Correlation of Pulmonary Embolism with D-dimer Level and Determination of Cut-off Values According to Age

Yıl 2022, Cilt: 5 Sayı: 4, 153 - 159, 30.12.2022

Nafis Vural , Yıldıray Çete , Murat Duyan

https://doi.org/10.54996/anatolianjem.1063767

Öz

Aim: This study was conducted to determine the D-dimer threshold levels according to age in patients diagnosed with pulmonary embolism (PE) by pulmonary computed tomography (CT) angiography.

Material and Methods: Patients who had pulmonary CT angiography performed and whose D-dimer test was obtained with the suspicion of pulmonary embolism (PE) in the emergency department of a tertiary university hospital between January 01, 2015, and December 30, 2019, were included in the study. The demographic characteristics of the patients, imaging reports, and 1-month mortality were evaluated retrospectively by examining the hospital information management system and patient files. Patients with missing records and patients who had diagnostic examinations other than the preliminary diagnosis of PE were excluded from the study.

Results: Among the 6240 patients included in the study, 58.1% were female. The mean age of the patients was 43±17 years. Of the 1,507 patients who had a pulmonary CT angiogram, 9.8% were diagnosed with PE. When we looked at the 1-month mortality of 6240 patients, whose D-dimer assay was analyzed with the preliminary diagnosis of PE, we found that 0.3% of patients died. The monthly mortality rate was 0.7% in patients with high D-dimer levels while the mortality rate in patients with normal D-dimer levels was 0.1%. A positive and statistically significant correlation was found between the location of the pulmonary embolism in pulmonary CT angiography and the D-dimer level (spearman’s rho= 0.251, p<0.001). The cut-off D-dimer value in predicting the presence of PE in all age groups was calculated as 1.34 mg/L. The cut-off values of D-dimer to predict the presence of PE according to age ranges was calculated as 1.18 mg/L (<50 years), 1.19 mg/L (50-60 years), 1.58 mg/L (60-70 years) 1.79 mg/L (70-80 years), 2.83 mg/L (>80 years) respectively.

Conclusion: As age increases, the D-dimer cut-off value for the diagnosis of PE also increases. There is a positive and significant relationship between D-dimer level and pulmonary embolism severity.

Anahtar Kelimeler

Pulmonary embolism, D-dimer for age, pulmonary angiography CT

Destekleyen Kurum

The authors declare no any financial support.

Proje Numarası

The authors declare no any financial support.

Teşekkür

Thank you to all the physicians in Akdeniz University Emergency Department.

Pulmoner Emboli ile D-dimer Düzeyinin Korelasyonu ve Yaşa Göre Eşik Değerlerinin Belirlenmesi

Öz

Amaç: Bu çalışma pulmoner bilgisayarlı tomografi (BT) anjiyografi ile pulmoner emboli (PE) tanısı konan hastalarda yaşa göre D-dimer eşik düzeylerinin belirlenmesi amacıyla yapılmıştır.

Gereç ve Yöntemler: 01 Ocak 2015-30 Aralık 2019 tarihleri arasında üçüncü basamak bir üniversite hastanesinin acil servisinde pulmoner emboli (PE) şüphesi ile pulmoner BT anjiyografi yapılan ve D-dimer testi tetkik edilen hastalar çalışmaya dahil edildi. Retrospektif olarak hastane bilgi yönetim sistemi ve hasta dosyaları incelenerek, hastaların demografik özellikleri, görüntüleme raporları, hastaların 1 aylık mortalitesi değerlendirildi. Kayıtları eksik olan ve PE ön tanısı dışında tanısal tetkikleri olan hastalar çalışma dışı bırakıldı.

Bulgular: Çalışmaya alınan 6240 hastanın %58,1’i kadındı. Hastaların yaş ortalaması 43±17 olarak saptandı. Pulmoner BT anjiyografisi yapılan 1.507 hastanın %9,8’ine PE tanısı kondu. PE ön tanısı ile D-dimer testi çalışılan 6240 hastanın 1 aylık mortalitesi incelendiğinde %0,3 hastanın öldüğü saptandı. D-dimer testi yüksek olan hastalarda aylık mortalite oranı %0,7, D-dimer testi normal olan hastalardaki mortalite oranı ise %0,1’idi. Pulmoner BT anjiyografideki pulmoner embolinin lokalizasyonu ile D-dimer seviyesi arasında pozitif ve istatistiksel anlamlı bir korelasyon saptanmıştır (spearman’s rho= 0.251, p<0.001). D-dimer değerinin tüm yaş gruplarından PE varlığını öngörmedeki eşik değeri 1,34 mg/L olarak hesaplandı. D-dimer değerinin yaş aralıklarına göre PE varlığını öngörmedeki eşik değerleri sırasıyla 1.18 mg/L (<50 yaş), 1.19 mg/L (50-60 yaş), 1.58 mg/L (60-70 yaş), 1.79 mg/L (70-80 yaş), 2.83 mg/L (>80 yaş) olarak hesaplandı.

Sonuç: Yaş arttıkça PE tanısı için D-dimer eşik değeri de artmaktadır. D-dimer düzeyi ile pulmoner emboli şiddeti arasında pozitif ve anlamlı ilişki bulunmaktadır.

Anahtar Kelimeler

Pulmoner emboli, yaşa göre D-dimer, pulmoner BT anjiyografi

Proje Numarası

The authors declare no any financial support.

Kaynakça

• Fesmire FM, Brown MD, Espinosa JA, Shih RD, Silvers SM, Wolf SJ,et all; American College of Emergency Physicians. Critical issues in the evaluation and management of adult patients presenting to the emergency department with suspected pulmonary embolism. Ann Emerg Med. 2011 Jun;57(6):628-652.e75.
• Ryu JH, Olson EJ, Pellikka PA. Clinical recognition of pulmonary embolism: Problem of unrecognized and asymptomatic cases. Mayo Clin Proc 1998; 73(9): 873–9. DOI: 10.44065/73.9.873
• Gibson NS, Sohne M, Kruip MJHA, Tick LW, Gerdes VE, Bossuyt PM, et al. Further validation and simplification of the Wells clinical decision rule in pulmonary embolism. Thromb Haemost 2008; 99(1): 229–34. DOI: 10.1160/TH07-05-0321
• Penaloza A, Soulie C, Moumneh T, Delmez Q, Ghuysen A, Kouri DE, et al. Pulmonary embolism rule-out criteria (PERC) rule in European patients with low implicit clinical probability (PERCEPIC): a multicentre, prospective, observational study. Lancet Haematol 2017; 4(12): 615–21. DOI: 10.1016/S2352-3026(17)30210-7
• Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, et al. 2019 ESC Guidelines for diagnosing and managing acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 2020; 41(4): 543-603. DOI: 10.1093/eurheartj/ehz405
• Barth BE, Waligora G, Gaddis GM. Rapid Systematic Review: Age-Adjusted D-Dimer for Ruling Out Pulmonary Embolism. J Emerg Med 2018; 55(4): 586–92. DOI: 10.1016/j.jemermed.2018.07.003
• Righini M, van Es J, Exter PLD, Roy PM, Verschuren F, Ghuysen A, et al. Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: The ADJUST-PE study. JAMA 2014; 311(11): 1117–24. DOI: 10.1001/jama.2014.2135
• Keller K, Beule J, Balzer JO, Dippold W. Typical symptoms for prediction of outcome and risk stratification in acute pulmonary embolism. Int Angiol 2016; 35(2): 184–91. PMID: 25743032
• Dogan C, Comert SS, Caglayan B, Mutlu S, Fidan A, Kıral N. Pulmoner Trombo-Emboli Olgularımızın Retrospektif Değerlendirilmesi. İzmir Göğüs Hastalıkları Derg 2016; XXX(1): 15-21.
• Hakemi EU, Alyousef T, Dang G, Hakmei J, Doukky R. The prognostic value of undetectable highly sensitive cardiac troponin I patients with acute pulmonary embolism. Chest 2015; 147(3): 685–94. DOI: 10.1378/chest.14-0700
• Huynh N, Fares WH, Brownson K, Brahmandam A, Lee AI, Dardik A, et al. Risk factors for presence and severity of pulmonary embolism in patients with deep venous thrombosis. J Vasc Surg Venous Lymphat Disord 2018; 6(1): 7–12. DOI: 10.1016/j.jvsv.2017.08.015
• Le Gal G, Bounameaux H. Diagnosing pulmonary embolism: running after the decreasing prevalence of cases among suspected patients. J Thromb Haemost 2004; 2(8): 1244–6. DOI: 10.1111/j.1538-7836.2004.00795.x
• Hacievliyagil SS, Mutlu LC, Kızkın O, Gunen H. Altmışüç Pulmoner Emboli Olgusunun Retrospektif Değerlendirilmesi / A retrospective analysis of 63 cases of pulmonary embolism. Solunum Hastalıkları 2004; 15: 15-21.
• Kadıoğlu E. Atatürk Üniversitesi Tıp Fakültesi acil tıp kliniğinde pulmoner emboli tanısı konan hastaların geriye dönük 5 yıllık incelenmesi. (2017)[Online]. Available: https://acikbilim.yok.gov.tr/handle/20.500.12812/42548 [Accessed: 28-Dec-2020].
• Tanabe Y, Obayashi T, Yamamoto T, Takayama M, Nagao K. Predictive value of biomarkers for the prognosis of acute pulmonary embolism in Japanese patients: Results of the Tokyo CCU Network registry. J Cardiol 2015; 66(6): 460-5. https://doi.org/10.1016/j.jjcc.2015.03.002
• Pruszczyk P, Bochowicz A, Torbicki A, Szulc M, Kurzyna M, Fijalkowska A, et al. Cardiac troponin T monitoring identifies high-risk group of normotensive patients with acute pulmonary embolism. Chest 2003; 123(6): 1947–52. doi: 10.1378/chest.123.6.1947
• Becattini C, Vedovati MC, Agnelli G. Prognostic value of troponins in acute pulmonary embolism: A meta-analysis. Circulation 2007; 116(4): 427–33. DOI: 10.1161/CIRCULATIONAHA.106.680421
• Liu M, Miao R, Guo X, Zhu L, Zhang H, Hou Q, et al. Saddle Pulmonary Embolism: Laboratory and Computed Tomographic Pulmonary Angiographic Findings to Predict Short-term Mortality. Heart Lung Circ 2017; 26(2): 134–42. DOI: 10.1016/j.hlc.2016.02.019
• Grau E, Tenias JM, Soto MJ, Gutierrez MR, Lecumberri R, Perez JL, et al. D-dimer levels correlate with mortality in patients with acute pulmonary embolism: Findings from the RIETE registry. Crit Care Med 2007; 35(8): 1937–41. DOI: 10.1097/01.CCM.0000277044.25556.93
• Klok FA, Djurabi RK, Nijkeuter M, Eikenboom HCJ, Leebeek FWG, Kramer MHH, et al. High D-dimer level is associated with increased 15-d and three months mortality through a more central localization of pulmonary emboli and serious comorbidity. Br J Haematol 2008; 140(2): 218-22.
• Coşkun FF. D-Dimer değeri yüksek olup pulmoner bilgisayarlı tomografi anjiografisinde pulmoner emboli saptanmayarak taburcu edilen hastaların 28 günlük mortalitelerinin araştırılması. Dokuz Eylül Ü Tıp F Acil Tıp AD Uzmanlık Tezi, Tez Danışmanı: Prof. Dr Ercan Aksay, İzmir 2018.
• Cini M, Legnani C, Frascaro M, Sartori M, Cosmi B, Palareti G. D-dimer use for deep venous thrombosis exclusion in elderly patients: a comparative analysis of three different approachesestablishinglish cut-off values for an assay with results expressed in D-dimer units. Int J.Lab Hematol 2014; 36(5): 541–7.
• Nagel SN, Steffen IG, Schwartz S, Hamm B, Elgeti T. Age-dependent diagnostic accuracy of clinical scoring systems and D-dimer levels in the diagnosis of pulmonary embolism with computed tomography pulmonary angiography (CTPA). Eur Radiol 2019; 29(9): 4563–71.
• Rawat N, Mathur N, Rawat K, Mathur M, Tinna R, Kakkar R, et al. Correlation of D-Dimer level with the presence and severity of pulmonary embolism on computed tomography pulmonary angiography. J Assoc Physicians India 2018; 66(10): 40–1. PMID: 31317707
• Kubak MP, Lauritzen PM, Borthne A, Ruud EA, Ashraf H. Elevated d-dimer cut-off values for computed tomography pulmonary angiography-d-dimer correlates with the location of embolism. Ann Transl Med 2016; 4(11): 212. DOI: 10.21037/atm.2016.05.55