The proposed serum D-dimer level for selecting patients for pulmonary thromboembolism diagnosis using Computed Tomography Pulmonary Angiography in patients with acute dyspnea at Chaiyaphum Hospital
Keywords:
Pulmonary thromboembolism, Computed Tomography Pulmonary Angiography, D-dimer, acute dyspnea, Chaiyaphum HospitalAbstract
Pulmonary embolism (PE) is an emergency condition associated with high mortality rates. D-dimer testing is a primary screening tool, but the standard cut-off value of 500 ng/mL has low specificity, leading to an excessive number of unnecessary CT Pulmonary Angiography (CTPA) scans. This study aimed to determine the optimal cut-off value for D-dimer and analyze the clinical risk factors associated with the occurrence of PE in patients presenting with acute dysnea at Chaiyaphum Hospital. This was a retrospective diagnostic study of 96 patients (22 with PE, 74 non-PE) who underwent D-dimer and CTPA testing between December 2023 and August 2024. Data were analyzed using ROC Curve Analysis combined with the Youden Index and Univariable logistic regression.
The results showed that D-dimer had an Area Under the Curve (AUC) of 0.603 (95% CI: 0.454, 0.751). The optimal cut-off value of 4,233 ng/mL yielded a sensitivity of 68.2%, specificity of 59.5%, PPV of 33.3%, and NPV of 86.3%. Compared to the standard value of 500 ng/mL (sensitivity 100%, specificity 2.7%) and the minimum value in the PE group of 1,140 ng/mL (sensitivity 100%, specificity 16.2%), the optimal cut-off value was able to reduce unnecessary CTPA referrals by more than half (false positives decreased from 62 to 30 cases). Regarding clinical risk factors, Tachycardia (Heart rate > 100 bpm) was the only factor significantly associated with the occurrence of PE (OR = 3.47; 95% CI: 1.26, 9.52).
In conclusion, a D-dimer cut-off value of 4,233 ng/mL provides a high NPV, making it suitable for ruling out PE, and can effectively reduce unnecessary CTPA scans. It is recommended to use D-dimer in conjunction with a clinical probability score and to consider Tachycardia in patient assessment. The cut-off value can be adjusted according to the context of care. This approach is practically applicable in provincial-level hospitals to improve the efficiency and safety in diagnosing pulmonary embolism.
References
Bělohlávek J, Dytrych V, Linhart A. Pulmonary embolism, part I: epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis and nonthrombotic pulmonary embolism. Exp Clin Cardiol 2013;18(2): 129-38. PMID:23940438
Killeen RB, Kok SJ. D-Dimer Test. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/ books/NBK431064/
Arnautovic-Torlak V, Pojskic B, Zutic H, Rama A. Values of D-dimer test in the diagnostics of pulmonary embolism. Med Glas (Zenica) 2014;11(2):258-63. PMID: 25082237
Shah K, Quaas J, Rolston D, Bansal S, Bania T, Newman D, et al. Magnitude of D-dimer matters for diagnosing pulmonary embolus. Am J Emerg Med 2013;31(6):942-5. DOI:10.1016/j.ajem.2013.03.009
Sikora-Skrabaka M, Skrabaka D, Ruggeri P, Caramori G, Skoczynski S, Barczyk A. D-dimer value in the diagnosis of pulmonary embolism-may it exclude only?. J Thorac Dis 2019;11(3):664-72. DOI:10.21037/jtd.2019.02.88
Righini M, Van Es J, Den Exter PL, 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
Kearon C, de Wit K, Parpia S, et al. Diagnosis of pulmonary embolism with d-dimer adjusted to clinical probability. N Engl J Med 2019;381(22):2125-34. DOI:10.1056/NEJMoa1909159
Van der Hulle T, Cheung WY, Kooij S, et al. Simplified diagnostic management of suspected pulmonary embolism (the YEARS study): a prospective, multicentre, cohort study. Lancet 2017;390(10091):289-97. DOI:10.1016/S0140-6736(17)30885-1
Van der Pol LM, Tromeur C, Bistervels IM, et al. Pregnancy-adapted YEARS algorithm for diagnosis of suspected pulmonary embolism. N Engl J Med 2019;380(12):1139-49. DOI:10.1056/NEJMoa1813865
Gao H, Liu H, Li Y. Value of D-dimer levels for the diagnosis of pulmonary embolism: An analysis of 32 cases with computed tomography pulmonary angiography. Exp Ther Med 2018;16(2):1554-60. DOI:10.3892/etm.2018.6314
Fu, Z., Zhuang, X., He, Y. et al. The diagnostic value of D-dimer with simplified Geneva score (SGS) pre-test in the diagnosis of pulmonary embolism (PE). J Cardiothorac Surg 15, 176 (2020). DOI:10.1186/s13019-020-01222-y
Koch V, Biener M, Müller-Hennessen M, Vafaie M, Staudacher I, Katus HA, Giannitsis E. Diagnostic performance of D-dimer in predicting venous thromboembolism and acute aortic dissection. Eur Heart J Acute Cardiovasc Care 2021;10(5):559–66. DOI:10.1177/2048872620907322
Konstantinides SV, Meyer G, Becattini C, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism. Eur Heart J 2020;41(4):543-603. DOI: 10.1093/eurheartj/ehz405
Righini M, Robert-Ebadi H, Le Gal G. Age-Adjusted and Clinical Probability Adapted D-Dimer Cutoffs to Rule Out Pulmonary Embolism: A Narrative Review of Clinical Trials. J Clin Med 2024;13(12):3441. DOI:10.3390/jcm13123441
Hesselvik JF, Blombäck M, Brodin B, Maller R. Coagulation, fibrinolysis, and kallikrein systems in sepsis: relation to outcome. Crit Care Med 1989;17(8):724–33. DOI:10.1097/00003246-198908000-00002
Schouten HJ, Geersing GJ, Koek HL, et al. Diagnostic accuracy of conventional or age adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism: systematic review. BMJ 2013;346:f2492. DOI:10.1136/bmj.f2492
Iwuji K, Almekdash H, Nugent KM, Islam E, Hyde B, Kopel J, Opiegbe A, Appiah D. Age-Adjusted D-Dimer in the Prediction of Pulmonary Embolism: Systematic Review and Meta-analysis. J Prim Care Community Health 2021;12:21501327211054996. DOI:10.1177/21501327211054996.
Roy PM, Friou E, Germeau B, Douillet D, Kline JA, Righini M, Le Gal G, Moumneh T, Penaloza A. Derivation and Validation of a 4-Level Clinical Pretest Probability Score for Suspected Pulmonary Embolism to Safely Decrease Imaging Testing. JAMA Cardiol 2021;6(6):669-77. DOI:10.1001/jamacardio.2021.0064
Kruip MJHA, Söhne M, Nijkeuter M, et al. A simple diagnostic strategy in hospitalized patients with clinically suspected pulmonary embolism. J Intern Med 2006;260(5):459–66. DOI:10.1111/j.1365-2796.2006.01709.x
Le Gal G, Righini M, Roy PM, et al. Prediction of pulmonary embolism in the emergency department: the revised Geneva score. Ann Intern Med 2006;144(3):165-71. DOI:10.7326/0003-4819-144-3-200602070-00004
Chiang P, Robert-Ebadi H, Perrier A, Roy PM, Sanchez O, Righini M, Le Gal G. Pulmonary embolism risk stratification: external validation of the 4-level Clinical Pretest Probability Score (4PEPS). Res Pract Thromb Haemost.2024;8(1):102348. DOI:10.1016/j.rpth.2024.102348.
Downloads
Published
Issue
Section
License
Copyright (c) 2025 Chaiyaphum Medical Journal
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
