Kwon Hyojeong, Kim Youn-Jung, Her Eun-Ju, Chae Bora, Lee Yoon-Seon
Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
Intern Emerg Med. 2022 Mar;17(2):495-502. doi: 10.1007/s11739-021-02730-y. Epub 2021 Apr 10.
Recent guidelines for diagnosing acute pulmonary embolism (PE) are based on clinical decision rules and D-dimer. D-dimer measurement is recommended only for patients who are 'PE-unlikely'. We aimed to assess the current guidelines for cancer patients and to determine an optimal D-dimer cut-off level. This retrospective observational study was conducted in the emergency department of Asan Medical Center (Seoul, Korea) between 02/2017 and 09/2017 for the development cohort and between 06/2018 and 02/2019 for the validation cohort. Among adult active cancer patients with suspected PE, we included those who were 'PE-unlikely' according to Wells' criteria and who underwent D-dimer testing and computed tomographic pulmonary angiography (CTPA). A total of 498 patients (227 in the development cohort and 271 in the validation cohort) were included, and PE was diagnosed in 8.8% and 18.5% of patients, respectively. The optimal D-dimer cut-off level was 2.0 μg/mL. This elevated cut-off level showed a much higher specificity of 21.3% (95% confidence interval [CI] 16.2-27.3%) and 21.7% (95% CI 16.8-7.6%) in the development and validation sets, respectively, compared with the specificity of 4.4% (95% CI 2.3-8.1%) and 4.1% (95% CI 2.2-7.6%) using the age-adjusted cut-off. The new D-dimer cut-off value identified unnecessary CTPA for 21.3% of patients (absolute difference, 16.9%, 35 of 207) in the development cohort and 21.7% (absolute difference, 17.6%, 39 of 221) of patients in the validation cohort compared to using the standard age-adjusted cut-off. The elevated D-dimer cut-off value combined with Wells' criteria might reduce unnecessary CTPA in active cancer patients with a 'PE-unlikely' classification. Further clinical trials are warranted to improve the PE diagnostic strategy in cancer patients.
近期急性肺栓塞（PE）的诊断指南基于临床决策规则和D-二聚体。仅建议对“PE可能性低”的患者进行D-二聚体检测。我们旨在评估针对癌症患者的现行指南，并确定最佳的D-二聚体临界值。这项回顾性观察研究于2017年2月至2017年9月在峨山医学中心（韩国首尔）急诊科进行了开发队列研究，于2018年6月至2019年2月进行了验证队列研究。在疑似PE的成年活动性癌症患者中，我们纳入了那些根据Wells标准“PE可能性低”且接受了D-二聚体检测和计算机断层扫描肺动脉造影（CTPA）的患者。共纳入498例患者（开发队列227例，验证队列271例），分别有8.8%和18.5%的患者被诊断为PE。最佳D-二聚体临界值为2.0μg/mL。与使用年龄调整临界值时4.4%（95%置信区间[CI]2.3-8.1%）和4.1%（95%CI 2.2-7.6%）的特异性相比，这个升高的临界值在开发集和验证集中分别显示出更高的特异性，为21.3%（95%CI 16.2-27.3%）和21.7%（95%CI 16.8-27.6%）。与使用标准年龄调整临界值相比，新的D-二聚体临界值在开发队列中确定21.3%的患者（绝对差异16.9%，207例中的35例）和验证队列中21.7%（绝对差异17.6%，221例中的39例）的患者无需进行CTPA。升高的D-二聚体临界值与Wells标准相结合，可能会减少“PE可能性低”分类的活动性癌症患者不必要的CTPA检查。有必要进行进一步的临床试验以改进癌症患者的PE诊断策略。
