Clinical decision rule and D-dimer have lower clinical utility to exclude pulmonary embolism in cancer patients

Renée A. Douma; Geerte L. van Sluis; Pieter W. Kamphuisen; Maaike Söhne; Frank W. G. Leebeek; Patrick M. M. Bossuyt; Harry R. Büller

doi:10.1160/TH10-02-0093

Thrombosis and Haemostasis, Table of Contents

Thromb Haemost 2010; 104(04): 831-836
DOI: 10.1160/TH10-02-0093

New Technologies, Diagnostic Tools and Drugs

Schattauer GmbH

Clinical decision rule and D-dimer have lower clinical utility to exclude pulmonary embolism in cancer patients

Explanations and potential ameliorations

Renée A. Douma

¹Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands

,

Geerte L. van Sluis

¹Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands

,

Pieter W. Kamphuisen

¹Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands

,

Maaike Söhne

¹Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands

,

Frank W. G. Leebeek

²Department of Hematology, Erasmus Medical Center, Rotterdam, the Netherlands

,

Patrick M. M. Bossuyt

³Department of Clinical Epidemiology and Biostatistics, Academic Medical Center, Amsterdam, the Netherlands

,

Harry R. Büller

¹Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands

› Author Affiliations

Abstract

Summary

Patients with malignancy frequently present with clinically suspected pulmonary embolism (PE). However, the safe and efficient combination of a clinical decision rule (CDR) and D-dimer test to rule out PE performs less well in patients with malignancy. We examined potential explanations and analysed whether elevating the D-dimer cut-off could improve the clinical utility. We used data on consecutive patients with suspected PE included in a multicenter management study. The performance of the Wells CDR and the D-dimer test was compared between patients with and without malignancy and multivariable analysis was used to compare the weights of the CDR variables. Furthermore, we combined the CDR (cut-off ≤4) with different D-dimer cut-off levels for the exclusion of PE. Of 3,306 patients with suspected PE, 475 (14%) had cancer. The Wells rule variables were less diagnostic in cancer patients. Increasing the D-dimer cut-off level to 700 μg/l for all ages or using an age-dependent cut-off resulted in an increase in the proportion of patients in whom PE could be excluded from 8.4% to 13% and 12%, respectively. The corresponding false-negative rates were 1.6% (95% confidence interval 0.3–8.7%) and 0.0% (0.0–6.3%). The Wells CDR and D-dimer perform less well in patients with suspected PE if they have cancer. Individual variables in the Wells rule are less diagnostic in cancer patients than in non-cancer patients with suspected PE. A CDR combined with an age-dependent D-dimer cut-off shows a modest improvement of the strategy in cancer patients.

Keywords

Pulmonary embolism - venous thromboembolism - D-dimer - clinical decision rule - malignancy

Full Text

References

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