What level of D-dimers can safely exclude pulmonary embolism in COVID-19 patients presenting to the emergency department?

Abstract

OBJECTIVES:

To identify which level of D-dimer would allow the safe exclusion of pulmonary embolism (PE) in COVID-19 patients presenting to the emergency department (ED).

METHODS:

This retrospective study was conducted on the COVID database of Assistance Publique - Hôpitaux de Paris (AP-HP). COVID-19 patients who presented at the ED of AP-HP hospitals between March 1 and May 15, 2020, and had CTPA following D-dimer dosage within 48h of presentation were included. The D-dimer sensitivity, specificity, and positive and negative predictive values were calculated for different D-dimer thresholds, as well as the false-negative and failure rates, and the number of CTPAs potentially avoided.

RESULTS:

A total of 781 patients (mean age 62.0 years, 53.8% men) with positive RT-PCR for SARS-Cov-2 were included and 60 of them (7.7%) had CTPA-confirmed PE. Their median D-dimer level was significantly higher than that of patients without PE (4,013 vs 1,198 ng·mL-1, p < 0.001). Using 500 ng·mL-1, or an age-adjusted cut-off for patients > 50 years, the sensitivity and the NPV were above 90%. With these thresholds, 17.1% and 31.5% of CTPAs could have been avoided, respectively. Four of the 178 patients who had a D-dimer below the age-adjusted cutoff had PE, leading to an acceptable failure rate of 2.2%. Using higher D-dimer cut-offs could have avoided more CTPAs, but would have lowered the sensitivity and increased the failure rate.

CONCLUSION:

The same D-Dimer thresholds as those validated in non-COVID outpatients should be used to safely rule out PE.

KEY POINTS:

• The median D-dimer level was significantly higher in COVID-19 patients with PE as compared to those without PE (4,013 ng·mL-1 vs 1,198 ng·mL-1 respectively, p < 0.001). • Using 500 ng·mL-1, or an age-adjusted D-dimer cut-off to exclude pulmonary embolism, the sensitivity and negative predictive value were above 90%. • Higher cut-offs would lead to a reduction in the sensitivity below 85% and an increase in the failure rate, especially for patients under 50 years.

• Authors: Marie-Pierre Revel, Nathanael Beeker, Raphael Porcher, Léa Jilet, Laure Fournier, Bastien Rance, Guillaume Chassagnon, Michaela Fontenay, Olivier Sanchez, AP-HP /Universities/Inserm COVID-19 research collaboration, AP-HP Covid CDR Initiative
• Journal: European radiology (Eur Radiol) Vol. 32 Issue 4 Pg. 2704-2712 (Apr 2022) ISSN: 1432-1084 [Electronic] Germany
• PMID: 34994845 (Publication Type: Journal Article)
• Copyright: © 2022. The Author(s), under exclusive licence to European Society of Radiology.

Chemical References

• Fibrin Fibrinogen Degradation Products
• fibrin fragment D

Topics

• COVID-19
• Emergency Service, Hospital
• Female
• Fibrin Fibrinogen Degradation Products
• Humans
• Male
• Middle Aged
• Pulmonary Embolism
• Retrospective Studies
• SARS-CoV-2