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Original Research: Pulmonary Vascular Disease |

Assessment of the Safety and Efficiency of Using an Age-Adjusted D-dimer Threshold to Exclude Suspected Pulmonary EmbolismAge-Adjusted D-Dimer to Exclude Pulmonary Embolism

Scott C. Woller, MD; Scott M. Stevens, MD; Daniel M. Adams, MD; R. Scott Evans, PhD; James F. Lloyd, BS; Gregory L. Snow, PhD; Joseph R. Bledsoe, MD; David Z. Gay, MD; Richard M. Patten, MD; Valerie T. Aston, RRT; C. Gregory Elliott, MD
Author and Funding Information

From the Department of Medicine (Drs Woller, Stevens, and Elliott and Ms Aston), Department of Emergency Medicine (Dr Bledsoe), and Division of Pulmonary and Critical Care Medicine (Ms Aston), Intermountain Medical Center, Murray, UT; Department of Medicine (Drs Woller, Stevens, and Elliott), University of Utah School of Medicine, Salt Lake City, UT; Tufts Medical Center Department of Radiology (Dr Adams), Boston, MA; Department of Medical Informatics (Dr Evans and Mr Lloyd) and Department of Medical Statistics (Dr Snow), LDS Hospital, Salt Lake City, UT; Department of Ophthalmology (Dr Gay), Georgia Regents University, Augusta, GA; and Intermountain Riverton Hospital (Dr Patten), Riverton, UT.

CORRESPONDENCE TO: Scott C. Woller, MD, Intermountain Medical Center, Eccles Outpatient Care Center, 5169 Cottonwood St, Ste 307, PO Box 577000, Murray, UT 84157-7000; e-mail: scott.woller@imail.org


FOR EDITORIAL COMMENT SEE PAGE 1423

FUNDING/SUPPORT: This research was supported by a grant from the Intermountain Research & Medical Foundation (Project #691).

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(6):1444-1451. doi:10.1378/chest.13-2386
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BACKGROUND:  D-dimer levels increase with age, and research has suggested that using an age-adjusted D-dimer threshold may improve diagnostic efficiency without compromising safety. The objective of this study was to assess the safety of using an age-adjusted D-dimer threshold in the workup of patients with suspected pulmonary embolism (PE).

METHODS:  We report the outcomes of 923 patients aged > 50 years presenting to our ED with suspected PE, a calculated Revised Geneva Score (RGS), and a D-dimer test. All patients underwent CT pulmonary angiography (CTPA). We compared the false-negative rate for PE of a conventional D-dimer threshold with an age-adjusted D-dimer threshold and report the proportion of patients for whom an age-adjusted D-dimer threshold would obviate the need for CTPA.

RESULTS:  Among 104 patients with a negative conventional D-dimer test result and an RGS ≤ 10, no PE was observed within 90 days (false-negative rate, 0%; 95% CI, 0%-2.8%). Among 273 patients with a negative age-adjusted D-dimer result and an RGS ≤ 10, four PEs were observed within 90 days (false-negative rate, 1.5%; 95% CI, 0.4%-3.7%). We observed an 18.3% (95% CI, 15.9%-21.0%) absolute reduction in the proportion of patients aged > 50 years who would merit CTPA by using an age-adjusted D-dimer threshold compared with a conventional D-dimer threshold.

CONCLUSIONS:  Use of an age-adjusted D-dimer threshold reduces imaging among patients aged > 50 years with an RGS ≤ 10. Although the adoption of an age-adjusted D-dimer threshold is probably safe, the CIs surrounding the additional 1.5% of PEs missed necessitate prospective study before this practice can be adopted into routine clinical care.

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