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Article Dans Une Revue Journal of the American Medical Association Année : 2014

Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study.

Franck Verschuren
Alexandre Ghuysen
  • Fonction : Auteur
Olivier T Rutschmann
  • Fonction : Auteur
Olivier Sanchez
Farès Moustafa
Marije ten Wolde
  • Fonction : Auteur
Germa Hazelaar
  • Fonction : Auteur
Klaas W van Kralingen
  • Fonction : Auteur
Marco J J H Grootenboers
  • Fonction : Auteur
Marc F Durian
  • Fonction : Auteur
y Whitney Cheung
  • Fonction : Auteur
Menno V Huisman
  • Fonction : Auteur

Résumé

IMPORTANCE: D-dimer measurement is an important step in the diagnostic strategy of clinically suspected acute pulmonary embolism (PE), but its clinical usefulness is limited in elderly patients. OBJECTIVE: To prospectively validate whether an age-adjusted D-dimer cutoff, defined as age × 10 in patients 50 years or older, is associated with an increased diagnostic yield of D-dimer in elderly patients with suspected PE. DESIGN, SETTINGS, AND PATIENTS: A multicenter, multinational, prospective management outcome study in 19 centers in Belgium, France, the Netherlands, and Switzerland between January 1, 2010, and February 28, 2013. INTERVENTIONS: All consecutive outpatients who presented to the emergency department with clinically suspected PE were assessed by a sequential diagnostic strategy based on the clinical probability assessed using either the simplified, revised Geneva score or the 2-level Wells score for PE; highly sensitive D-dimer measurement; and computed tomography pulmonary angiography (CTPA). Patients with a D-dimer value between the conventional cutoff of 500 µg/L and their age-adjusted cutoff did not undergo CTPA and were left untreated and formally followed-up for a 3-month period. MAIN OUTCOMES AND MEASURES: The primary outcome was the failure rate of the diagnostic strategy, defined as adjudicated thromboembolic events during the 3-month follow-up period among patients not treated with anticoagulants on the basis of a negative age-adjusted D-dimer cutoff result. RESULTS: Of the 3346 patients with suspected PE included, the prevalence of PE was 19%. Among the 2898 patients with a nonhigh or an unlikely clinical probability, 817 patients (28.2%) had a D-dimer level lower than 500 µg/L (95% CI, 26.6%-29.9%) and 337 patients (11.6%) had a D-dimer between 500 µg/L and their age-adjusted cutoff (95% CI, 10.5%-12.9%). The 3-month failure rate in patients with a D-dimer level higher than 500 µg/L but below the age-adjusted cutoff was 1 of 331 patients (0.3% [95% CI, 0.1%-1.7%]). Among the 766 patients 75 years or older, of whom 673 had a nonhigh clinical probability, using the age-adjusted cutoff instead of the 500 µg/L cutoff increased the proportion of patients in whom PE could be excluded on the basis of D-dimer from 43 of 673 patients (6.4% [95% CI, 4.8%-8.5%) to 200 of 673 patients (29.7% [95% CI, 26.4%-33.3%), without any additional false-negative findings. CONCLUSIONS AND RELEVANCE: Compared with a fixed D-dimer cutoff of 500 µg/L, the combination of pretest clinical probability assessment with age-adjusted D-dimer cutoff was associated with a larger number of patients in whom PE could be considered ruled out with a low likelihood of subsequent clinical venous thromboembolism. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01134068.

Dates et versions

hal-01027476 , version 1 (22-07-2014)

Identifiants

Citer

Marc Righini, Josien van Es, Paul L den Exter, Pierre-Marie Roy, Franck Verschuren, et al.. Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study.. Journal of the American Medical Association, 2014, 311 (11), pp.1117-24. ⟨10.1001/jama.2014.2135⟩. ⟨hal-01027476⟩
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