Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, OH.
Case Western Reserve University School of Medicine, Cleveland Clinic, Cleveland, OH.
Acad Emerg Med. 2018 Nov;25(11):1235-1241. doi: 10.1111/acem.13517. Epub 2018 Aug 10.
D-dimer is used to aid in diagnosing adult pulmonary embolism (PE). D-dimer has not been validated in adolescents. Clinicians must balance the risk of overtesting with that of a missed PE. D-dimer may be useful in this context. This study evaluates D-dimer in PE-positive and PE-negative adolescents.
PE-positive patients < 22 years were diagnosed with PE by computed tomography (CT) or high-probability ventilation/perfusion, seen at emergency departments (EDs)/hospitals within a 16-hospital system across two states, January 1998 through December 2016. Of the 189 PE-positive patients, 88 (46.5%) had a D-dimer and were matched 1:1 by age, sex, and race to patients suspected of PE but confirmed negative by CT angiogram.
Ages of PE-positive patients ranged from 13 to 21 years, 64 (73%) were female, and 52 (60%) were Caucasian. Mean D-dimer was significantly higher (3,256 ng/mL, 95% confidence interval [CI] = 2,505-4,006 ng/mL) in PE-positive versus PE-negative patients (1,244 ng/mL, 95% CI = 493-1,995 ng/mL; p < 0.001). Mean D-dimer was higher in patients with massive or submassive PE (8,742 ng/mL, 95% CI = 5,994-11,491 ng/mL), followed by PE in central (4,795 ng/mL [95% CI = 3,465-6,125 ng/mL), lobar (3,758 ng/mL [95% CI = 1,841-5,676), and distal (2,327 ng/mL [95% CI = 1,273-3,381 ng/mL]) arteries. When comparing thresholds of positive D-dimer (≥500, ≥750, and ≥1,000 ng/mL), D-dimer had sensitivities of 90, 82, and 67% and specificities of 16, 53, and 67%, respectively. Negative predictive values were 61, 75, and 71% while positive likelihood ratios were 1.1, 1.8, and 2.2, respectively.
This study represents the largest available cohort of adolescent patients examining the diagnostic value of D-dimer for PE. Our results indicate that depending on the threshold selected, D-dimer can be a sensitive test for PE in adolescents and that discriminative value is higher for a cutoff of 750 ng/mL than that for 500 ng/mL. Prospective studies investigating the diagnostic value of D-dimer and a clinical decision rule for PE in pediatrics are needed.
D-二聚体用于辅助诊断成人肺栓塞（PE）。尚未在青少年中验证 D-二聚体。临床医生必须平衡过度检测的风险和漏诊 PE 的风险。D-二聚体在这种情况下可能有用。本研究评估了 PE 阳性和 PE 阴性青少年中的 D-二聚体。
1998 年 1 月至 2016 年 12 月期间，在两个州的 16 家医院系统内的急诊室（ED）/医院通过计算机断层扫描（CT）或高概率通气/灌注诊断年龄<22 岁的 PE 阳性患者。在 189 名 PE 阳性患者中，88 名（46.5%）进行了 D-二聚体检测，并通过年龄、性别和种族与疑似但通过 CT 血管造影证实为阴性的 PE 患者进行 1:1 匹配。
PE 阳性患者的年龄为 13 至 21 岁，64 名（73%）为女性，52 名（60%）为白种人。PE 阳性患者的 D-二聚体明显高于 PE 阴性患者（3256ng/mL，95%置信区间 [CI] = 2505-4006ng/mL）（1244ng/mL，95%CI = 493-1995ng/mL；p<0.001）。大量或亚大量 PE（8742ng/mL，95%CI = 5994-11491ng/mL）和中央（4795ng/mL [95%CI = 3465-6125ng/mL]）、叶（3758ng/mL [95%CI = 1841-5676ng/mL]）和远端（2327ng/mL [95%CI = 1273-3381ng/mL]）动脉的 D-二聚体更高。当比较阳性 D-二聚体（≥500ng/mL、≥750ng/mL 和≥1000ng/mL）的阈值时，D-二聚体的敏感性分别为 90%、82%和 67%，特异性分别为 16%、53%和 67%。阴性预测值分别为 61%、75%和 71%，阳性似然比分别为 1.1、1.8 和 2.2。
本研究代表了目前可获得的最大的青少年患者队列，用于检查 D-二聚体对 PE 的诊断价值。我们的结果表明，根据所选的阈值，D-二聚体可以作为青少年 PE 的敏感检测方法，并且 750ng/mL 比 500ng/mL 的截断值具有更高的判别值。需要前瞻性研究来研究 D-二聚体的诊断价值和儿科 PE 的临床决策规则。
