Key result
Implementation of an increased D-dimer threshold of 1.0 µg/mL and clinical probability assessment increased the prevalence of pulmonary embolism detected by PCTA from 4.7% to 11.7% (p < 0.001).
Why the study?
Does increasing the D-dimer threshold to 1.0 µg/mL and recommending clinical probability assessment improve the diagnostic yield of PCTA for suspected pulmonary embolism in ED patients?
Observational (n=1,057)
No
Does increasing the D-dimer threshold to 1.0 µg/mL and recommending clinical probability assessment improve the diagnostic yield of PCTA for suspected pulmonary embolism in ED patients?
Absolute Event Rate: 11.7% vs 4.7%
p-value: p=<0.001
Increasing the D-dimer threshold to 1.0 µg/mL and recommending clinical probability assessment significantly improved the diagnostic yield of PCTA for pulmonary embolism in the emergency department.
May enhance CT yield for suspected PE in the ED; hypothesis-generating and requires prospective validation before practice change.
OBJECTIVE: To determine whether the implementation of an increased D-dimer threshold value and clinical probability assessment increases the prevalence of pulmonary embolism (PE) in patients undergoing pulmonary computed tomography angiography (PCTA) in an Emergency Department setting. METHODS: A retrospective review of all patients undergoing PCTA during 2 separate 12-month intervals, 1 before the implementation of an increased D-dimer threshold and recommendation for formal clinical probability assessment and the other after regional implementation. The primary outcome measure was the prevalence of acute PE in each of the samples. RESULTS: After the implementation of the increased D-dimer threshold and recommendation for formal clinical probability assessment, the prevalence of PE detected by PCTA increased from 4.7% to 11.7% (p < 0.001). Among all PCTAs performed after the new guidelines were promulgated, 8.6% were still performed on patients who had serum D-dimer values lower than the threshold of 1.0 µg/mL. Despite the recommendation for formal clinical probability assessment before ordering a PCTA, only 4% of patients had a formal clinical probability assessment recorded in their electronic medical record. CONCLUSION: The implementation of an increased D-dimer threshold value increased the prevalence of PE in patients undergoing PCTA in an Emergency Department setting, but more consistent application of clinical probability assessment remains an elusive target.
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Char et al. (2014) conducted an observational in Suspected acute pulmonary embolism (n=1,057). Increased D-dimer threshold (1.0 µg/mL) and clinical probability assessment vs. Standard D-dimer threshold (0.4 µg/mL) without formal clinical probability assessment recommendation was evaluated on Prevalence of acute pulmonary embolism detected by pulmonary computed tomography angiography (p=<0.001). Implementation of an increased D-dimer threshold of 1.0 µg/mL and clinical probability assessment increased the prevalence of pulmonary embolism detected by PCTA from 4.7% to 11.7% (p < 0.001).
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