D-dimer can help differentiate suspected pulmonary embolism patients that require anti-coagulation

• Published in: The American journal of emergency medicine 2021-07, Vol.45, p.361-367
• Main Authors: Narang, Jatin, Nowacki, Amy S., Seballos, Spencer S., Wang, Philip R., Mace, Sharon E.
• Format: Article
• Language: English
• Subjects: Age; Age Factors; Anti-coagulation; Anticoagulants; Anticoagulants - therapeutic use; Biomarkers - analysis; Clinical deterioration; Coagulation; D-dimer; Decision Making; Embolism; Emergency medical care; Emergency Service, Hospital; Estrogens; Female; Fibrin Fibrinogen Degradation Products - analysis; Hospital systems; Humans; Male; Middle Aged; Mortality; Patients; Pulmonary arteries; Pulmonary embolism; Pulmonary Embolism - blood; Pulmonary Embolism - drug therapy; Pulmonary embolisms; Retrospective Studies; Statistical analysis; Thromboembolism; Venous thromboembolism
• ISSN: 0735-6757; 1532-8171
• DOI: 10.1016/j.ajem.2020.08.086

Determine whether D-dimer concentration in the absence of imaging can differentiate patients that require anti-coagulation from patients who do not require anti-coagulation. Data was obtained retrospectively from 366 hemodynamically stable adult ED patients with suspected pulmonary embolism (PE). Patients were categorized by largest occluded artery and aggregated into: ‘Require anti-coagulation’ (main, lobar, and segmental PE), ‘Does not require anti-coagulation’ (sub-segmental and No PE), ‘High risk of deterioration’ (main and lobar PE), and ‘Not high risk of deterioration’ (segmental, sub-segmental, and No PE) groups. Wilcoxon rank-sum test was used for 2 sample comparisons of median D-dimer concentrations. Receiver operating characteristic (ROC) curve analysis was utilized to determine a D-dimer cut-off that could differentiate ‘Require anti-coagulation’ from ‘Does not require anti-coagulation’ and ‘High risk of deterioration’ from ‘Low risk of deterioration’ groups. The ‘Require anti-coagulation’ group had a maximum area under the curve (AUC) of 0.92 at an age-adjusted D-dimer cut-off of 1540 with a specificity of 86% (95% CI, 81–91%), and sensitivity of 84% (79–90%). The ‘High risk of deterioration’ group had a maximum AUC of 0.93 at an age-adjusted D-dimer cut-off of 2500 with a specificity of 90% (85–93%) and sensitivity of 83% (77–90%). An age-adjusted D-dimer cut-off of 1540 ng/mL differentiates suspected PE patients requiring anti-coagulation from those not requiring anti-coagulation. A cut-off of 2500 differentiates those with high risk of clinical deterioration from those not at high risk of deterioration. When correlated with clinical outcomes, these cut-offs can provide an objective method for clinical decision making when imaging is unavailable. •ED providers are faced with risks and benefits when empirically administering anti-coagulation for suspected PE patients.•We show that D-dimer concentration can be used as a clinical decision making tool to minimize these risks.•A D-dimer cut-off of 1540 ng/mL can be used to minimize unnecessary anti-coagulation exposure in patients who do not need it.•Using a 2500 ng/mL D-dimer cut-off minimizes the risk of withholding treatment for those at risk of clinical deterioration.•Both cut-offs along with clinical gestalt are an objective measure weighing the risks & benefits of empiric anti-coagulation.