title: Age-Adjusted Cutoff D-Dimer Level to Rule Out Acute Pulmonary Embolism: A Validation Cohort Study.
abstract: BACKGROUND
  The diagnosis of pulmonary embolism in the Emergency Room setting is challenging. Multiple patients have to undergo radiologic assessment with its inherent shortcomings. The D-dimer test with accepted cutoff level of 500 μg/L is associated with a high proportion of false-positive results. The present study aimed to validate the advantages of using an age-adjusted D-dimer cutoff level, compared with 500-μg/L value in the diagnosis of acute pulmonary embolism.
  
  
  METHODS
  This study evaluated patients admitted to the Rambam Emergency Room between 2011 and 2014 with a suspected diagnosis of pulmonary embolism. Patient data, D-dimer plasma levels, and imaging results were collected. The study cohort was subdivided according to the D-dimer levels below and above 500 μg/L. The group with levels above 500 μg/L was further assessed using the newly suggested age-adjusted D-dimer cutoff level, defined as age multiplied by 10.
  
  
  RESULTS
  Files of 1241 patients were reviewed; 654 patients with low or intermediate risk for pulmonary embolism had a D-dimer level above 500 μg/L. Two hundred eight (208) patients had a D-dimer level above 500 μg/L but below the age-adjusted cutoff value; one of them was diagnosed with pulmonary embolism (0.48% [95% confidence interval 0%-2.6%]). Four hundred forty-six (446) patients had a D-dimer level above the age-adjusted cutoff value, and 28 of them were diagnosed with pulmonary embolism (6.28% [95% confidence interval 4.2%-8.9%]), representing a negative predictive value of 99.5% for the age-adjusted cutoff level.
  
  
  CONCLUSIONS
  An age-adjusted D-dimer cutoff level may be safely used to exclude pulmonary embolism in patients with a low or intermediate probability for acute pulmonary embolism, alleviating the need to perform unnecessary imaging evaluations.
authors.affiliation: Internal Medicine C, Rambam Health Care Campus, Haifa, Israel.
authors.forename: Eyal
authors.initials: E
authors.lastname: Fuchs
authors.affiliation: Faculty of Medicine, Technion, Haifa, Israel.
authors.forename: Suwar
authors.initials: S
authors.lastname: Asakly
authors.affiliation: Internal Medicine C, Rambam Health Care Campus, Haifa, Israel.
authors.forename: Amir
authors.initials: A
authors.lastname: Karban
authors.affiliation: Internal Medicine C, Rambam Health Care Campus, Haifa, Israel; Department of Hematology, Rambam Health Care Campus, Haifa, Israel. Electronic address: i_tzoran@rambam.health.gov.il.
authors.forename: Inna
authors.initials: I
authors.lastname: Tzoran
mesh_terms: D000367:Age Factors; D000368:Aged; D015415:Biomarkers / Q000032:analysis; D004636:Emergency Service, Hospital; D005260:Female; D005338:Fibrin Fibrinogen Degradation Products / Q000032:analysis*; D006801:Humans; D007557:Israel; D008297:Male; D008875:Middle Aged; D011655:Pulmonary Embolism / Q000175:diagnosis*
chemical_list: D015415:Biomarkers; D005338:Fibrin Fibrinogen Degradation Products; C036309:fibrin fragment D
keywords: Age-adjusted D-dimer cutoff level; Diagnosis; Emergency Room; Pulmonary embolism