Ostermayer at 15:39, 17 April 2015

2015-04-17T15:39:50Z

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	==Clinical Question==		==Clinical Question==

Neil.m.young: Created page with "{{JC info | title= Age-Adjusted D-Dimer Cutoff Levels to Rule Out Pulmonary Embolism | abbreviation= The ADJUST-PE Study | expansion= | published= | author= Righini M, Van Es..."

2015-04-17T15:16:46Z

Created page with "{{JC info | title= Age-Adjusted D-Dimer Cutoff Levels to Rule Out Pulmonary Embolism | abbreviation= The ADJUST-PE Study | expansion= | published= | author= Righini M, Van Es..."

New page

{{JC info
| title= Age-Adjusted D-Dimer Cutoff Levels to Rule Out Pulmonary Embolism
| abbreviation= The ADJUST-PE Study
| expansion=
| published=
| author= Righini M, Van Es J,Den Exter PL, et al.
| journal= JAMA
| year= 2014
| volume= 311
| issue= 11
| pages= 1117-1124
| pmid= 24643601
| fulltexturl= http://jama.jamanetwork.com/article.aspx?articleid=1841967
| pdfurl=
}}
==Clinical Question==
Is an age-adjusted D-dimer cutoff (age × 10 in patients >50 yrs) associated with an increased diagnostic yield of
D-dimer in elderly patients with suspected PE?

==Conclusion==
An age-adjusted D-dimer in combination with pretest probability was associated with a larger number of patients in whom PE could be considered ruled out with a low likelihood of subsequent clinical venous thromboembolism.

==Major Points==
*An age-adjusted D-dimer is associated with a greater number of patients in whom PE can be safely ruled out

==Study Design==
A multicenter, multinational, prospective management outcome study in 19 centers in Belgium, France, the Netherlands, and Switzerland between January 1, 2010, and February 28, 2013.

==Population==
===Patient Demographics===
*Women: 56.8%
*Age: median 63 yrs (53-74 1st/3rd quartile)
*H/O VTE: 14.0%
*Active malignancy: 12.9%
*Surgery within 1 month: 11.8%
*Estrogen use: 5.5%
*Chest pain: 48.3%
*Dyspnea: 62.9%
*Syncope: 7.9%
*Hemoptysis: 4.1%
*Heart rate: mean 87.1 beats/min
*Respiratory rate: mean 19.2 breaths/min

===Inclusion Criteria===
*Clinical suspicion of PE
**Acute onset SOB
**Worsening SOB
**Chest pain without obvious etiology

===Exclusion Criteria===
*PE suspicion raised more than 24 hrs after admission
*Taking anticoagulant therapy
*Inability to receive a CTPA study
*Life expectancy <3 mos
*Ongoing pregnancy
*Unable to follow up

==Interventions==
*Risk assessed with revised Geneva score or Wells
*Highly sensitive D-dimer measurement
*CTPA
*Participants with a D-dimer value between the conventional cutoff of 500 μg/L and their age-adjusted cutoff did not undergo CTPA and were left untreated and formally followed-up for a 3-month period

==Outcomes==

===Primary Outcome===
*Failure rate of the diagnostic strategy
*Conventional 500 μg/L cut off lead to 1 nonfatal PE in 810 patients (0.1% [0.0%-0.7%])
*Age-adjusted cut off lead to 1 nonfatal PE in 331 patients (0.3% [0.1%-1.7%])

===Secondary Outcomes===
*Proportion of patients with a low-intermediate probability and a D-dimer between 500 μg/L and their age-adjusted cutoff
value
*Age-adjusted cutoff resulted in an 11.6% absolute increase [10.5%-12.9%] or a 41.2% relative increase [31.3%-52.0%] in the proportion of negative D-dimer results

===Subgroup analysis===
*Elderly patients, defined as patients 75 years or older
*None of the 195 patients had a confirmed VTE during follow-up (0.0% [95% CI, 0.0%-1.9%])

Discussion
==Criticisms & Further Discussion==
*The assays used had a cutoff of 500 ug/L; take caution in applying age x 10 until you know your hospitals assay
*R.E.B.E.L EM
**2 different pretest probability scores and 6 different d-dimer assays were used
**Not a randomized clinical control study, so there was no control group
**7 patients were deceased in the > 500 ug/L and < age adjusted cutoff d-dimer, but only one had an autopsy to confirm diagnosis, therefore hard to exclude PE as the cause of death
**Prevalence of PE was higher than what is cited in most North American studies, but the same rate as European studies
**Patient follow up was not with the gold standard CTPA

==External Links==
[http://rebelem.com/age-adjusted-d-dimer-testing/ R.E.B.E.L EM: Age-Adjusted D-dimer]

==Funding==
*Swiss National Research Foundation grant 32003B-130863
*International Society on Thrombosis and Haemostasis 2007 presidential fund
*Dutch Thrombosis Foundation grant 2010-5
*Projets Hospitaliers de Recherche Clinique, French Ministry of Health grant PHRC 2011 08-01
*France, the study was sponsored by Direction de la Recherche Clinique et de l’Innovation, Brest University Hospital

==Sources==
<references/>

[[Category:EBQ]]

EBQ:The ADJUST-PE Study - Revision history

Ostermayer at 15:39, 17 April 2015

Neil.m.young: Created page with "{{JC info | title= Age-Adjusted D-Dimer Cutoff Levels to Rule Out Pulmonary Embolism | abbreviation= The ADJUST-PE Study | expansion= | published= | author= Righini M, Van Es..."