ADJUST PE trial

Should we use an age-adjusted value for D-dimer in patients >50 presenting with SOB, chest pain with normal ECG and CXR and with low-intermediate probability of PE ?

1

** In 200 of patients <75 yo, 157 had D-dimer between 500 and age cutoff value and 43 had D-dimer <500. 5 patients were excluded later but no mention on which group they were from.

Wouldn’t say much because it has been discussed extensively in

My summary is:

  1. There is low prevalence of PE in the population studied (19%). Predictive values in this study may not be applicable in your setting. Unfortunately, no sens, spec or likelihood ratio is provided.
  2. Actually, only 337 of patients had D-dimer value between 500-age adjusted value.
  3. No control group in this study.
  4. Use of 2 different scoring systems and 6 different assays for D-dimer,
    – As seen from the below table, 70% of the patients used mainly 2 types of assays.For other assays, we don’t know whether including more patients in these assays will result in more missed PE. (i.e are the other assays equivalent or just lucky that the patients didn’t have PE?)Capture
    – We need to know the type of assays used in our hospital
  5. The outcome was adjudicated, not confirmed by CTPA. Similarly the cause of death is adjudicated, not confirmed by biopsy.
  6. Most of the elderly patients will get CTPA regardless of D-dimer because they are often at higher risk (immobilization, DVT history, CHF etc). So this study may not change the way you are practising right now.

Reference:

Rhigini et al. The ADJUST PE Study. JAMA. 2014;311(11):1117-1124

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