Factors Associated With Positive D-dimer Results in Patients Evaluated for Pulmonary Embolism

Authors

  • Christopher Kabrhel MD, MPH,

    1. From the Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School (CK, CAC), Boston, MA; the Department of Emergency Medicine, Northwestern University Medical Center (DMC), Chicago, IL; the Department of Emergency Medicine, St. Vincent Mercy Medical Center (MCP), Toledo, OH; the Division of Emergency Medicine, Department of Surgery, University of Colorado (KEN), Denver, CO; the Department of Emergency Medicine, Yale University Medical Center (CLM), New Haven, CT; the Department of Emergency Medicine, Mayo Clinic Arizona (PBR), Scottsdale, AZ; the Department of Emergency Medicine, Baystate Medical Center (HAS), Springfield, MA; the East Carolina University School of Medicine (DMB), Greenville, NC; and the Department of Emergency Medicine, Carolinas Medical Center (JAK), Charlotte, NC.
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  • D. Mark Courtney MD,

    1. From the Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School (CK, CAC), Boston, MA; the Department of Emergency Medicine, Northwestern University Medical Center (DMC), Chicago, IL; the Department of Emergency Medicine, St. Vincent Mercy Medical Center (MCP), Toledo, OH; the Division of Emergency Medicine, Department of Surgery, University of Colorado (KEN), Denver, CO; the Department of Emergency Medicine, Yale University Medical Center (CLM), New Haven, CT; the Department of Emergency Medicine, Mayo Clinic Arizona (PBR), Scottsdale, AZ; the Department of Emergency Medicine, Baystate Medical Center (HAS), Springfield, MA; the East Carolina University School of Medicine (DMB), Greenville, NC; and the Department of Emergency Medicine, Carolinas Medical Center (JAK), Charlotte, NC.
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  • Carlos A. Camargo Jr MD, DrPH,

    1. From the Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School (CK, CAC), Boston, MA; the Department of Emergency Medicine, Northwestern University Medical Center (DMC), Chicago, IL; the Department of Emergency Medicine, St. Vincent Mercy Medical Center (MCP), Toledo, OH; the Division of Emergency Medicine, Department of Surgery, University of Colorado (KEN), Denver, CO; the Department of Emergency Medicine, Yale University Medical Center (CLM), New Haven, CT; the Department of Emergency Medicine, Mayo Clinic Arizona (PBR), Scottsdale, AZ; the Department of Emergency Medicine, Baystate Medical Center (HAS), Springfield, MA; the East Carolina University School of Medicine (DMB), Greenville, NC; and the Department of Emergency Medicine, Carolinas Medical Center (JAK), Charlotte, NC.
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  • Michael C. Plewa MD,

    1. From the Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School (CK, CAC), Boston, MA; the Department of Emergency Medicine, Northwestern University Medical Center (DMC), Chicago, IL; the Department of Emergency Medicine, St. Vincent Mercy Medical Center (MCP), Toledo, OH; the Division of Emergency Medicine, Department of Surgery, University of Colorado (KEN), Denver, CO; the Department of Emergency Medicine, Yale University Medical Center (CLM), New Haven, CT; the Department of Emergency Medicine, Mayo Clinic Arizona (PBR), Scottsdale, AZ; the Department of Emergency Medicine, Baystate Medical Center (HAS), Springfield, MA; the East Carolina University School of Medicine (DMB), Greenville, NC; and the Department of Emergency Medicine, Carolinas Medical Center (JAK), Charlotte, NC.
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  • Kristen E. Nordenholz MD,

    1. From the Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School (CK, CAC), Boston, MA; the Department of Emergency Medicine, Northwestern University Medical Center (DMC), Chicago, IL; the Department of Emergency Medicine, St. Vincent Mercy Medical Center (MCP), Toledo, OH; the Division of Emergency Medicine, Department of Surgery, University of Colorado (KEN), Denver, CO; the Department of Emergency Medicine, Yale University Medical Center (CLM), New Haven, CT; the Department of Emergency Medicine, Mayo Clinic Arizona (PBR), Scottsdale, AZ; the Department of Emergency Medicine, Baystate Medical Center (HAS), Springfield, MA; the East Carolina University School of Medicine (DMB), Greenville, NC; and the Department of Emergency Medicine, Carolinas Medical Center (JAK), Charlotte, NC.
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  • Christopher L. Moore MD,

    1. From the Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School (CK, CAC), Boston, MA; the Department of Emergency Medicine, Northwestern University Medical Center (DMC), Chicago, IL; the Department of Emergency Medicine, St. Vincent Mercy Medical Center (MCP), Toledo, OH; the Division of Emergency Medicine, Department of Surgery, University of Colorado (KEN), Denver, CO; the Department of Emergency Medicine, Yale University Medical Center (CLM), New Haven, CT; the Department of Emergency Medicine, Mayo Clinic Arizona (PBR), Scottsdale, AZ; the Department of Emergency Medicine, Baystate Medical Center (HAS), Springfield, MA; the East Carolina University School of Medicine (DMB), Greenville, NC; and the Department of Emergency Medicine, Carolinas Medical Center (JAK), Charlotte, NC.
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  • Peter B. Richman MD, MBA,

    1. From the Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School (CK, CAC), Boston, MA; the Department of Emergency Medicine, Northwestern University Medical Center (DMC), Chicago, IL; the Department of Emergency Medicine, St. Vincent Mercy Medical Center (MCP), Toledo, OH; the Division of Emergency Medicine, Department of Surgery, University of Colorado (KEN), Denver, CO; the Department of Emergency Medicine, Yale University Medical Center (CLM), New Haven, CT; the Department of Emergency Medicine, Mayo Clinic Arizona (PBR), Scottsdale, AZ; the Department of Emergency Medicine, Baystate Medical Center (HAS), Springfield, MA; the East Carolina University School of Medicine (DMB), Greenville, NC; and the Department of Emergency Medicine, Carolinas Medical Center (JAK), Charlotte, NC.
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  • Howard A. Smithline MD,

    1. From the Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School (CK, CAC), Boston, MA; the Department of Emergency Medicine, Northwestern University Medical Center (DMC), Chicago, IL; the Department of Emergency Medicine, St. Vincent Mercy Medical Center (MCP), Toledo, OH; the Division of Emergency Medicine, Department of Surgery, University of Colorado (KEN), Denver, CO; the Department of Emergency Medicine, Yale University Medical Center (CLM), New Haven, CT; the Department of Emergency Medicine, Mayo Clinic Arizona (PBR), Scottsdale, AZ; the Department of Emergency Medicine, Baystate Medical Center (HAS), Springfield, MA; the East Carolina University School of Medicine (DMB), Greenville, NC; and the Department of Emergency Medicine, Carolinas Medical Center (JAK), Charlotte, NC.
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  • Daren M. Beam,

    1. From the Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School (CK, CAC), Boston, MA; the Department of Emergency Medicine, Northwestern University Medical Center (DMC), Chicago, IL; the Department of Emergency Medicine, St. Vincent Mercy Medical Center (MCP), Toledo, OH; the Division of Emergency Medicine, Department of Surgery, University of Colorado (KEN), Denver, CO; the Department of Emergency Medicine, Yale University Medical Center (CLM), New Haven, CT; the Department of Emergency Medicine, Mayo Clinic Arizona (PBR), Scottsdale, AZ; the Department of Emergency Medicine, Baystate Medical Center (HAS), Springfield, MA; the East Carolina University School of Medicine (DMB), Greenville, NC; and the Department of Emergency Medicine, Carolinas Medical Center (JAK), Charlotte, NC.
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  • Jeffrey A. Kline MD

    1. From the Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School (CK, CAC), Boston, MA; the Department of Emergency Medicine, Northwestern University Medical Center (DMC), Chicago, IL; the Department of Emergency Medicine, St. Vincent Mercy Medical Center (MCP), Toledo, OH; the Division of Emergency Medicine, Department of Surgery, University of Colorado (KEN), Denver, CO; the Department of Emergency Medicine, Yale University Medical Center (CLM), New Haven, CT; the Department of Emergency Medicine, Mayo Clinic Arizona (PBR), Scottsdale, AZ; the Department of Emergency Medicine, Baystate Medical Center (HAS), Springfield, MA; the East Carolina University School of Medicine (DMB), Greenville, NC; and the Department of Emergency Medicine, Carolinas Medical Center (JAK), Charlotte, NC.
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  • Presented at the Society of Academic Emergency Medicine annual meeting, New Orleans, LA, 2009.

  • Supported by NIH-2R42 HL074415–02A1, 2004–2006.

  • A related commentary appears on page 649.

Address for correspondenceand reprints: Christopher Kabrhel, MD, MPH; e-mail: ckabrhel@partners.org.

Abstract

Objectives:  Available D-dimer assays have low specificity and may increase radiographic testing for pulmonary embolism (PE). To help clinicians better target testing, this study sought to quantify the effect of risk factors for a positive quantitative D-dimer in patients evaluated for PE.

Methods:  This was a prospective, multicenter, observational study. Emergency department (ED) patients evaluated for PE with a quantitative D-dimer were eligible for inclusion. The main outcome of interest was a positive D-dimer. Odds ratio (ORs) and 95% confidence intervals (CIs) were determined by multivariable logistic regression. Adjusted estimates of relative risk were also calculated.

Results:  A total of 4,346 patients had D-dimer testing, of whom 2,930 (67%) were women. A total of 2,500 (57%) were white, 1,474 (34%) were black or African American, 238 (6%) were Hispanic, and 144 (3%) were of other race or ethnicity. The mean (±SD) age was 48 (±17) years. Overall, 1,903 (44%) D-dimers were positive. Model fit was adequate (c-statistic = 0.739, Hosmer and Lemeshow p-value = 0.13). Significant positive predictors of D-dimer positive included female sex; increasing age; black (vs. white) race; cocaine use; general, limb, or neurologic immobility; hemoptysis; hemodialysis; active malignancy; rheumatoid arthritis; lupus; sickle cell disease; prior venous thromboembolism (VTE; not under treatment); pregnancy and postpartum state; and abdominal, chest, orthopedic, or other surgery. Warfarin use was protective. In contrast, several variables known to be associated with PE were not associated with positive D-dimer results: body mass index (BMI), estrogen use, family history of PE, (inactive) malignancy, thrombophilia, trauma within 4 weeks, travel, and prior VTE (under treatment).

Conclusions:  Many factors are associated with a positive D-dimer test. The effect of these factors on the usefulness of the test should be considered prior to ordering a D-dimer.

ACADEMIC EMERGENCY MEDICINE 2010; 17:589–597 © 2010 by the Society for Academic Emergency Medicine

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