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
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Thank you for listening!


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

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