Higher D-Dimer Thresholds for Excluding Pulmonary Embolism: No Free Lunch?
Authors: Daniel J. Brotman
Journal: Annals of Internal Medicine (2021)

EditorialsFebruary 2022Higher D-Dimer Thresholds for Excluding Pulmonary Embolism: No Free Lunch?Daniel J. Brotman, MDDaniel J. Brotman, MDDivision of Hospital Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MarylandAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M21-4295 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Diagnosis of venous thromboembolism (VTE)—including pulmonary embolism (PE) and deep venous thrombosis—has been revolutionized over the last 2 decades by the development, validation, and dissemination of clinical decision rules that couple readily available clinical data with D-dimer levels to identify low-risk patients who do not require advanced imaging. But with multiple diagnostic strategies available, clinicians may be uncertain about which approach is best. One important question is whether to apply a fixed D-dimer cutoff (generally 500 μg/L) or to use a higher threshold in selected patients. Clearly, increasing the D-dimer cutoff will lower the number of patients who require radiographic ...References1. Stals MAM, Takada T, Kraaijpoel N, et al. Safety and efficiency of diagnostic strategies for ruling out pulmonary embolism in clinically relevant patient subgroups. A systematic review and individual-patient data meta-analysis. Ann Intern Med. 2022;175:244-255. doi:10.7326/M21-2625 Google Scholar2. Wells PS, Anderson DR, Rodger M, et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and D-dimer. Ann Intern Med. 2001;135:98-107. [PMID: 11453709] doi:10.7326/0003-4819-135-2-200107170-00010 LinkGoogle Scholar3. Le Gal G, Righini M, Roy PM, et al. Prediction of pulmonary embolism in the emergency department: the revised Geneva score. Ann Intern Med. 2006;144:165-71. [PMID: 16461960] doi:10.7326/0003-4819-144-3-200602070-00004 LinkGoogle Scholar4. Righini M, Van Es, Den Exter, et al. Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study. JAMA. 2014;311:1117-24. [PMID: 24643601] doi:10.1001/jama.2014.2135 CrossrefMedlineGoogle Scholar5. van der Hulle T, Cheung WY, Kooij S, et al; YEARS Study Group. Simplified diagnostic management of suspected pulmonary embolism (the YEARS study): a prospective, multicentre, cohort study. Lancet. 2017;390:289-297. [PMID: 28549662] doi:10.1016/S0140-6736(17)30885-1 CrossrefMedlineGoogle Scholar6. Brotman DJ, Segal JB, Jani JT, et al. Limitations of D-dimer testing in unselected inpatients with suspected venous thromboembolism. Am J Med. 2003;114:276-82. [PMID: 12681454] doi:10.1016/s0002-9343(02)01520-6 CrossrefMedlineGoogle Scholar7. van der Hulle T, van Es N, den Exter PL, et al. Is a normal computed tomography pulmonary angiography safe to rule out acute pulmonary embolism in patients with a likely clinical probability? A patient-level meta-analysis. Thromb Haemost. 2017;117:1622-1629. [PMID: 28569924] doi:10.1160/TH17-02-0076 CrossrefMedlineGoogle Scholar8. Chi G, Goldhaber SZ, Hull RD, et al. Thrombus burden of deep vein thrombosis and its association with thromboprophylaxis and D-dimer measurement: insights from the APEX trial. Thromb Haemost. 2017;117:2389-2395. [PMID: 29212126] doi:10.1160/TH17-08-0538 CrossrefMedlineGoogle Scholar9. van der Pol LM, Bistervels IM, van Mens TE, et al. Lower prevalence of subsegmental pulmonary embolism after application of the YEARS diagnostic algorithm. Br J Haematol. 2018;183:629-635. [PMID: 30198551] doi:10.1111/bjh.15556 CrossrefMedlineGoogle Scholar Author, Article, and Disclosure InformationAffiliations: Division of Hospital Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MarylandDisclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M21-4295.Corresponding Author: Daniel J. Brotman, MD, 600 North Wolfe Street, Meyer 8-134A, Baltimore, MD 21287; e-mail, [email protected]edu.This article was published at Annals.org on 14 December 2021. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoSafety and Efficiency of Diagnostic Strategies for Ruling Out Pulmonary Embolism in Clinically Relevant Patient Subgroups Milou A.M. Stals , Toshihiko Takada , Noémie Kraaijpoel , Nick van Es , Harry R. Büller , D. Mark Courtney , Yonathan Freund , Javier Galipienzo , Grégoire Le Gal , Waleed Ghanima , Menno V. Huisman , Jeffrey A. Kline , Karel G.M. Moons , Sameer Parpia , Arnaud Perrier , Marc Righini , Helia Robert-Ebadi , Pierre-Marie Roy , Maarten van Smeden , Phil S. Wells , Kerstin de Wit , Geert-Jan Geersing , and Frederikus A. Klok Metrics February 2022Volume 175, Issue 2Page: 295-296KeywordsD-dimerHospital medicinePulmonary embolismThrombosisVenous thromboembolism ePublished: 14 December 2021 Issue Published: February 2022 Copyright & PermissionsCopyright © 2021 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...