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Start Over Author "Service d'Accueil des Urgences (AGEN - SAU)" Topic 0302 clinical medicine
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1. Pulmonary embolism rule-out criteria (PERC) rule in European patients with low implicit clinical probability (PERCEPIC): a multicentre, prospective, observational study

Author

Andrea Penaloza, Quentin Delmez, Olivier Sanchez, N. Delvau, Nicolas Marjanovic, Alexandre Ghuysen, Jeannot Schmidt, Thomas Moumneh, Farès Moustafa, Christian Brice, Philippe Girard, Guy Meyer, Grégoire Le Gal, Béatrice Gable, Jacques Bouget, Lionel Imsaad, Caroline Soulie, Pierre-Marie Roy, Catherine Le Gall, A Trinh-Duc, Dominique El Kouri, Jean-Marie Chretien, Service des Urgences [CHU Nantes], Hôtel-Dieu de Nantes, Modélisation Conceptuelle des Connaissances Biomédicales, Université de Rennes (UR), Département des Urgences, CHU Clermont-Ferrand, Service d'Accueil des Urgences (AGEN - SAU), Centre Hospitalier d'Agen, Centre Hospitalier Victor Dupouy, Délégation à la recherche clinique et innovation, Centre Hospitalier Universitaire d'Angers (CHU Angers), PRES Université Nantes Angers Le Mans (UNAM)-PRES Université Nantes Angers Le Mans (UNAM), Laboratoire de l'intégration, du matériau au système (IMS), Université Sciences et Technologies - Bordeaux 1 (UB)-Institut Polytechnique de Bordeaux-Centre National de la Recherche Scientifique (CNRS), Unité de soins intensifs [Clermont Ferrand], CHU Clermont-Ferrand-CHU Gabriel Montpied [Clermont-Ferrand], Groupe d'Etude de la Thrombose de Bretagne Occidentale (GETBO), Université de Brest (UBO)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Institut Brestois Santé Agro Matière (IBSAM), Université de Brest (UBO)-Université de Brest (UBO), Centre de Recherche Clinique (CRC Angers), Université d'Angers (UA)-Centre Hospitalier Universitaire d'Angers (CHU Angers), Université de Rennes 1 (UR1), Université de Rennes (UNIV-RENNES)-Université de Rennes (UNIV-RENNES), Université Sciences et Technologies - Bordeaux 1-Institut Polytechnique de Bordeaux-Centre National de la Recherche Scientifique (CNRS), Université de Brest (UBO)-Institut Brestois Santé Agro Matière (IBSAM), Institut Brestois Santé Agro Matière (IBSAM), and Université de Brest (UBO)-Université de Brest (UBO)-Université de Brest (UBO)

Subjects
Adult, Pediatrics, medicine.medical_specialty, [SDV]Life Sciences [q-bio], Population, 030204 cardiovascular system & hematology, White People, Fibrin Fibrinogen Degradation Products, 03 medical and health sciences, 0302 clinical medicine, [SDV.MHEP.CSC]Life Sciences [q-bio]/Human health and pathology/Cardiology and cardiovascular system, Risk Factors, medicine, Clinical endpoint, Humans, Prospective Studies, 030212 general & internal medicine, education, Prospective cohort study, False Negative Reactions, Case report form, ComputingMilieux_MISCELLANEOUS, Aged, Ultrasonography, education.field_of_study, Intention-to-treat analysis, business.industry, Angiography, Anticoagulants, Hematology, Emergency department, Middle Aged, medicine.disease, 3. Good health, Pulmonary embolism, Treatment Outcome, Observational study, Emergency Service, Hospital, Pulmonary Embolism, business, [SDV.MHEP]Life Sciences [q-bio]/Human health and pathology
Abstract

Summary Background The ability of the pulmonary embolism rule-out criteria (PERC) to exclude pulmonary embolism without further testing remains debated outside the USA, especially in the population with suspected pulmonary embolism who have a high prevalence of the condition. Our main objective was to prospectively assess the predictive value of negative PERC to rule out pulmonary embolism among European patients with low implicit clinical probability. Methods We did a multicentre, prospective, observational study in 12 emergency departments in France and Belgium. We included consecutive patients aged 18 years or older with suspected pulmonary embolism. Patients were excluded if they had already been hospitalised for more than 2 days, had curative anticoagulant therapy in progress for more than 48 h, or had a diagnosis of thromboembolic disease documented before admission to emergency department. Physicians completed a standardised case report form comprising implicit clinical probability assessment (low, moderate, or high) and a list of risk factors including criteria of the PERC rule. They were asked to follow international recommendations for diagnostic strategy, masked to PERC assessment. The primary endpoint was the proportion of patients with low implicit clinical probability and negative PERC who had venous thromboembolic events, diagnosed during initial diagnostic work-up or during 3-month follow-up, as externally adjudicated by an independent committee masked to the PERC and clinical probability assessment. The upper limit of the 95% CI around the 3-month thromboembolic risk was set at 3%. We did all analyses by intention to treat, including all patients with complete follow-up. This trial is registered with ClinicalTrials.gov, number NCT02360540. Findings Between May 1, 2015, and April 30, 2016, 1773 consecutive patients with suspected pulmonary embolism were prospectively assessed for inclusion, of whom 1757 were included. 1052 (60%) patients were classed as having low clinical probability, 49 (4·7%, 95% CI 3·5–6·1) of whom had a venous thromboembolic event. In patients with a low implicit clinical probability, 337 (32%) patients had negative PERC, of whom four (1·2%; 95% CI 0·4–2·9) went on to have a pulmonary embolism. Interpretation In European patients with low implicit clinical probability, PERC can exclude pulmonary embolism with a low percentage of false-negative results. The results of our prospective, observational study allow and justify an implementation study of the PERC rule in Europe. Funding French Ministry of Health.

Published
2017
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2. Management of Severe Bleeding in Patients Treated with Direct Oral Anticoagulants

Author

Dennis, Jessica, Medina-Rivera, Alejandra, Truong, Vinh, Antounians, Lina, Zwingerman, Nora, Carrasco, Giovana, Strug, Lisa, Wells, Phil, Trégouët, France, Morange, France, Wilson, Michael, Gagnon, France, Albaladejo, Pierre, Samama, Marc, Sié, Pierre, Kauffmann, Sophie, Mémier, Vincent, Suchon, Pierre, Viallon, Alain, David, Stéphane, Gruel, Yves, Bellamy, Lorenn, de Maistre, Emmanuel, Romegoux, Pauline, Thoret, Sophie, Pernod, Gilles, Bosson, Jean-Luc, Bazin, Etienne, Combaret, Nicolas, Cherprenet, Anne, Fares, Moustafa, Dufraisse, Sophie, Minville, Vincent, Morange, Pierre-Emmanuel, Leone, Marc, Cohen, William, Néant, Nadège, Marlu, Raphaël, Carpentier, Françoise, Defaye, Pascal, Mismetti, Patrick, Molliex, Serge, Lanoiselée, Julien, Piriou, Vincent, Delaleu-Rague, Carine, Lefèvre, Mathilde, Lagrange, Sophie, Ardillon, Lauren, Ozier, Yves, Bovet, Julien, Steib, Annick, Mebaouj, Sonia, Profumo, Louis, Roullet, Stéphanie, Smadja, David, Meyer, Guy, Journois, Didier, Trinh-Duc, Albert, Viard, Thibault, Belle, Loic, Levrat, Albrice, Gautheron, Etienne, Heluwaert, Frédéric, Schlumberger, Sylvie, Blanié, Antonia, Benhamou, Dan, Flaujac, Claire, Rosencher, Nadia, Beloeil, Hélène, Blery, Catherine, Daviet, Lauren, Guéret, Pierre, Faraoni, David, Schved, Jean François, Deras, Pauline, Jaber, Samir, Gueugniaud, Pierre Yves, Floccard, Bernard, Asehnoune, Karim, Paulus, Jerome, Amrani, Omar, Gonthier, Marie Caroline, Huisse, Marie Geneviève, Josserand, Julien, de Raucourt, Emmanuelle, Defournel, Cécile, Dubois, Yohann, Bouvier, Stéphane, Roy, Pierre-Marie, Lasocki, Sigismond, Carmagnac, Christian, Chastagner, Catherine, Thouret, Jean Marc, Sevestre, Marie Antoinette, Meaudre, Eric, Cungi, Pierre-Julien, Susen, Sophie, Lefrant, Jean Yves, Macey, Stéphane, Rieu, Jean Baptiste, Godier, Anne, University of Toronto, Program in genetics and genome biology, The Hospital for sick children [Toronto] (SickKids), Department of Molecular Genetics, Laboratorio Internacional de Investigación sobre el Genoma Humano, Universidad Nacional Autónoma de México = National Autonomous University of Mexico (UNAM), Division of Biostatistics, Dalla Lana School of Public Health, Ottawa Hospital Research Institute, ThEMAS, Techniques de l'Ingénierie Médicale et de la Complexité - Informatique, Mathématiques et Applications, Grenoble - UMR 5525 (TIMC-IMAG), Université Joseph Fourier - Grenoble 1 (UJF)-Institut polytechnique de Grenoble - Grenoble Institute of Technology (Grenoble INP )-VetAgro Sup - Institut national d'enseignement supérieur et de recherche en alimentation, santé animale, sciences agronomiques et de l'environnement (VAS)-Centre National de la Recherche Scientifique (CNRS)-Université Joseph Fourier - Grenoble 1 (UJF)-Institut polytechnique de Grenoble - Grenoble Institute of Technology (Grenoble INP )-VetAgro Sup - Institut national d'enseignement supérieur et de recherche en alimentation, santé animale, sciences agronomiques et de l'environnement (VAS)-Centre National de la Recherche Scientifique (CNRS)-Pôle Anesthésie Réanimation, CHU Grenoble-Hôpital Michallon-CHU Grenoble-Hôpital Michallon, Institut de médecine moléculaire de Rangueil (I2MR), Université Toulouse III - Paul Sabatier (UT3), Université de Toulouse (UT)-Université de Toulouse (UT)- Institut Fédératif de Recherche Bio-médicale Institution (IFR150)-Institut National de la Santé et de la Recherche Médicale (INSERM), Nutrition, obésité et risque thrombotique (NORT), Institut National de la Recherche Agronomique (INRA)-Aix Marseille Université (AMU)-Institut National de la Santé et de la Recherche Médicale (INSERM), Centre Hospitalier Universitaire de Saint-Etienne [CHU Saint-Etienne] (CHU ST-E), Génétique, immunothérapie, chimie et cancer (GICC), UMR 7292 CNRS [2012-2017] (GICC UMR 7292 CNRS), Université de Tours (UT)-Centre National de la Recherche Scientifique (CNRS), Service d'Hématologie Clinique (CHU de Dijon), Centre Hospitalier Universitaire de Dijon - Hôpital François Mitterrand (CHU Dijon), Techniques pour l'Evaluation et la Modélisation des Actions de la Santé (TIMC-IMAG-ThEMAS), Institut polytechnique de Grenoble - Grenoble Institute of Technology (Grenoble INP )-VetAgro Sup - Institut national d'enseignement supérieur et de recherche en alimentation, santé animale, sciences agronomiques et de l'environnement (VAS)-Centre National de la Recherche Scientifique (CNRS)-Université Grenoble Alpes [2016-2019] (UGA [2016-2019])-Institut polytechnique de Grenoble - Grenoble Institute of Technology (Grenoble INP )-VetAgro Sup - Institut national d'enseignement supérieur et de recherche en alimentation, santé animale, sciences agronomiques et de l'environnement (VAS)-Centre National de la Recherche Scientifique (CNRS)-Université Grenoble Alpes [2016-2019] (UGA [2016-2019]), Institut polytechnique de Grenoble - Grenoble Institute of Technology (Grenoble INP )-VetAgro Sup - Institut national d'enseignement supérieur et de recherche en alimentation, santé animale, sciences agronomiques et de l'environnement (VAS)-Centre National de la Recherche Scientifique (CNRS)-Université Grenoble Alpes [2016-2019] (UGA [2016-2019]), Pôle Anesthésie Réanimation [CHU de Toulouse], Centre Hospitalier Universitaire de Toulouse (CHU Toulouse), Unité de Recherche sur les Maladies Infectieuses et Tropicales Emergentes (URMITE), Institut de Recherche pour le Développement (IRD)-Aix Marseille Université (AMU)-Institut National de la Santé et de la Recherche Médicale (INSERM)-IFR48, Institut des sciences biologiques (INSB-CNRS)-Institut des sciences biologiques (INSB-CNRS)-Centre National de la Recherche Scientifique (CNRS), Biotechnologies, Pharmacologie Moléculaire et Cellulaire, Institut de Recherches Servier, Service des urgences, CHU Grenoble, Cardiac Stimulation and Rhythmology, Groupe de recherche sur la thrombose, pharmacologie des antithrombotiques et situations à risque (GRT), Université Jean Monnet - Saint-Étienne (UJM), Santé Ingénierie Biologie Saint-Etienne (SAINBIOSE), Centre Ingénierie et Santé (CIS-ENSMSE), École des Mines de Saint-Étienne (Mines Saint-Étienne MSE), Institut Mines-Télécom [Paris] (IMT)-Institut Mines-Télécom [Paris] (IMT)-École des Mines de Saint-Étienne (Mines Saint-Étienne MSE), Institut Mines-Télécom [Paris] (IMT)-Institut Mines-Télécom [Paris] (IMT)-Université Jean Monnet - Saint-Étienne (UJM)-Institut National de la Santé et de la Recherche Médicale (INSERM), Hopital Cardiovasculaire, Hôpital Cardiologique de Lyon, Service de réanimation médicale polyvalente [CHU Cochin], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Hôpital Cochin [AP-HP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP), Service d'Anesthésie-Réanimation (TP - SAR), CHU Strasbourg, Espace Ethiques et Politiques - Institut Hannah Arendt (EEP), Université Paris-Est Marne-la-Vallée (UPEM), Hôpital Européen Georges Pompidou [APHP] (HEGP), Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Hôpitaux Universitaires Paris Ouest - Hôpitaux Universitaires Île de France Ouest (HUPO), Service d'Accueil des Urgences (AGEN - SAU), Centre Hospitalier d'Agen, Université de Bordeaux (UB), Service de Cardiologie (hôpital d'Annecy), Centre hospitalier de la région d'Annecy, Service d'hépato-gastroentérologie, Hôpital Cochin [AP-HP], Service d'anesthésie réanimation chirurgicale [Rennes], Université de Rennes (UR)-Hôpital Pontchaillou, CHU Pontchaillou [Rennes], Centre Hospitalier Régional Universitaire [Montpellier] (CHRU Montpellier), Service de réanimation chirurgicale, Hôpital Edouard Herriot [CHU - HCL], Hospices Civils de Lyon (HCL)-Hospices Civils de Lyon (HCL), Thérapeutiques cliniques et expérimentales des infections (EA 3826) (EA 3826), Université de Nantes - UFR de Médecine et des Techniques Médicales (UFR MEDECINE), Université de Nantes (UN)-Université de Nantes (UN), Clinique de réanimation médicale, Université Joseph Fourier - Grenoble 1 (UJF)-CHU Grenoble-Hôpital Michallon, Laboratoire SUBATECH Nantes (SUBATECH), Mines Nantes (Mines Nantes)-Université de Nantes (UN)-Institut National de Physique Nucléaire et de Physique des Particules du CNRS (IN2P3)-Centre National de la Recherche Scientifique (CNRS), Service des Urgences (PMR), CHRU - ANGERS, CHU d'Angers [Département Urgences], Centre Hospitalier Universitaire d'Angers (CHU Angers), PRES Université Nantes Angers Le Mans (UNAM)-PRES Université Nantes Angers Le Mans (UNAM), Pôle de Pathologie cardiologie-vasculaire, Institut d'Hématologie-Transfusion-Université de Lille, Droit et Santé-Centre Hospitalier Régional Universitaire [Lille] (CHRU Lille), Unité de soins intensifs, Centre Hospitalier Universitaire de Nîmes (CHU Nîmes), Université Sorbonne Paris Cité (USPC), Universidad Nacional Autónoma de México (UNAM), Université Joseph Fourier - Grenoble 1 (UJF)-Institut polytechnique de Grenoble - Grenoble Institute of Technology (Grenoble INP)-IMAG-Centre National de la Recherche Scientifique (CNRS)-Université Grenoble Alpes (UGA)-Université Joseph Fourier - Grenoble 1 (UJF)-Institut polytechnique de Grenoble - Grenoble Institute of Technology (Grenoble INP)-IMAG-Centre National de la Recherche Scientifique (CNRS)-Université Grenoble Alpes (UGA)-Pôle Anesthésie Réanimation, Université Fédérale Toulouse Midi-Pyrénées-Université Fédérale Toulouse Midi-Pyrénées-IFR150-Institut National de la Santé et de la Recherche Médicale (INSERM), Aix Marseille Université (AMU)-Institut National de la Recherche Agronomique (INRA)-Institut National de la Santé et de la Recherche Médicale (INSERM), Centre Hospitalier Universitaire de Saint-Etienne (CHU de Saint-Etienne), Université de Tours-Centre National de la Recherche Scientifique (CNRS), Université Joseph Fourier - Grenoble 1 (UJF)-Institut polytechnique de Grenoble - Grenoble Institute of Technology (Grenoble INP)-IMAG-Centre National de la Recherche Scientifique (CNRS)-Université Grenoble Alpes (UGA)-Université Joseph Fourier - Grenoble 1 (UJF)-Institut polytechnique de Grenoble - Grenoble Institute of Technology (Grenoble INP)-IMAG-Centre National de la Recherche Scientifique (CNRS)-Université Grenoble Alpes (UGA), Université Joseph Fourier - Grenoble 1 (UJF)-Institut polytechnique de Grenoble - Grenoble Institute of Technology (Grenoble INP)-IMAG-Centre National de la Recherche Scientifique (CNRS)-Université Grenoble Alpes (UGA), Institut de Chimie de la Matière Condensée de Bordeaux (ICMCB), Centre National de la Recherche Scientifique (CNRS)-Université de Bordeaux (UB), Service d'Anesthésie-Réanimation, CHU Toulouse [Toulouse]-Institut Louis Bugnard-Hôpital de Rangueil, CHU Toulouse [Toulouse], INSB-INSB-Centre National de la Recherche Scientifique (CNRS), Groupe de recherche sur la thrombose (GRT (EA 3065)), Université Jean Monnet [Saint-Étienne] (UJM), INSERM U1059, SAINBIOSE - Santé, Ingénierie, Biologie, Saint-Etienne (SAINBIOSE-ENSMSE), Institut Mines-Télécom [Paris] (IMT)-Institut Mines-Télécom [Paris] (IMT)-Université Jean Monnet [Saint-Étienne] (UJM)-Institut National de la Santé et de la Recherche Médicale (INSERM), Assistance publique - Hôpitaux de Paris (AP-HP) (APHP)-CHU Cochin [AP-HP], Assistance publique - Hôpitaux de Paris (AP-HP) (APHP)-Hôpitaux Universitaires Paris Ouest - Hôpitaux Universitaires Île de France Ouest (HUPO), CHU Cochin [AP-HP], Service Anesthésie et Réanimation, Centre Hospitalier Régional Universitaire de Nîmes (CHRU Nîmes), VetAgro Sup - Institut national d'enseignement supérieur et de recherche en alimentation, santé animale, sciences agronomiques et de l'environnement (VAS)-Institut polytechnique de Grenoble - Grenoble Institute of Technology (Grenoble INP )-Centre National de la Recherche Scientifique (CNRS)-Université Joseph Fourier - Grenoble 1 (UJF)-VetAgro Sup - Institut national d'enseignement supérieur et de recherche en alimentation, santé animale, sciences agronomiques et de l'environnement (VAS)-Institut polytechnique de Grenoble - Grenoble Institute of Technology (Grenoble INP )-Centre National de la Recherche Scientifique (CNRS)-Université Joseph Fourier - Grenoble 1 (UJF)-Pôle Anesthésie Réanimation, Hôpital Pontchaillou-Université de Rennes 1 (UR1), Université de Rennes (UNIV-RENNES)-Université de Rennes (UNIV-RENNES), Centre National de la Recherche Scientifique (CNRS)-Institut National de Physique Nucléaire et de Physique des Particules du CNRS (IN2P3)-Université de Nantes (UN)-Mines Nantes (Mines Nantes), Université Fédérale Toulouse Midi-Pyrénées-Université Fédérale Toulouse Midi-Pyrénées- Institut Fédératif de Recherche Bio-médicale Institution (IFR150)-Institut National de la Santé et de la Recherche Médicale (INSERM), CHU Toulouse [Toulouse]-Institut Louis Bugnard, Université de Rennes 1 (UR1), Université de Rennes (UNIV-RENNES)-Université de Rennes (UNIV-RENNES)-Hôpital Pontchaillou, Université Jean Monnet [Saint-Étienne] (UJM)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre Ingénierie et Santé (CIS-ENSMSE), and Institut Mines-Télécom [Paris] (IMT)-Institut Mines-Télécom [Paris] (IMT)

Subjects
Rivaroxaban, business.industry, [SDV]Life Sciences [q-bio], Renal function, 030204 cardiovascular system & hematology, 3. Good health, Dabigatran, 03 medical and health sciences, 0302 clinical medicine, Anesthesiology and Pain Medicine, Anesthesia, Medicine, Apixaban, Observational study, In patient, 030212 general & internal medicine, business, Prospective cohort study, [SDV.MHEP]Life Sciences [q-bio]/Human health and pathology, medicine.drug, Cohort study
Abstract

Background The use of prothrombin complex concentrates and the role of plasma concentration of anticoagulants in the management of bleeding in patients treated with direct oral anticoagulants are still debated. Our aim was to describe management strategies and outcomes of severe bleeding events in patients treated with direct oral anticoagulants. Methods We performed a prospective cohort study of 732 patients treated with dabigatran, rivaroxaban, or apixaban hospitalized for severe bleeding, included prospectively in the registry from June 2013 to November 2015. Results Bleeding was gastrointestinal or intracranial in 37% (212 of 732) and 24% (141 of 732) of the cases, respectively. Creatinine clearance was lower than 60 ml/min in 61% (449 of 732) of the cases. The plasma concentration of direct oral anticoagulants was determined in 62% (452 of 732) of the cases and was lower than 50 ng/ml or higher than 400 ng/ml in 9.2% (41 of 452) and in 6.6% (30 of 452) of the cases, respectively. Activated or nonactivated prothrombin complex concentrates were administered in 38% of the cases (281 of 732). Mortality by day 30 was 14% (95% CI, 11 to 16). Conclusions Management of severe bleeding in patients treated with direct oral anticoagulants appears to be complex. The use of prothrombin complex concentrates differs depending on bleeding sites and direct oral anticoagulant plasma concentrations. Mortality differs according to bleeding sites and was similar to previous estimates.

Published
2017
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3. Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study

Author

Morgan Jaffrelot, Marije Ten Wolde, Renée A. Douma, Menno V. Huisman, Paul L. den Exter, Olivier Thierry Rutschmann, Farès Moustafa, Pierre-Marie Roy, Josien van Es, Alessandra Principe, Pieter Willem Kamphuisen, A Trinh-Duc, Marc Philip Righini, Olivier Sanchez, Marco J. J. H. Grootenboers, Marc Durian, Y. Whitney Cheung, Guy Meyer, Catherine Le Gall, Franck Verschuren, Grégoire Le Gal, Klaas W Van Kralingen, Petra M. G. Erkens, Henri Bounameaux, Anja A. van Houten, Alexandre Ghuysen, Germa Hazelaar, Service d'angiologie et d'hémostase (MR), Hôpital Universitaire de Genève, Department of Vascular Medicine (AMSTERDAM - DVM), Academic Medical Center - Academisch Medisch Centrum [Amsterdam] (AMC), University of Amsterdam [Amsterdam] (UvA)-University of Amsterdam [Amsterdam] (UvA), Department of Thrombosis and Hemostasis (LEIDEN - DTH), Leiden University Medical Center (LUMC), Service des Urgences (PMR), CHRU - ANGERS, Emergency Department (FV - ED), Saint Luc University Hospital, Hôpital Européen Georges Pompidou [APHP] (HEGP), Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Hôpitaux Universitaires Paris Ouest - Hôpitaux Universitaires Île de France Ouest (HUPO), Service des Urgences (MG), Centre Hospitalier Régional Universitaire de Brest (CHRU Brest), Service d'Accueil des Urgences (AGEN - SAU), Centre Hospitalier d'Agen, Service d'Accueil des Urgences (ARGENTEUIL - SAU), CH Argenteuil, Département des Urgences, CHU Clermont-Ferrand, Service des Urgences (CHPM - SU), CH Morlaix, Department of Internal Medicine (ROTTERDAM - Med Int), Maasstad Hospital, Department of Vascular Medicine (DVM - AMC), Department of General Practice (CAPHRI), Maastricht University [Maastricht], Department of Vascular Medicine (DVM - Groningen), University Medical Center Groningen [Groningen] (UMCG), Groupe d'Etude de la Thrombose de Bretagne Occidentale (GETBO), Institut Brestois Santé Agro Matière (IBSAM), Université de Brest (UBO)-Université de Brest (UBO)-Université de Brest (UBO), Centre d'Investigation Clinique (CIC - Brest), Université de Brest (UBO)-Institut National de la Santé et de la Recherche Médicale (INSERM), Cardiovascular Centre (CVC), Vascular Ageing Programme (VAP), Vascular Medicine, Other departments, 01 Internal and external specialisms, Family Medicine, RS: CAPHRI School for Public Health and Primary Care, Biochemie, RS: CAPHRI - Clinical epidemiology, and Hematology

Subjects
Male, MESH: Pulmonary Embolism, REVISED GENEVA SCORE, [SDV]Life Sciences [q-bio], 030204 cardiovascular system & hematology, Gastroenterology, MESH: Venous Thromboembolism, 0302 clinical medicine, Reference Values, Outpatients, EXCLUSION, Prevalence, Cutoff, Prospective Studies, 030212 general & internal medicine, Geneva score, Prospective cohort study, ELDERLY-PATIENTS, ddc:616, MESH: Aged, MESH: Angiography, MESH: Risk, Respiratory disease, Age Factors, Angiography, MESH: Reference Values, General Medicine, EMERGENCY, Thrombosis, 3. Good health, Pulmonary embolism, Europe, MESH: Emergency Service, Hospital, Acute Disease, MESH: Diagnostic Errors, MESH: Acute Disease, Female, Emergency Service, Hospital, Risk, medicine.medical_specialty, MESH: Probability, Age adjustment, Sensitivity and Specificity, Fibrin Fibrinogen Degradation Products, 03 medical and health sciences, Internal medicine, D-dimer, medicine, MANAGEMENT, MESH: Fibrin Fibrinogen Degradation Products, Humans, COMPUTED-TOMOGRAPHY, Diagnostic Errors, MESH: Prevalence, Aged, Probability, MESH: Age Factors, VENOUS THROMBOEMBOLISM, MESH: Humans, business.industry, DIAGNOSTIC STRATEGIES, medicine.disease, MESH: Male, MESH: Prospective Studies, MESH: Sensitivity and Specificity, Surgery, CLINICAL PROBABILITY, MESH: Outpatients, THROMBOSIS, MESH: Europe, Pulmonary Embolism, business, MESH: Female
Abstract

International audience; IMPORTANCE: D-dimer measurement is an important step in the diagnostic strategy of clinically suspected acute pulmonary embolism (PE), but its clinical usefulness is limited in elderly patients. OBJECTIVE: To prospectively validate whether an age-adjusted D-dimer cutoff, defined as age × 10 in patients 50 years or older, is associated with an increased diagnostic yield of D-dimer in elderly patients with suspected PE. DESIGN, SETTINGS, AND PATIENTS: A multicenter, multinational, prospective management outcome study in 19 centers in Belgium, France, the Netherlands, and Switzerland between January 1, 2010, and February 28, 2013. INTERVENTIONS: All consecutive outpatients who presented to the emergency department with clinically suspected PE were assessed by a sequential diagnostic strategy based on the clinical probability assessed using either the simplified, revised Geneva score or the 2-level Wells score for PE; highly sensitive D-dimer measurement; and computed tomography pulmonary angiography (CTPA). Patients with a D-dimer value between the conventional cutoff of 500 µg/L and their age-adjusted cutoff did not undergo CTPA and were left untreated and formally followed-up for a 3-month period. MAIN OUTCOMES AND MEASURES: The primary outcome was the failure rate of the diagnostic strategy, defined as adjudicated thromboembolic events during the 3-month follow-up period among patients not treated with anticoagulants on the basis of a negative age-adjusted D-dimer cutoff result. RESULTS: Of the 3346 patients with suspected PE included, the prevalence of PE was 19%. Among the 2898 patients with a nonhigh or an unlikely clinical probability, 817 patients (28.2%) had a D-dimer level lower than 500 µg/L (95% CI, 26.6%-29.9%) and 337 patients (11.6%) had a D-dimer between 500 µg/L and their age-adjusted cutoff (95% CI, 10.5%-12.9%). The 3-month failure rate in patients with a D-dimer level higher than 500 µg/L but below the age-adjusted cutoff was 1 of 331 patients (0.3% [95% CI, 0.1%-1.7%]). Among the 766 patients 75 years or older, of whom 673 had a nonhigh clinical probability, using the age-adjusted cutoff instead of the 500 µg/L cutoff increased the proportion of patients in whom PE could be excluded on the basis of D-dimer from 43 of 673 patients (6.4% [95% CI, 4.8%-8.5%) to 200 of 673 patients (29.7% [95% CI, 26.4%-33.3%), without any additional false-negative findings. CONCLUSIONS AND RELEVANCE: Compared with a fixed D-dimer cutoff of 500 µg/L, the combination of pretest clinical probability assessment with age-adjusted D-dimer cutoff was associated with a larger number of patients in whom PE could be considered ruled out with a low likelihood of subsequent clinical venous thromboembolism. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01134068.

Published
2014
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