Current Healthcare Education
One of the challenges of deciding what content to provide your online community is the amount and frequency of new information that is being published. As healthcare providers, the task is daunting just to keep up with what is going on in your specialty, even more so if you are reviewing your profession in general. One of the benefits of Provider Practice Essentials workshops for attendees is the personalized attention provided by faculty. This not only includes hands on workshops but plenty of Q & A opportunities. In one of my recent discussions with Course Director, Rachel Beatty she shared some of the numerous questions asked by attendees. One of the most pressing questions surrounded the topic of “age adjusted d-dimer”.
Age Adjusted D-Dimer Testing
Whether you are a seasoned provider, or fresh out of your academic training, most of you have seen or used Wells Criteria for Pulmonary Embolism, or Pulmonary Embolism Rule-out Criteria. Depending on scores both criteria may consider high sensitivity d-dimer testing. You need to decide, to CTA or not to CTA. The challenge is that the next generation d-dimer has a high sensitivity but low specificity (approximately 50%).
The question: Can age-adjusted d-dimer be adopted to in emergency departments to exclude pulmonary embolism? Apparently, this is a HOT TOPIC! A quick search of the literature at a local university using key words, “age adjusted d-dimer”, resulted in 127 articles over the past 6 months. The addition of emergency department or emergency rooms, resulted in 23 articles. Six articles that included Wells Criteria for PE, PERC criteria, and age adjusted d-dimer were reviewed. A more palatable number of articles to glean when not being forced to complete an academic assignment. I share the process because it is important for us to remember to “dive” into the literature when seeking to provide the highest level of care for our patients.
Age Adjusted D-Dimer Studies
A rapid review of the literature: Age adjusted d-dimer (AADD) is calculated by Age (years) x 10 µg/L = cutoff (for patients > 50 years). Five studies reported that AADD increased specificity when used with low and intermediate risk patients (1, 2, 3, 4, 5). Four studies reported and increased sensitivity when AADD was utilized in combination with Wells Criteria for PE and PERC criteria (1, 2, 4, 5). A single study reported that the utilization of AADD resulted in a decreased sensitivity and an increase in false negatives (3). Lastly, one study reported that PE risk score sensitivity was similar to age adjusted d-dimer sensitivity.
The practice take away: Reasonable and prudent care must be taken with patients who arrive with signs and symptoms of a PE. Traditional risk criteria are evidence-based and provide sensitive information in determining the need for further diagnostics, such as a d-dimer. Utilizing appropriate criteria, the age adjusted d-dimer may increase sensitivity and specificity when excluding for PE, eliminating the risk and cost of a CT or VQ scan. Finally, as in all practice, the provider must use gestalt and intuition whether to begin testing for PE.
Author: John W. Rothwell III, DNP, APN, FNP-BC
- Jaconelli, T., Eragat, M., & Crane, S. (2018). Can an age-adjusted D-dimer level be adopted in managing venous thromboembolism in the emergency department? A retrospective cohort study. European Journal of Emergency Medicine, (4), 288.
- Sharif, S., Eventov, M., Kearon, C., Parpia, S., Li, M., Jiang, R., … de Wit, K. (2018). Comparison of the age-adjusted and clinical probability-adjusted D-dimer to exclude pulmonary embolism in the emergency department. American Journal of Emergency Medicine
- Senior, K., Burles, K., Wang, D., Grigat, D., Innes, G. D., Andruchow, J. E., … McRae, A. D. (2018). Age-adjusted D-dimer thresholds in the investigation of suspected pulmonary embolism: A retrospective evaluation in patients ages 50 and older using administrative data. CJEM: Canadian Journal of Emergency Medicine, 20(5), 725–731.
- Gómez-Jabalera E, Bellmunt Montoya S, Fuentes-Camps E, Escudero Rodríguez JR. Age-adjusted D-dimer for the diagnosis of deep vein thrombosis. Phlebology. 2018;33(7):458-463. doi:10.1177/0268355517718762.
- Barth, B. E., Waligora, G., & Gaddis, G. M. (2018). Rapid Systematic Review: Age-Adjusted D-Dimer for Ruling Out Pulmonary Embolism. Journal of Emergency Medicine, (4). Retrieved from https://doi.org/10.1016/j.jemermed.2018.07.003
- Ackerly, I., Klim, S., McFarlane, J., & Kelly, A.-M. (2018). Diagnostic utility of an age-specific cut-off for d-dimer for pulmonary embolism assessment when used with various pulmonary embolism risk scores. INTERNAL MEDICINE JOURNAL, 48(4), 465–468. doi:10.1111/imj.13753.