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Do Emergency Physicians Use Serum d-Dimer Effectively to Determine the Need for CT When Evaluating Patients for Pulmonary Embolism? Review of 5,344 Consecutive Patients

¹ Department of Diagnostic Imaging, Warren Alpert Medical School of Brown University and Rhode Island Hospital, 593 Eddy St., Providence, RI 02903.
² Department of Emergency Medicine, Warren Alpert Medical School of Brown University and Rhode Island Hospital, Providence, RI.

OBJECTIVE. The purpose of our study was to investigate whether D-dimer screening is being used effectively to determine the need for MDCT in diagnosing acute pulmonary embolism (PE) in emergency department patients.

MATERIALS AND METHODS. We performed a retrospective review of all patients who underwent D-dimer testing or MDCT in the emergency department from January 1, 2003, through October 31, 2005. A D-dimer value of > 0.43 µg/mL was considered positive. Diagnosis of PE was made on the basis of the MDCT. Clinical algorithms for diagnosing PE mandate that patients with a low clinical suspicion for PE undergo D-dimer testing, then MDCT if positive. For patients with a high clinical suspicion for PE, MDCT should be performed without D-dimer testing.

RESULTS. Of 3,716 D-dimer tests, 1,431 (39%) were positive and 2,285 (61%) were negative. MDCT was performed in 166 (7%) patients with negative D-dimer results and in 826 (58%) patients with positive D-dimer results. The prevalence of PE in patients with a high clinical suspicion and no D-dimer testing was 9% (139/1,628), which was higher than the rate of PE in the positive D-dimer group at 2% (19/826) (p < 0.0001). There was no significant difference in the prevalence of PE in the positive and negative D-dimer groups (2% vs 0.6%, respectively) (p = 0.23). The sensitivity and negative predictive value of D-dimer for PE were 95% (95% CI, 73.1–99.7%) and 99% (95% CI, 96.2–99.9%), respectively.

CONCLUSION. D-dimer screening is not used according to established diagnostic algorithms to determine the need for MDCT in diagnosing acute pulmonary embolism in our emergency department.

Keywords: CT angiography • D-dimer • emergency department • pulmonary embolism

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