D-dimer and D-dimer/fibrinogen ratio in predicting pulmonary embolism in patients evaluated in a hospital emergency department

Diagnostic performance of plasma D-dimer, fibrinogen, and D-dimer to fibrinogen ratio as potential biomarkers to predict hypertension-associated acute ischemic stroke

Background

Ischemic stroke is a common type of stroke that leads to death and functional disability in hypertensive patients. However, there are no well-studied non-invasive and less expensive fluid biomarkers routinely used to detect ischemic stroke in hypertensive patients. Hence, this study aimed to tease out the performance of D-dimer, fibrinogen, and the D-dimer to fibrinogen ratio (DDFR) in predicting hypertension-associated acute ischemic stroke.

Methods

A hospital-based cross-sectional study was done from October 2022 to January 2022 at Yikatit 12 Hospital Medical College, Ethiopia. We recruited 55 hypertensive patients who had an ischemic stroke and 110 who did not. A ROC curve was used to calculate the areas under the curves (AUCs) and determine the diagnostic power of the D-dimer, fibrinogen, and DDFR. The Youden index was used to find the best cut-off points for biomarkers in detecting acute ischemic stroke. A De Long test was employed to show whether there was a significant difference between the AUCs of biomarkers in diagnosing ischemic stroke.

Results

D-dimer yielded the highest diagnostic power (AUC = 0.776) in detecting acute ischemic stroke, followed by DDFR (AUC = 0.763) and fibrinogen (AUC = 0.694), but there was no significant difference between them. At 0.52 μg/ml cut-off point, D-dimer had 82.9% sensitivity, 66.7% specificity, 62.5% PPV, and 85.3% NPV to diagnose acute ischemic stroke. Fibrinogen could detect acute ischemic stroke at 405.85 mg/dl level, with 70.0% sensitivity, 57.1% specificity, 41.2% PPV and 81.6% NPV. At a 1.83 ratio, DDFR might also identify ischemic stroke with 80.0% sensitivity, 67.1% specificity, 51.1% PPV, and 88.7% NPV.

Conclusion

We showed D-dimer, fibrinogen, and DDFR as promising, affordable, and non-invasive biomarkers for the detection of ischemic stroke among subjects with hypertension. This will help clinicians make an early diagnosis and better guide patient therapy.

D-dimer to fibrinogen ratio predicts early neurological deterioration in ischemic stroke with atrial fibrillation

INTRODUCTION

The D-dimer to fibrinogen ratio (DFR) is a good indicator of clot-producing activity in thrombotic disease, but its clinical usefulness in stroke patients with nonvalvular atrial fibrillation (NVAF) has not been studied. We evaluated the association between the DFR and early neurological deterioration (END) in acute ischemic stroke (AIS) patients with NVAF.

METHODS

We included consecutive AIS patients with NVAF between 2013 and 2015 from the registry of a real-world prospective cohort from 11 large centers in South Korea. END was defined as an increase ≥2 in the total NIHSS score or ≥ 1 in the motor NIHSS score within the first 72 h of admission. The DFR was calculated as follows: DFR = D-dimer (mg/L)/fibrinogen (mg/dL) x 100.

RESULTS

A total of 1018 AIS patients with NVAF were evaluated. In multivariable logistic regression analysis, the highest DFR tertile was closely associated with END (adjusted odds ratio [aOR] = 2.14, 95 % confidence interval [CI]: 1.24-3.69). Hypertension (aOR = 1.71, 95 % CI: 1.09-2.70), initial NIHSS score (aOR = 1.05, 95 % CI: 1.02-1.07) and use of anticoagulants (aOR = 0.41, 95 % CI: 0.28-0.60) were also correlated with END. In addition to END, the DFR was correlated with discharge NIHSS and modified Rankin Scale (mRS) scores and the 3-month mRS score.

CONCLUSIONS

High DFR values were associated with END in AIS patients with NVAF. As the DFR is an indicator directly related to the main pathological mechanism of NVAF patients (fibrinolysis and coagulation), it may be useful in predicting their prognosis.

Using an age and fibrinogen levels adjusted D-dimer cutoff significantly improves the specificity of two equivalent D-dimer assays for excluding pulmonary embolism

OBJECTIVES

Our single-center prospective study compared two methods of D-dimer determination used in the exclusion of pulmonary embolism: bioMérieux method, VIDAS® D-Dimer Exclusion™ II, and Diagnostica Stago method, STA®-Liatest® D-Di Plus. For each of these two methods, we calculated optimized variable cutoffs based on fibrinogen and/or age to improve the specificity of the methods.

PATIENTS - METHODS

2530 patients admitted to the Emergency Department of the Brest University Hospital for suspected pulmonary embolism were included in this study. The comparison of the two methods was performed by calculating their different characteristics: sensitivity, specificity and negative predictive value for different cutoffs systems: fixed or age-adjusted according to Douma et al. An optimization of the variable cutoff according to age and fibrinogen was then performed.

RESULTS

The two methods VIDAS and STAGO are approximately equivalent in terms of performance even if the STAGO method presents a better specificity (57.1 %) at the fixed cutoff of 0.5 μg/mL. The adoption of age-adjusted, fibrinogen-adjusted or doubly-adjusted (age and fibrinogen) cutoffs, significantly improves the specificity of the tests without affecting their excellent sensitivity. These specificities peak respectively at 75.8 % and 76 % for the VIDAS and STAGO tests when using a doubly-adjusted, age and fibrinogen, cutoff, i.e. a gain in specificity of approximately 10 % compared with the age-adjusted cutoff of Douma et al. and of approximately 20 % compared with the fixed cutoff of 0.5 μg/mL.

CONCLUSION

Adopting an optimized variable cutoff based on fibrinogen and/or age significantly improves specificity of D-dimer methods for pulmonary embolism exclusion.

Developing a nomogram-based scoring model to estimate the risk of pulmonary embolism in respiratory department patients suspected of pulmonary embolisms

Objective

Pulmonary embolisms (PE) are clinically challenging because of their high morbidity and mortality. This study aimed to create a nomogram to accurately predict the risk of PE in respiratory department patients in order to enhance their medical treatment and management.

Methods

This study utilized a retrospective method to collect information on medical history, complications, specific clinical characteristics, and laboratory biomarker results of suspected PE patients who were admitted to the respiratory department at Affiliated Dongyang Hospital of Wenzhou Medical University between January 2012 and December 2021. This study involved a total of 3,511 patients who were randomly divided into a training group (six parts) and a validation group (four parts) based on a 6:4 ratio. The LASSO regression and multivariate logistic regression were used to develop a scoring model using a nomogram. The performance of the model was evaluated using receiver operating characteristic curve (AUC), calibration curve, and clinical decision curve.

Results

Our research included more than 50 features from 3,511 patients. The nomogram-based scoring model was established using six predictive features including age, smoke, temperature, systolic pressure, D-dimer, and fibrinogen, which achieved AUC values of 0.746 in the training cohort (95% CI 0.720-0.765) and 0.724 in the validation cohort (95% CI 0.695-0.753). The results of the calibration curve revealed a strong consistency between probability predicted by the nomogram and actual probability. The decision curve analysis (DCA) also demonstrated that the nomogram-based scoring model produced a favorable net clinical benefit.

Conclusion

In this study, we successfully developed a novel numerical model that can predict the risk of PE in respiratory department patients suspected of PE, which can not only appropriately select PE prevention strategies but also decrease unnecessary computed tomographic pulmonary angiography (CTPA) scans and their adverse effects.

Contemporary Biomarkers in Pulmonary Embolism Diagnosis: Moving beyond D-Dimers

Pulmonary embolism (PE) is a rather common cardiovascular disorder constituting one of the major manifestations of venous thromboembolism (VTE). It is associated with high mortality and substantial recurrence rates, and its diagnosis may be challenging, especially in patients with respiratory comorbidities. Therefore, providing a prompt and accurate diagnosis for PE through developing highly sensitive and specific diagnostic algorithms would be of paramount importance. There is sound evidence supporting the use of biomarkers to enhance the diagnosis and predict the recurrence risk in patients with PE. Therefore, several novel biomarkers, such as factor VIII, Ischemia Modified Albumin, and fibrinogen, as well as several MicroRNAs and microparticles, have been investigated for the diagnosis of this clinical entity. The present review targets to comprehensively present the literature regarding the novel diagnostic biomarkers for PE, as well as to discuss the evidence for their use in daily routine.

Diagnostic Value of Galectin-3 for Identifying Acute Pulmonary Embolism in the Emergency Department

BACKGROUND

Pulmonary embolism (PE) is a common disease associated with high mortality and morbidity. Diagnosing PE is challenging due to diverse clinical presentations and the lack of specific biomarkers.

OBJECTIVE

We hypothesized that plasma galectin-3 (Gal-3) levels might reflect the severity of acute PE and be useful for diagnostic assessment.

METHODS

In this prospective study, 150 patients (100 patients with PE and 50 control patients) were included. Patients were stratified into high-risk, medium-risk, and low-risk groups according to the Wells and revised Geneva scoring systems, and Gal-3 levels were compared among the groups. PE was diagnosed by means of computed tomography pulmonary angiography.

RESULTS

In this study, of the 100 PE patients included in the study, 69 patients recovered and were discharged and 31 patients died. Median Gal-3 value in the PE group was 27.0 ng/mL (range 11.5-35.0 ng/mL), whereas the median Gal-3 value in the control group was significantly lower at 8.8 ng/mL (range 1.0-21.0 ng/mL) (p < 0.001). When the Gal-3 values of the PE group and the control group were evaluated with the receiver operator characteristic curve, the area under the curve was calculated as 0.99 (95% confidence interval 0.979-1). At a Gal-3 cutoff value of 13.55 ng/mL, which was determined to be the most appropriate value for PE diagnosis, the sensitivity was 98% and the specificity was 92%.

CONCLUSIONS

A biomarker that rapidly and accurately diagnoses acute PE in the emergency department can be an extremely useful tool. We concluded that plasma Gal-3 levels can be regarded as a promising marker of acute PE.

Prognostic value of D-dimer/fibrinogen ratio on in-hospital outcomes of patients with heart failure and COVID-19

Aim: In the present study, the relationship between D-dimer/fibrinogen ratio (DFR) and in-hospital outcomes was evaluated in patients with COVID-19 and a diagnosis of heart failure (HF). Materials & methods: In-hospital outcomes were compared in patients with high and low DFR values. Results: With regard to in-hospital outcomes, patients in the third tertile of DFR had a higher rate of mechanical ventilation, cardiogenic shock and death (p < 0.001). The length of ICU stay was longer in the third tertile group (p < 0.001). When evaluated together with infection markers, DFR was found to be an independent predictor of outcomes. Conclusion: DFR can be used as a prognostic marker in patients with COVID-19 with a diagnosis of HF, and perhaps more valuable than other infection markers.

Relationship between anaemia, coagulation parameters during pregnancy and postpartum haemorrhage at childbirth: a prospective cohort study

OBJECTIVES

To investigate the association between coagulation parameters and severity of anaemia (moderate anaemia: haemoglobin (Hb) 7-9.9 g/dL and severe anaemia: Hb <7 g/dL) during pregnancy and relate these to postpartum haemorrhage (PPH) at childbirth.

DESIGN

A prospective cohort study of pregnant women recruited in the third trimester and followed-up after childbirth.

SETTING

Ten hospitals across four states in India.

PARTICIPANTS

1342 pregnant women.

INTERVENTION

Not applicable.

METHODS

Hb and coagulation parameters: fibrinogen, D-dimer, D-dimer/fibrinogen ratio, platelets and international normalised ratio (INR) were measured at baseline. Participants were followed-up to measure blood loss within 2 hours after childbirth and PPH was defined based on blood loss and clinical assessment. Associations between coagulation parameters, Hb, anaemia and PPH were examined using multivariable logistic regression models.

OUTCOMES MEASURES

Adjusted OR with 95% CI.

RESULTS

In women with severe anaemia during the third trimester, the D-dimer was 27% higher, mean fibrinogen 117 mg/dL lower, D-dimer/fibrinogen ratio 69% higher and INR 12% higher compared with women with no/mild anaemia. Mean platelets in severe anaemia was 37.8×109/L lower compared with women with moderate anaemia. Similar relationships with smaller effect sizes were identified for women with moderate anaemia compared with women with no/mild anaemia. Low Hb and high INR at third trimester of pregnancy independently increased the odds of PPH at childbirth, but the other coagulation parameters were not found to be significantly associated with PPH.

CONCLUSION

Altered blood coagulation profile in pregnant women with severe anaemia could be a risk factor for PPH and requires further evaluation.

Could a D-dimer/fibrinogen ratio have a role in ruling-out venous thromboembolism?

BACKGROUND

Diagnosis of venous thromboembolism (VTE) requires chest CT angiography for pulmonary embolism and venous ultrasound for deep vein thrombosis. To reduce imaging, guidelines recommend D-dimer levels to rule-out VTE in patients with a low pre-test probability. The most widely used D-dimer cut-off is 500 ng/mL. This cut-off has low specificity, meaning many patients without disease require imaging.

METHODS

In this retrospective chart review, we evaluated the diagnostic performance of the D-dimer/fibrinogen ratio (DFR) for identifying thromboembolism and compared it to the performance of two different D-dimer cut-offs (500 ng/mL and 1000 ng/mL) in patients who underwent a chest CT angiography or a venous ultrasound in the ED of San Raffaele Hospital, Italy, in 2017. Patients had a retrospective Wells score calculated after chart review, identifying both high-risk and low-risk pre-test probability patients for this study and low probability patients were further stratified into low-risk of deep vein thrombosis or pulmonary embolism.

RESULTS

Enrolled patients included 92 with suspected pulmonary embolism and 154 with suspected deep vein thrombosis; of whom 67 (27%) were diagnosed with VTE. The most accurate cut-off for DFR in terms of discriminative power was 2.65. In the whole sample and in low-risk patients, this cut-off had the same sensitivity values of the 500 ng/mL D-dimer cut-off (97% (95% CI: 89.8% to 99.2%)), while slightly lower sensitivity values were found for the 1000 ng/mL D-dimer cut-off (95.5% (95% CI: 87.6% to 98.5%)). Specificity was higher for the 2.65 DFR cut-off (55.3% (95% CI: 48.0% to 62.4%)) in the whole sample compared with both 500 ng/mL D-dimer cut-off (22.9% (95% CI: 17.4% to 29.6%)) and 1000 ng/mL D-dimer cut-off (45.8% (95% CI: 38.7% to 53.1%)). Similar results were found in all subgroups.

CONCLUSION

A DFR, with a cut-off of 2.65, may improve the specificity for VTE patients when compared with D-dimer alone in high-risk VTE emergency medicine populations. This is exploratory information only, needing evaluation in prospective, multicentre studies, prior to consideration for use in routine clinical work.

D-Dimer to Fibrinogen Ratio as a Novel Prognostic Marker in Patients After Undergoing Percutaneous Coronary Intervention: A Retrospective Cohort Study

The role of activation of the coagulation and fibrinolysis system in the pathogenesis and prognosis of cardiovascular diseases (CVDs) has drawn wide attention. Recently, the D-dimer to fibrinogen ratio (DFR) is considered as a useful biomarker for the diagnosis and prognosis of ischemic stroke and pulmonary embolism. However, few studies have explored the relationship between DFR and cardiovascular disease. In our study, patients were divided into 2 groups according to DFR value: the lower group (DFR < 0.52, n = 2123) and the higher group (DFR ≥ 0.52, n = 1073). The primary outcome was all-cause mortality (ACM) and cardiac mortality (CM). The average follow-up time was 37.59 ± 22.24 months. We found that there were significant differences between the 2 groups in term of ACM (2.4% vs 6.6%, P < 0.001) and CM (1.5% vs 4.0%, P < 0.001). Kaplan-Meier analyses showed that elevated DFR had higher incidences of ACM (log rank P < 0.001) and CM (log rank P < 0.001). Multivariate Cox regression analyses showed that DFR was an independent predictor of ACM (HR = 1.743, 95%CI: 1.187-2.559 P = 0.005) and CM (HR = 1.695, 95%CI: 1.033-2.781 P = 0.037). This study indicates that DFR is an independent and novel predictor of long-term ACM and CM in post-PCI patients with CAD.

Dynamic changes in fibrinogen and D-dimer levels in COVID-19 patients on nafamostat mesylate

Critical illnesses associated with coronavirus disease 2019 (COVID-19) are attributable to a hypercoagulable status. There is limited knowledge regarding the dynamic changes in coagulation factors among COVID-19 patients on nafamostat mesylate, a potential therapeutic anticoagulant for COVID-19. First, we retrospectively conducted a cluster analysis based on clinical characteristics on admission to identify latent subgroups among fifteen patients with COVID-19 on nafamostat mesylate at the University of Tokyo Hospital, Japan, between April 6 and May 31, 2020. Next, we delineated the characteristics of all patients as well as COVID-19-patient subgroups and compared dynamic changes in coagulation factors among each subgroup. The subsequent dynamic changes in fibrinogen and D-dimer levels were presented graphically. All COVID-19 patients　were classified into three subgroups: clusters A, B, and C, representing low, intermediate, and high risk of poor outcomes, respectively. All patients were alive 30 days from symptom onset. No patient in cluster A required mechanical ventilation; however, all patients in cluster C required mechanical ventilation, and half of them were treated with venovenous extracorporeal membrane oxygenation. All patients in cluster A maintained low D-dimer levels, but some critical patients in clusters B and C showed dynamic changes in fibrinogen and D-dimer levels. Although the potential of nafamostat mesylate needs to be evaluated in randomized clinical trials, admission characteristics of patients with COVID-19 could predict subsequent coagulopathy.

The Potential Value of D-Dimer to Fibrinogen Ratio in Diagnosis of Acute Ischemic Stroke

INTRODUCTION AND OBJECTIVE

At present, there is no hematology marker with high specificity to the diagnosis and differential diagnosis of acute ischemic stroke (AIS). How to use the existing test items to improve the diagnosis efficiency worthy of discussion. D-Dimer (DD) and fibrinogen (FIB) were the common indicators in thrombotic diseases, but D-dimer to fibrinogen ratio (D/F) in AIS has not been used in clinical practice. In this work, we focus on the evaluation of D/F.

METHODS

90 AIS patients were selected as the observation group and 65 other patients without coagulation function disorder as the control group. Meanwhile, a total of 33 patients with other diseases with impaired consciousness in the same period were collected. Based on the AIS patients with or without consciousness disorder divided it into consciousness disorder group and unconsciousness disorder group. Then based on the patients with or without consciousness disorder divided it into other diseases with unconsciousness disorder group and Other diseases with lacunar cerebral infarction (LCI)and disturbance of consciousness group. then compare the differences of plasma DD, FIB and D/F between groups.

RESULTS

All plasma DD, FIB and D/F ratio in AIS patients were significantly higher than in other disease group (P = 0.000, P = 0.001, P = 0.000), but DD, D/F in disorders of consciousness group was significantly higher than in unconsciousness disorders group (P = 0.007, P = 0.005). The DD of the AIS with consciousness disorder group were significantly higher than that of the other disease with consciousness disorder group (P = 0.042), and the DD, D/F ratio of Other diseases with lacunar cerebral infarction and disturbance of consciousness group were significantly higher than one(P = 0.000, P = 0.003). All others are undifferentiated.

CONCLUSIONS

When DD, D/F ratio is high, other diseases caused by consciousness disorders are likely to be combined with infarcts, which can be used for the diagnosis and differential diagnosis of patients with different types of consciousness disorders, especially hospitalized patients.

D-dimer/fibrinogen ratio for the prediction of progressive hemorrhagic injury after traumatic brain injury

BACKGROUND

Progressive hemorrhagic injury (PHI) greatly affects prognosis of traumatic brain injury (TBI). D-dimer/fibrinogen ratio (D/F ratio) may be a potential predictor for venous thromboembolism. This study sought to describe and evaluate any relationship between D/F ratio and PHI after TBI.

METHODS

This retrospective study included a cohort of 192 TBI patients. Plasma D-dimer and fibrinogen were measured, and subsequently D/F ratio was calculated. Multivariate logistic regression analysis was applied to identify predictors of PHI. Receiver operating characteristic (ROC) curve was conFig.d to analyze predictive capability for PHI.

RESULTS

A total of 43 patients (22.4%) experienced PHI. Both Glasgow coma scale (GCS) score (odds ratio [OR], 0.565; 95% CI, 0.464-0.689) and D/F ratio (OR, 4.026; 95% CI, 2.219-7.305) were the two independent predictor for PHI. Area under ROC curve (AUC) of D/F ratio was similar to that of GCS score (AUC, 0.816; 95% CI, 0.754-0.868 vs. AUC, 0.834; 95% CI, 0.773-0.883; P = 0.699). Moreover, D/F ratio significantly improved AUC of GCS score to 0.928 (95% CI, 0.881-0.960; P < 0.001).

CONCLUSIONS

D/F ratio was strongly predictive of PHI in the studied cohort and, thereby should be considered in the clinical management of TBI patients.

Is Bedside End-Tidal CO2 Measurement a Screening Tool to Exclude Pulmonary Embolism in Emergency Department?

Background

Pulmonary embolism (PE) is among the most difficult conditions to diagnose in emergency department. The majority of patients thought to have PE are tested positive for D-dimer and subsequently tested with advanced diagnostic modalities. Novel noninvasive tests capable of excluding PE may obviate the need for advanced imaging tests. We studied the role of combined clinical probability assessment and end-tidal carbon dioxide (ETCO₂) measurement for diagnosis of possible PE in emergency department.

Methods

We included 100 consecutive subjects suspected to have PE and a positive D-dimer test to study clinical probability of PE and ETCO₂ levels. ETCO₂ > 34 mm Hg was found to be the best cut-off point for diagnosing PE. PE was ultimately eliminated or diagnosed by spiral computed tomography (CT).

Results

Diagnostic performances of tests were as follows: ETCO₂ and D-dimer had a sensitivity of 100% and a negative predictive value (NPV) of 100% at the cut-off levels of 34 mm Hg and 500 ng/mL, respectively; Wells score had a sensitivity of 80% and NPV of 69.7% at a score of 4.

Conclusions

ETCO₂ alone cannot reliably exclude PE. Combining it with clinical probability, however, reliably and correctly eliminates or diagnoses PE and prevents further testing to be done.

Potential Risk Factors Associated With Vascular Diseases in Patients Receiving Treatment for Hypertension

Background

Currently, the hypertension (HTN) patients undergo appropriate medical treatment, and traditional risk factors are highly controlled. Therefore, potential risk factors of atherosclerotic vascular diseases (AVD) and venous thromboembolisms (VTE) in HTN should be reconsidered. We investigated thrombophilic genetic mutations and existing biomarkers for AVD or VTE in HTN patients receiving treatment.

Methods

A total of 183 patients were enrolled: AVD with HTN (group A, n=45), VTE with HTN (group B, n=62), and HTN patients without any vascular diseases (group C, n=76). The lipid profile, homocysteine (Hcy) levels, D-dimers, fibrinogen, antithrombin, lupus anticoagulant, and anti-cardiolipin antibody (aCL) were evaluated. Prothrombin G20210A, Factor V G1691A, and methylenetetrahydrofolate reductase (MTHFR) C677T and A1298C were analyzed.

Results

All patients revealed wild type prothrombin G20210A and Factor V G1691A polymorphisms. The frequency of MTHFR polymorphisms was 677CT (n=84, 45.9%); 677TT (n=46, 25.1%); 1298AC (n=46, 25.1%); and 1298CC (n=2, 1.1%). The MTHFR 677TT genotype tended to increase the odds ratio (OR) to AVD events in HTN patients (OR 2.648, confidence interval 0.982-7.143, P=0.05). The group A demonstrated significantly higher Hcy levels (P=0.009), fibrinogen (P=0.004), and platelet counts (P=0.04) than group C. Group B had significantly higher levels of D-dimers (P=0.0001), platelet count (P=0.0002), and aCL (P=0.02) frequency than group C.

Conclusions

The MTHFR 677TT genotype and Hcy level could be potential risk factors associated with development of AVD in HTN patients receiving treatment. D-dimer and aCL might be useful to estimate the occurrence of VTE in them.