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Accuracy of combining clinical probability score and simpliRED d-dimer for diagnosis of pulmonary embolism
  1. Russell Boyd, Consultant,
  2. Kerstin Hogg, Clinical Research Fellow
  1. Department of Emergency Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK; kevin.mackway-jones:man.ac.uk

    Abstract

    A short cut review was carried out to establish whether bedside clinical examination and simpliRED d-dimer are sufficiently sensitive to rule out pulmonary embolus. A total of 272 papers were found using the reported search, of which five presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.

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    Report by Russell Boyd,ConsultantChecked by Kerstin Hogg, Clinical Research Fellow

    Clinical scenario

    A 34 year old woman presents with a two day history of pleuritic chest pain. There are no abnormal physical signs and her only risk factor is that she is taking oral contraceptives long term. You wonder if a combination of clinical examination and the available d-dimer test (SimpliRED) would be suitable to rule out pulmonary embolism.

    Three part question

    In [suspected PE] is [bedside clinical examination and simpliRED d-dimer sufficiently sensitive] at [ruling out PE]?

    Search strategy

    Medline 1966–04/03 using the OVID interface. [D-dimer.mp OR simplired.mp OR whole blood.mp] AND [exp thromboembolism OR exp pulmonary embolism OR PE.mp OR pulmonary embol$.mp OR pulmonary infarct$.mp] AND [exp“sensitivity and specificity”.mp OR sensitivity.tw OR di.xs OR du.fs OR specificity.tw] LIMIT to human AND English.

    Search outcome

    Altogether 272 papers were identified of which five were relevant and of sufficient quality. These are shown in table 7.

    Table 7

    Comment(s)

    Use of a bedside clinical decision rule for PE probability with the additional use of latex agglutination d-dimer testing results in high levels of sensitivity and high negative predictive values in the low PE risk groups. It is this group of patients that makes up the bulk of patients with a putative diagnosis of PE. However, latex agglutination d-dimers do not perform well in high or even moderate risk groups.

    CLINICAL BOTTOM LINE

    Patients at low clinical risk with a negative bedside d-dimer can have pulmonary embolus ruled out.

    Report by Russell Boyd,ConsultantChecked by Kerstin Hogg, Clinical Research Fellow

    References

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