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Age-dependent diagnostic accuracy of clinical scoring systems and D-dimer levels in the diagnosis of pulmonary embolism with computed tomography pulmonary angiography (CTPA)

  • Emergency Radiology
  • Published:
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Abstract

Objective

The aim of this study was to compare the age-dependent diagnostic performance of clinical scores and D-dimer testing to identify patients with suspected pulmonary embolism (PE).

Methods

Consecutive patients with suspected PE referred from the emergency department for computed tomography pulmonary angiography (CTPA) were retrospectively evaluated. Diagnostic scores (classic Wells score (WS), modified WS, simplified WS, revised Geneva score (GS), simplified GS, and YEARS score) were calculated from medical records. Results of D-dimer testing were retrieved from the laboratory database. CTPA was the diagnostic reference standard. Four age groups were analyzed (< 50, 50–64, 65–74, and ≥ 75 years). Statistical analysis used receiver operating characteristics as well as uni- and multivariate analyses with calculation of prediction models. The study was IRB approved.

Results

One thousand consecutive patients were included. Areas under the curve (AUC) and accuracies were superior in patients < 50 years. For the classic WS, the AUC decreased by 11% with the optimal cutoff dropping 1.5 points in patients ≥ 75 years; for D-dimer levels, the optimal cutoff was 900 μg/L higher in both ≥ 65 years groups with a max. decrease of the AUC of 9%. In terms of accuracy, the YEARS score performed best across all groups. Classic WS and D-dimer level showed a significant interaction with patient age in prediction models.

Conclusion

D-dimer measurement and clinical scores perform best in patients < 50 years. The YEARS score performs best across all age groups and is therefore recommended.

Key Points

• The probability of pulmonary embolism predicted by fibrin fibrinogen degradation products and clinical scores shows the highest accuracy in patients < 50 years.

• The probability of pulmonary embolism predicted by the YEARS score shows the highest accuracy in each age group.

• Classic Wells score and fibrin fibrinogen degradation products show a significant interaction with patient age in a logistic regression model.

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Abbreviations

AUC:

Area under the curve

CTPA:

Computed tomography pulmonary angiography

cWS:

Classic Wells score

DDL:

D-dimer level

DVT:

Deep vein thrombosis

mWS:

Modified Wells score

PE:

Pulmonary embolism

rGS:

Revised Geneva score

ROC:

Receiver operating characteristics

sGS:

Simplified Geneva score

sWS:

Simplified Well score

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Acknowledgements

We want to thank Hans Tepe and Christine Naedler for their support with the database queries. The study was in part presented at ECR 2018.

Funding

The authors state that this work has not received any funding.

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Authors and Affiliations

  1. Klinik und Hochschulambulanz für Radiologie, Charité – Universitätsmedizin Berlin Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany

    Sebastian N. Nagel, Ingo G. Steffen, Bernd Hamm & Thomas Elgeti

  2. Medizinische Klinik mit Schwerpunkt Hämatologie und Onkologie, Charité – Universitätsmedizin Berlin Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany

    Stefan Schwartz

  3. Klinik für Nuklearmedizin, Charité – Universitätsmedizin Berlin Campus Virchow Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany

    Thomas Elgeti

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  1. Sebastian N. Nagel
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  2. Ingo G. Steffen
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Corresponding author

Correspondence to Sebastian N. Nagel.

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Guarantor

The scientific guarantor of this publication is Sebastian Nagel.

Conflict of interest

The authors of this manuscript declare relationships with the following companies:

Bernd Hamm is Grant Recipient for the Department of Radiology, Charité, and has further received funding from Abbott, AbbVie, Ablative Solutions, Accovion, Achaogen Inc., Actelion Pharmaceuticals, ADIR, Aesculap, AGO, AIF Arbeitsgemeinschaft industrieller Forschungsvereinigungen, AIO Arbeitsgemeinschaft lnternistische Onkologie, Alexion Pharmaceuticals, Amgen, AO Foundation, Arena Pharmaceuticals, art photonics GmbH Berlin, ASR Advanced sleep research, Astellas, AstraZeneca, BARD, Bayer Healthcare, Bayer Schering Pharma, Bayer Vital, BBraun, Berlin-Brandenburger Centrum für Regenerative Therapien (BCRT), Berliner Krebsgesellschaft, Biotronik, Bioven, BMBF Bundesministerium für Bildung und Forschung, Boehring Ingelheimer, Boston Biomedical Inc., BRACCO Group, Brainsgate, Bristol-Myers Squibb, Cascadian Therapeutics, Inc., Celgene, CELLACT Pharma, Celldex Therapeutics, CeIoNova BioSciences, Charité research organisation GmbH, Chiltern, CCovance, CUBIST, Curis, Daiichi, DC Devices, Inc. USA, Delcath Systems, Dermira Inc., Deutsche Krebshilfe, Deutsche Rheuma Liga, DFG, DSM Nutritional Products AG, Dt. Stiftung für Herzforschung, Dynavax, Eisai Ltd.‚ European Knowledge Centre, Mosquito Way, Hatfield, Eli Lilly and Company Ltd., EORTC, Epizyme, Inc., Essex Pharma, EU Programmes, Euroscreen S.A., Fibrex Medical Inc., Focused Ultrasound Surgery Foundation, Fraunhofer Gesellschaft, Galena Biopharma, Galmed Research and Development Ltd., Ganymed, GE, Genentech. Inc., GETNE (Grupo Español de Tumores Neuroendocrinos), Gilead Sciences, Inc., Glaxo Smith Kline, Glycotope GmbH, Berlin, Goethe Uni Frankfurt, Guerbet, Guidant Europe NV, Halozyme, Holaira Inc., ICON (CRO), Immunomedics Inc., Immunocore, Incyte, INC Research, Innate Pharma, InSightec Ltd., Inspiremd, inVentiv Health Clinical UK Ltd, Inventivhealth, IOMEDICO, IONIS, IPSEN Pharma, ISA Therapeutics, lsis Pharmaceuticals Inc., ITM Solution GmbH, Jansen, Kantar Health GmbH (CRO), Karyopharm Therapeutics, Inc., Kendle/MorphoSys AG, Kite Pharma, La Roche, Land Berlin, Lilly GmbH, Lion Biotechnology, Lombard Medical, Loxo Oncology, Inc, LSK BioPartners, USA; Lundbeck GmbH, LUX Biosciences, LYSARC, MacroGenics, MagForce, Medlmmune Inc., Medlmmune Limited, Medpace, Medpace Germany GmbH (CRO), MedPass (CRO), Medronic, Merck, Merrimack Pharmaceuticals Inc, MeVis Medical Solutions AG, Millennium Pharmaceuticals Inc., Mologen, MSD Sharp, NeoVacs SA, Nexus Oncology, Novartis, novocure, Nuvisan, Ockham oncology, Orion Corporation Orion Pharma, Parexel CRO Service, Perceptive, Pfizer GmbH, Pharma Mar, Pharmaceutical Research Associates GmbH (PRA), Pharmacyclics Inc., Philipps, PIQUR Therapeutics Ltd., Pluristem, Portola Pharmaceuticals, PPD (CRO), PRAint, Premier-research, Provectus Biopharmaceuticals, Inc., psi-cro, Pulmonx International Sàrl, Quintiles Gmbh, Respicardia, Roche, Samsung, Sanofi, sanofis-aventis S.A, Schumacher GmbH, Seattle Genetics, Servier (CRO), SGS Life Science Services (CRO), Siemens, Silena Therapeutics, Spectranetics GmbH, Spectrum Pharmaceuticals, St. Jude Medical, Stiftung Wolfgang Schulze, Symphogen, Taiho Pharmaceutical Co., Taqu Therapeutics Ltd., Terumo Medical Corporation, Tesaro, TETEC AG, TEVA, Theorem, Theradex, Threshold Pharmaceuticals Inc., TNS Healthcare GmbH, Toshiba, UCB Pharma, Uni München, VDI/VDE, Winicker Norimed, Wyeth Pharma, Xcovery Holding Company, Zukunftsfond Berlin (TSB).

Stefan Schwartz is receiving grants from Pfizer and Enzon.

Statistics and biometry

One of the authors (Ingo Steffen) has significant statistical expertise.

Informed consent

Written informed consent was waived by the Institutional Review Board.

Ethical approval

Institutional Review Board approval was obtained.

Methodology

• This study is a retrospective study performed at one institution on the diagnostic performance of clinical decision rules and D-dimer measurements in patients who had undergone computed tomography angiography in the diagnostic workup of suspected pulmonary embolism.

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Nagel, S.N., Steffen, I.G., Schwartz, S. et al. Age-dependent diagnostic accuracy of clinical scoring systems and D-dimer levels in the diagnosis of pulmonary embolism with computed tomography pulmonary angiography (CTPA). Eur Radiol 29, 4563–4571 (2019). https://doi.org/10.1007/s00330-019-06039-5

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  • DOI: https://doi.org/10.1007/s00330-019-06039-5

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