D-dimer value in the diagnosis of pulmonary embolism-may it exclude only?

Novel insights into pulmonary embolism with negative D-dimer results

A patient in his mid-40s presented with exertional dyspnoea and pleuritic chest pain persisting for 6 weeks. Despite repeated normal investigations, including D-dimer tests, chest X-rays, serial troponins and ECGs, a CT pulmonary angiogram (CTPA) was performed to rule out pulmonary embolism (PE) or other pulmonary abnormalities, revealing a left main pulmonary artery thrombus with no evidence of right ventricular strain. The patient was managed with oral rivaroxaban 15 mg two times per day for 21 days followed by 20 mg once daily for 6 months. The patient showed full recovery at the 6-month follow-up. This case highlights the diagnostic challenges in patients with persistent symptoms, low risk of venous thromboembolisms (VTEs) and normal initial investigations. It is novel because previous case reports of PE with negative D-dimer results have predominantly involved patients with identifiable risk factors, such as prior VTEs, malignancy or other conditions that increase the likelihood of PE. In contrast, this case demonstrates that PE can occur even in the absence of these risk factors, emphasising the importance of clinical diligence and the use of advanced imaging in diagnosing PE in atypical presentations.

Unusual cause of muscle weakness, type II respiratory failure and pulmonary hypertension: a case report of ryanodine receptor type 1(RYR1)-related myopathy

BACKGROUND

Patients with congenital myopathies may experience respiratory involvement, resulting in restrictive ventilatory dysfunction and respiratory failure. Pulmonary hypertension (PH) associated with this condition has never been reported in congenital ryanodine receptor type 1(RYR1)-related myopathy.

CASE PRESENTATION

A 47-year-old woman was admitted with progressively exacerbated chest tightness and difficulty in neck flexion. She was born prematurely at week 28. Her bilateral lower extremities were edematous and muscle strength was grade IV-. Arterial blood gas analysis revealed hypoventilation syndrome and type II respiratory failure, while lung function test showed restrictive ventilation dysfunction, which were both worse in the supine position. PH was confirmed by right heart catheterization (RHC), without evidence of left heart disease, congenital heart disease, or pulmonary artery obstruction. Polysomnography indicated nocturnal hypoventilation. The ultrasound revealed reduced mobility of bilateral diaphragm. The level of creatine kinase was mildly elevated. Magnetic resonance imaging showed myositis of bilateral thigh muscle. Muscle biopsy of the left biceps brachii suggested muscle malnutrition and congenital muscle disease. Gene testing revealed a missense mutation in the RYR1 gene (exon33 c.C4816T). Finally, she was diagnosed with RYR1-related myopathy and received long-term non-invasive ventilation (NIV) treatment. Her symptoms and cardiopulmonary function have been greatly improved after 10 months.

CONCLUSIONS

We report a case of RYR1-related myopathy exhibiting hypoventilation syndrome, type II respiratory failure and PH associated with restrictive ventilator dysfunction. Pulmonologists should keep congenital myopathies in mind in the differential diagnosis of type II respiratory failure, especially in patients with short stature and muscle weakness.

Right ventricular area predicts short-term mortality in acute pulmonary embolism based on CT pulmonary angiography: A retrospective study

We performed this cohort study to assess the prognostic value of right ventricular size, including diameter, area, and volume, in short-term mortality of acute pulmonary embolism (APE) based on 256-slice computed tomography compared with D-dimer, creatine kinase muscle and brain isoenzyme, and Wells scores. A total of 225 patients with APE, who were followed up for 30 days were enrolled in this cohort study. Clinical data, laboratory indices (creatine kinase, creatine kinase muscle and brain isoenzyme, and D-dimer), and Wells scores were collected. The 256-slice computed tomography was used to quantify cardiac parameters (RVV/LVV, RVD/LVD-ax, RVA/LVA-ax, RVD/LVD-4ch, RVA/LVA-4ch) and the diameter of the coronary sinus. Participants were divided into non-death and death groups. The values mentioned above were compared between the 2 groups. The RVD/LVD-ax, RVA/LVA-ax, RVA/LVA-4ch, RVV/LVV, D-dimer, and creatine kinase levels were significantly higher in the death group than in the non-death group (P < .05). The active period of the malignant tumor, heart rate ≥ 100 beats/minutes, and RVA/LVA-ax were positively correlated with early death from APE (P < .05). Active stage of malignant tumor (OR:9.247, 95%CI:2.682-31.888, P < .001) and RVA/LVA-ax (OR:3.073, 95%CI:1.447-6.528, P = .003) were independent predictors of early death due to APE. According to the receiver operating characteristic curve, the cutoff point of RVA/LVA-ax was 1.68 with a sensitivity of 46.7% and specificity of 84.8%. The measurement of ventricular size in the short-axis plane is more convenient and reliable than that in the 4-chamber cardiac plane. RVA/LVA-ax is an independent predictor of early death from APE, and when RVA/LVA-ax > 1.68, the risk of early death from APE increases.

Be aware of non-specific presentation of pulmonary embolism: a case report

BACKGROUND

The early diagnosis of non-specific presentation of pulmonary embolism (PE) is difficult because the symptoms are non-specific and varied.

CASE PRESENTATION

A 69-year-old female patient had syncope accompanied by gait disturbance, without obvious inducement. The patient was initially suspected to have cerebral infarction, but the symptoms did not improve and myocardial markers increased after two days of symptomatic treatment for myocardial infarction. Hence, PE was suspected and computed tomography pulmonary angiography (CTPA) examination confirmed the diagnosis. CTPA showed multiple emboli in pulmonary artery and its branches, so high-risk PE was diagnosed. Intravenous thrombolysis was administered, and pulmonary CTA showed a significant reduction of emboli in pulmonary artery and its left and right branches.

CONCLUSION

This case report highlights the importance of improving the clinical awareness about non-specific presentation of PE and avoiding misdiagnosis or missed diagnosis.

Risk factors and potential predictors of pulmonary embolism in cancer patients undergoing thoracic and abdominopelvic surgery: a case control study

BACKGROUND

Postoperative pulmonary embolism (PE) is a severe complication leading to death and poor prognosis. The present study investigated the risk factors and potential predictors of PE in cancer patients undergoing thoracic and abdominopelvic surgery.

METHODS

A retrospective study was conducted on the patients with cancer who underwent thoracic and abdominopelvic surgery in Sichuan Cancer Hospital from December 2016 to January 2022. A total of 189 patients were included, in which 63 patients diagnosed PE after operation were collected as PE group, and 126 patients matched by age, type of cancer and cancer location were enrolled as control group. Conditional logistic regression was conducted to analyze the association between PE and risk factors. Predictive values of key factors were compared by the area under the curve (AUC) in receiver operating characteristic curve (ROC) curve.

RESULTS

Conditional multivariate logistic regression showed that BMI (odds ratio [OR] 4.065, 95% confidence interval [CI] 1.138-14.527; p = 0.031), intraoperative hypotension time (OR 4.095, 95% CI 1.367-12.266; p = 0.009), same day fluid balance (OR 0.245, 95% CI 0.061-0.684; p = 0.048), and postoperative D-Dimer (OR 1.693, 95% CI 1.098-2.611; p = 0.017) were significantly related to the occurrence of postoperative PE. Postoperative D-Dimer had the maximal AUC value 0.8014 (95% CI: 0.7260-0.8770) for predicting PE, with a cutoff value of 1.505 μg/ml.

CONCLUSIONS

BMI, intraoperative hypotension time, lower same day fluid balance and postoperative D-dimer are independent risk factors associated with PE in cancer patients undergoing thoracic and abdominopelvic surgery. Postoperative D-Dimer seems to be a good indicator to predict postoperative PE for cancer patients.

Diagnostic Accuracy of Multiple D-Dimer Cutoff Thresholds and Other Clinically Applicable Biomarkers for the Detection and Radiographic Evaluation of Pulmonary Embolism

Background: Diagnostic work-up of pulmonary embolism (PE) remains a challenge. Methods: We retrospectively studied all patients referred for computed tomography pulmonary angiography (CTPA) with suspicion of PE during a 12-month period (2018). The diagnostic accuracy of different D-dimer (Dd) cutoff thresholds for ruling out PE was evaluated. Furthermore, the association of Dd and red cell distribution width (RDW) with embolus location, CTPA findings, and patient outcome was recorded. Results: One thousand seventeen (n = 1017) patients were finally analyzed (mean age: 64.6 years (SD = 11.8), males: 549 (54%)). PE incidence was 18.7%. Central and bilateral embolism was present in 44.7% and 59.5%, respectively. Sensitivity and specificity for conventional and age-adjusted Dd cutoff was 98.2%, 7.9%, and 98.2%, 13.1%, respectively. A cutoff threshold (2.1 mg/L) with the best (64.4%) specificity was identified based on Receiver Operating Characteristics analysis. Moreover, a novel proposed Dd cutoff (0.74 mg/L) emerged with increased specificity (20.5%) and equal sensitivity (97%) compared to 0.5 mg/L, characterized by concurrent reduction (17.2%) in the number of performed CTPAs. Consolidation/atelectasis and unilateral pleural effusion were significantly associated with PE (p < 0.05, respectively). Patients with consolidation/atelectasis or intrapulmonary nodule(s)/mass on CTPA exhibited significantly greater median Dd values compared to patients without the aforementioned findings (2.34, (IQR 1.29−4.22) vs. 1.59, (IQR 0.81−2.96), and 2.39, (IQR 1.45−4.45) vs. 1.66, (IQR 0.84−3.12), p < 0.001, respectively). RDW was significantly greater in patients who died during hospitalization (p = 0.012). Conclusions: Age-adjusted Dd increased diagnostic accuracy of Dd testing without significantly decreasing the need for imaging. The proposed Dd value (0.74 mg/L) showed promise towards reducing considerably the need of CTPA. Multiple radiographic findings have been associated with increased Dd values in our study.

Current use of D-dimer for the exclusion of venous thrombosis in hospitalized patients

D-dimer assay’s utility for excluding venous thromboembolism (VTE) in hospitalized patients is debatable. We aimed to assess the current use of D-dimer as a diagnostic tool for excluding VTE in hospitalized patients and examine a mandatory age-adjusted D-dimer (AADD) threshold for diagnostic imaging. Retrospective cohort study between 2014 to 2019 that included patients from medical and surgical wards with a positive AADD result drawn during their hospitalization. The outcomes were determining a D-dimer threshold requiring further evaluation and assessing the prognostic value of D-dimer in predicting clinically relevant VTE in hospitalized patients. The cohort included 354 patients, 56% of them underwent definitive diagnostic imaging, and 7.6% were diagnosed with VTE after a positive AADD within 90 days of follow-up. Mortality rates were higher in patients diagnosed with VTE (33.3% vs. 15.9%, p = 0.03). Patients with pneumonia and other infectious etiologies were less likely to be further evaluated by definitive imaging (p = 0.001). Patients with a respiratory complaint (p = 0.02), chest pain (p < 0.001), or leg swelling (p = 0.01) were more likely to undergo diagnostic imaging. Patients with D-dimer levels > X2 the AADD were at increased risk of VTE [OR 3.87 (1.45–10.27)]. At 90 days of follow-up, no excess mortality was observed for patients without diagnostic evaluation following elevated AADD. D-dimer may be used in hospitalized patients to exclude VTE using the traditional AADD thresholds, with a high negative predictive value. D-dimer levels > X2 the AADD usually mandates further diagnostic imaging, while lower levels, probably do not require additional workup, with a sensitivity of almost 80% and no excess mortality.

DIAGNOSIS OF PULMONARY EMBOLISM IN THE EMERGENCY DEPARTMENT

The aim of this study was to determine the association of clinical presentation, the Wells scoring system and D-dimer values with MSCT pulmonary angiography. A case control study was conducted in the Emergency Department of the Clinical Hospital Sveti Duh throughout 2019. Patients with a referral diagnosis of a pulmonary embolism were included in the study. Patients were divided into two groups. The first group consisted of patients diagnosed with pulmonary embolism by MSCT pulmonary angiography or postmortem, and the second group consisted of patients excluded from pulmonary embolisms. For the Wells score, D-dimers, troponin, respiratory rate and peripheral blood oxygen saturation, statistically significant differences were found between groups of patients with confirmed or excluded pulmonary embolism (p <0.001). For heart rate, chest pain, syncope, and hemoptysis, no statistically significant differences were found between these two groups of patients. Deep venous thrombosis of the lower extremities was found by ultrasound in > 70% of patients with massive a pulmonary embolism. Pulmonary embolism was confirmed in all patients for whom a high risk was calculated according to the Wells score. In conclusion, a low degree of clinical probability (according to the Wells score), along with a normal concentration of D-dimer, are a sure strategy in excluding pulmonary embolism.

Low versus high dose anticoagulation in patients with Coronavirus 2019 pneumonia at the time of admission to critical care units: A multicenter retrospective cohort study in the Beaumont healthcare system

PURPOSE

Coagulopathy is common in patients with COVID-19. The ideal approach to anticoagulation remains under debate. There is a significant variability in existing protocols for anticoagulation, and these are mostly based on sporadic reports, small studies, and expert opinion.

MATERIALS AND METHODS

This multicenter retrospective cohort study evaluated the association between anticoagulation dose and inpatient mortality among critically ill COVID-19 patients admitted to the intensive care units (ICUs) or step-down units (SDUs) of eight Beaumont Healthcare hospitals in Michigan, USA from March 10th to April 15th, 2020.

RESULTS

Included were 578 patients with a median age of 64 years; among whom, 57.8% were males. Most patients (n = 447, 77.3%) received high dose and one in four (n = 131, 22.7%) received low dose anticoagulation. Overall mortality rate was 41.9% (n = 242). After adjusting for potential confounders (age, sex, race, BMI, ferritin level at hospital admission, intubation, comorbidities, mSOFA, and Padua score), administration of high anticoagulation doses at the time of ICU/SDU admission was associated with decreased inpatient mortality (OR 0.564, 95% CI 0.333-0.953, p = 0.032) compared to low dose.

CONCLUSION

Treatment with high dose anticoagulation at the time of ICU/SDU admission was associated with decreased adjusted mortality among critically ill adult patients with COVID-19.

A 10-fold and greater increase in D-dimer at admission in COVID-19 patients is highly predictive of pulmonary embolism in a retrospective cohort study

Background:

COVID-19 patients present with both elevated D-dimer and a higher incidence of pulmonary embolism (PE). This single-centre retrospective observational study investigated the prevalence of early PE in COVID-19 patients and its relation to D-dimer at presentation.

Methods:

The study included 1038 COVID-19-positive patients, with 1222 emergency department (ED) attendances over 11 weeks (16 March to 31 May 2020). Computed tomography pulmonary angiogram (CTPA) for PE was performed in 123 patients within 48 h of ED presentation, of whom 118 had D-dimer results. The remaining 875 attendances had D-dimer performed.

Results:

CTPA performed in 11.8% of patients within 48 h of ED presentation confirmed PE in 37.4% (46/123). Thrombosis was observed at all levels of pulmonary vasculature with and without right ventricular strain. In the CTPA cohort, patients with PE had significantly higher D-dimer, prothrombin time, C-reactive protein, troponin, total bilirubin, neutrophils, white cell count and lower albumin compared with non-PE patients. However, there was no difference in the median duration of inpatient stay or mortality. A receiver operator curve analysis demonstrated that D-dimer could discriminate between PE and non-PE COVID-19 patients (area under the curve of 0.79, p < 0.0001). Furthermore, 43% (n = 62/145) of patients with D-dimer >5000 ng/ml had CTPA with PE confirmed in 61% (n = 38/62), that is, 26% of >5000 ng/ml cohort. The sensitivity and specificity were related to D-dimer level; cutoffs of 2000, 3000, 4000, and 5000 ng/ml, respectively, had a sensitivity of 93%, 90%, 90% and 86%, and a specificity of 38%, 54%, 59% and 68%, and if implemented, an additional 229, 141, 106 and 83 CTPAs would be required.

Conclusion:

Our data suggested an increased PE prevalence in COVID-19 patients attending ED with an elevated D-dimer, and patients with levels >5000 ng/ml might benefit from CTPA to exclude concomitant PE.

Prognostic Value of D-Dimer in Younger Patients with Pulmonary Embolism

In patients with pulmonary embolism (PE), the D-Dimer assay is commonly utilized as part of the diagnostic workup, but data on D-Dimer for early risk stratification and short-term mortality prediction are limited. The purpose of this study was to determine D-Dimer levels as a predictive biomarker of PE outcomes in younger (<50 years of age) compared to older patients. We conducted retrospective analysis for 930 patients diagnosed with PE between 2015 and 2019 as part of the Serbian University Multicenter Pulmonary Embolism Registry (SUPER).All patients had D-Dimer levels measured within 24 hours of hospital admission. The primary outcome was mortality at 30 days or during hospitalization. Patients were categorized into two groups based on age (≤ 50 and >50 years of age). Younger patients constituted 20.5% of the study cohort. Regarding all-cause mortality, 5.2% (10/191)of patients died in group under the 50 years of age; the short-term all-causemortality was 12.4% (92/739) in older group.We have found that there was significant difference in plasma D-Dimer level between patients ≤ 50 years of age and older group (>50), p= 0.006.D-Dimer plasma level had good predictive value for the primary outcome in younger patients (c-statistics 0.710; 95% CI, 0.640-0.773; p<0.031). The optimal cutoff level for D-Dimer to predict PE-cause death in patients aged > 50 years was found to be 8.8 mg/l FEU(c-statistics 0,580; 95% CI 0.544-0.616; p=0.049). In younger PE patients, D-Dimer levels have good prognostic performance for 30-day all-cause mortalityand concentrations above 6.3 mg/l FEU are associated with increased risk of death. D-Dimer in patients aged over 50 years does not have predictive ability for all-caused short-term mortality. The relationship between D-Dimer and age in patients with PE may need further evaluation.

To scan or not to scan - D-dimers and computed tomography pulmonary angiography in the era of COVID-19

The COVID-19 pandemic has had many ramifications on healthcare delivery and practice. As part of this, utilising biomarkers to risk stratify patients has become increasingly popular. During the COVID-19 pandemic the use of D-dimer has increased due to the evidence of COVID-19 induced thrombo-embolic disease. We evaluated the use of D-dimer on all hospital admissions during the peak of the pandemic and evaluated its sensitivity in diagnosing pulmonary embolic disease (PE). Patients without COVID-19 infection were as likely to have evidence of PE as their COVID-positive counterparts. However, the sensitivity of a D-dimer was higher in COVID-positive patients at a lower D-dimer level (>1,500 μg/L, sensitivity 81%, specificity 70%) than in those without clinical, immunological or radiological evidence of COVID-19 infection (D-dimer >2,000 μg/L, sensitivity 80%, specificity 76%). These data suggest higher D-dimer thresholds should be considered for the exclusion of pulmonary emboli.

Application of an elevated plasma D-dimer cut-off value improves prognosis prediction of advanced non-small cell lung cancer

Background

Tumor-related coagulation dysfunction has been reported to be closely associated with poor prognosis. The present study is aimed to evaluate the prognostic prediction of an elevated plasma D-dimer cut-off value in advanced non-small cell lung cancer (NSCLC).

Methods

A total of 233 patients initially diagnosed with advanced NSCLC were retrospectively analyzed, an elevated plasma cut-off value 981 ng/mL of D-dimer, which was instead of the clinical cut-off value 500 mg/mL, was used to determine the high and low. Univariate analysis using the Kaplan-Meier method and log-ranking test, and the multivariate analysis using the Cox proportional hazard regression model were performed.

Results

Results showed when using the D-dimer value of 500 ng/mL as an evaluation standard, there was no significant difference in gender, age, smoking status, histopathology and overall survival rate between normal D-dimer (≤500 ng/mL) and high D-dimer (>500 ng/mL) group. However, when the evaluation standard for plasma D-dimer was set at 981 ng/mL, the age distribution of the high D-dimer (>981 ng/mL) group was significantly different from the normal D-dimer (≤981 ng/mL) group. Moreover, the overall survival rate in the high D-dimer (>981 ng/mL) group was significantly lower than that in the normal D-dimer (≤981 ng/mL) group.

Conclusions

The present study implied that increasing the plasma D-dimer cut-off value to 981 ng/mL is more beneficial to prognosis prediction in advanced NSCLC.

Elevated D-Dimers and Right Ventricular Dysfunction on Echocardiography for Diagnosis of Pulmonary Embolism: A Validation Study

Background

There is an increasing need to explore other non-invasive techniques for the diagnosis of pulmonary embolism in resource-limited countries.

Objective

To assess the validity of elevated D-dimer levels and right ventricular (RV) dysfunction on echocardiography in predicting definite massive pulmonary embolism among patients diagnosed with massive pulmonary embolism using computed tomography (CT) pulmonary angiography as the gold standard.

Methods

The patients with acute massive pulmonary embolism on CT pulmonary angiography were included. The participants underwent 12-lead electrocardiography, assessment of D-dimer levels, and bedside echocardiography to determine right ventricular dysfunction. The data were recorded on a proforma and analyzed using IBM SPSS software version 26.0 (IBM Corp., Armonk, NY).

Results

There were 160 patients in the study. The mean age was 49.19 ± 14.89 years. Elevated D-dimer levels were seen in 80.60% of the patients whereas ventricular dysfunction on echocardiography was seen in 90.00% of the patients. The sensitivity and specificity of elevated D dimer levels were 78.99% and 14.60%, respectively. The positive predictive values (PPV) and negative predictive values (NPV) for elevated D-dimer levels were 72.87% and 19.35%, respectively. In contrast, the sensitivity of ventricular dysfunction was 94.96% and specificity 24.39%. PPV was found to be 78.47% and NPV was 62.50%.

Conclusion

Positive D-dimer levels and ventricular dysfunction on echocardiography are sensitive enough to consider the diagnosis of massive pulmonary embolism but lack adequate specificity, thus, necessitating the presence of other noninvasive tests.

The diagnostic value of D-dimer with simplified Geneva score (SGS) pre-test in the diagnosis of pulmonary embolism (PE)

Background

Pulmonary embolism (PE) is the third most common cardiovascular syndrome with an average annual incidence rate of 77 per 100,000 population in the worldwide. The diagnose algorithms for suspected PE are generally include clinical scoring assessment and plasma D-dimer evaluation, patients with high risk of PE require computed tomographic pulmonary angiogram (CTPA) detection for confirmation.

Methods

In this retrospective analysis, 1035 patients with suspected PE were recruited. All the patients were clinically received simplified Geneva score (SGS) pre-test, determination of plasma D-dimer level, and CTPA detection. All enrolled patients were grouped according to the CTPA results: PE patients and non-PE patients. Then, receiver operating characteristic (ROC) curve were constructed to determine the optimal D-dimer cutoff point value which is based on Yonden’s index (YI).

Results

294 (28.4%) patients were confirmed with PE and 741(71.6%) individuals were regarded as non-PE cases by CTPA detection. Using the SGS pre-test, 829 (80.1%) patients were classified PE-unlikely (SGS ≤ 2) and 206 (19.9%) patients were PE-likely (SGS ≥ 3). Patients with D-dimer levels above 1.96 mg/L had a significant risk to suffer from PE (area under curve (AUC), 0.707; 95% CI, 0.678–0.735; p < 0.05). Meanwhile, in patients with SGS ≥ 3, the D-dimer cutoff point value moved to 2.2 mg/L (AUC, 0.644; 95% CI, 0.574–0.709; p < 0.05).

Conclusion

D-dimer test in combination with SGS pre-test could improve the accuracy of PE diagnosis. Patients with D-dimer levels over 1.96 mg/L (4 times of the normal level) have a significant risk for PE. In patients with SGS ≥ 3, the D-dimer cutoff point concentration for PE risk moves to the levels of 2.2 mg/L.