Episode 11 - Pulmonary Embolism: Part 1 - The Age-Adjusted D Dimer

This episode is all about pulmonary embolism (PE)! In this first segment, we explore the potential use of the age-adjusted d-dimer in the risk stratification of patients presenting with a possible PE; we will be joined by emergency physicians Dr Kevin Lai and Dr Arwen Morath.
Theme
Pulmonary Embolism.

Participants
Dr Kevin Lai (senior emergency physician), Dr Arwen Morath (emergency physician), Dr Pramod Chandru, Naveendran Rajendran, Harry Hong, Samoda Wilegoda Mudalige, Kit Rowe and Caroline Tyers.  
 
Discussion:
Robert-Ebadi, H., Robin, P., Hugli, O., Verschuren, F., Trinh-Duc, A., & Roy, P. et al. (2021). Impact of the Age-Adjusted D-Dimer Cutoff to Exclude Pulmonary Embolism. Circulation, 143(18), 1828-1830. https://doi.org/10.1161/circulationaha.120.052780.

Presenter:
Naveendran Rajendran - ED Resident at Westmead Hospital. 

Summary:
  • This was a multinational, prospective, diagnostic outcome study designed to determine the impact of the use of age-adjusted D-dimer on clinical practice in the outpatient setting.  
  • This study follows on from the ADJUST-PE study released in 2014, which established the safety of using an age-adjusted D-dimer cut-off retrospectively.  
  • The primary outcome was the incidence of symptomatic thromboembolic events in the period following which a PE had been excluded in a patient based on a negative D-dimer (with the age-adjusted cut-off), and a low pre-test probability. 
  • The secondary outcome looked at the number of D-dimer results which sat between the conventional cut-off of 0.5 and the age-adjusted value in the whole cohort, as well as more specifically in those aged over 75 years (to determine the diagnostic yield of the age-adjusted cut-off).  
  • Of the 1421 patients with a low pre-test probability for PE and a D-dimer below 0.5, only 1 was found to have a non-fatal PE. 
  • The proportion of patients with D-dimers that fell between the conventional cut-off of 0.5 and the age-adjusted cut-off was 301 of 1507 patients, with 0 identified thromboembolic events noted during follow-up.  
  • This translates to a 20% increase in the number of negative D-dimer tests using the age-adjusted cut-off, with an even more pronounced increase of 67% in the group of patients over the age of 75. 
 Take-Home Points:
  • The age-adjusted D-dimer is a potential tool to assist with risk-stratifying patients presenting with possible PE. 
  • Previous concerns regarding various assays may have limited the implementation of an age-adjusted D-dimer in prior years. 
  • Further audits to quantify the impact of utilizing the age-adjusted D-dimer (with regards to imaging, treatment, costs, etc.) are required.  

References: 
  • Righini M, Van Es J, Den Exter P. Age-Adjusted D-Dimer Cutoff Levels to Rule Out Pulmonary Embolism: The ADJUST-PE Study. Journal of Vascular Surgery. 2014;59(5):1469.

Credits:
This episode was produced by the ­­­­Emergency Medicine Training Network 5 with the assistance of Dr Kavita Varshney and, Deepa Dasgupta. 


Music/
Sound Effects
  • Got My Love by LiQWYD & Markvard | https://www.liqwydmusic.com, https://soundcloud.com/markvard, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.
  • Medical Examination by MaxKoMusic | https://maxkomusic.com/, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution-ShareAlike 3.0 Unported, https://creativecommons.org/licenses/by-sa/3.0/deed.en_US
  • Shine by LiQWYD | https://www.liqwydmusic.com, Music promoted by https://www.free-stock-music.com
    Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US. 
  • Sound effects from https://www.free-stock-music.com.

Thank you for listening!


Please send us an email to let us know what you thought.
You can contact us at westmeadedjournalclub@gmail.com.


You can also follow us on Facebook, Instagram, and Twitter!


See you next time,
Caroline, Kit, Pramod, Samoda, and Shreyas.

~
Subscribe & Follow Us! - Network Five Emergency Medicine Group