scenarios showed relevant improvements in efficiency as well, but all led to more missed diagnoses. Conclusion In our cohort, there was no added value of implementing ADJUST in the YEARS algorithm.
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: Kenneth Iwuji; Hasan Almekdash; Kenneth M Nugent; Ebtesam Islam; Briget Hyde; Jonathan Kopel; Adaugo Opiegbe; Duke Appiah Journal: J Prim Care Community Health Date: 2021 Jan-Dec