Bloodworth Phillip, Cail Kenneth, Morris Casey, Pando Brian, Helmly Brian
Memorial Health University Medical Center, Savannah, GA.
HCA Healthc J Med. 2021 Aug 29;2(4):297-301. doi: 10.36518/2689-0216.1219. eCollection 2021.
Acute pulmonary embolism (PE) is a common diagnosis that can lead to death if left untreated. Computerized tomography pulmonary angiogram scan (CTPA) is the gold standard for diagnosis of PE. Utilization of CTPA is increasing in the emergency setting even when suspicion for PE is very low. While CTPA is helpful, radiation exposure, contrast reactions, and cost must be considered. D-dimer is a well-established, high sensitivity and low specificity laboratory test that can effectively rule out PE in low-risk patients when negative. The ADJUST-PE trial showed that there is a natural rise of D-dimer levels with age. This age adjusted D-dimer level is meant to prevent unnecessary CTPA exams in low suspicion patients. We hypothesize that there are a significant amount of unwarranted CTPA exams ordered at our community hospital that would not have been performed if the age adjusted D-dimer level were implemented.
During a four-month period we collected a list of patients 18 years of age and older who received a CTPA exam for initial evaluation of possible acute PE at our institution. The primary outcome was to evaluate the percentage of patients who received an imaging study despite a negative D-dimer collected prior to the study, using the age adjusted upper limit of normal based on the ADJUST-PE study.
There were 734 CTPA exams that met our criteria in a four-month period. D-dimer levels were checked in 30.38% (223 of 734) of cases prior to imaging. Out of these 223 cases, 21.08% (47 of 223) were found to have negative age adjusted D-Dimer levels yet still received an imaging study. Out of these 47 cases, 44% (21 of 47) would have been positive using the traditional D-dimer threshold.
This study demonstrates that by adherence to the guideline-based pre-test algorithm and also utilizing the recommendations set forth by the ADJUST-PE study, approximately 21% of patients who undergo D-dimer testing would avoid unwarranted CT imaging. In addition to decreased radiation and contrast exposure, a significant amount of health care expense would be saved.
急性肺栓塞（PE）是一种常见的诊断疾病，如果不治疗可能导致死亡。计算机断层扫描肺动脉造影扫描（CTPA）是诊断PE的金标准。即使对PE的怀疑非常低，CTPA在急诊环境中的使用也在增加。虽然CTPA很有帮助，但必须考虑辐射暴露、造影剂反应和成本。D-二聚体是一种成熟的、高灵敏度和低特异性的实验室检查，当结果为阴性时可有效排除低风险患者的PE。ADJUST-PE试验表明，D-二聚体水平会随着年龄自然升高。这种年龄调整后的D-二聚体水平旨在防止对低怀疑度患者进行不必要的CTPA检查。我们假设，在我们的社区医院，有大量不必要的CTPA检查，如果实施年龄调整后的D-二聚体水平，这些检查就不会进行。
在四个月的时间里，我们收集了在我们机构接受CTPA检查以初步评估可能的急性PE的18岁及以上患者的名单。主要结果是评估在研究前D-二聚体阴性的情况下仍接受影像学检查的患者百分比，使用基于ADJUST-PE研究的年龄调整后的正常上限。
在四个月的时间里，有734次CTPA检查符合我们的标准。在30.38%（734例中的223例）的病例中，在成像前检查了D-二聚体水平。在这223例病例中，21.08%（223例中的47例）被发现年龄调整后的D-二聚体水平为阴性，但仍接受了影像学检查。在这47例病例中，44%（47例中的21例）使用传统的D-二聚体阈值会呈阳性。
本研究表明，通过遵循基于指南的检测前算法并采用ADJUST-PE研究提出的建议，约21%接受D-二聚体检测的患者可避免不必要的CT成像。除了减少辐射和造影剂暴露外，还可节省大量医疗费用。
