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Safety and Efficiency of Diagnostic Strategies for Ruling out Pulmonary Embolism in Important Patient Subgroups: A Systematic Review and Individual-patient Data Meta-analysis

1Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands, 2Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands, 3Department of Vascular Medicine, Amsterdam University Medical Center, location AMC, Amsterdam Cardiovascular Science, Amsterdam, Netherlands, 4Department of Emergency Medicine, Centre Hospitalo-Universitaire Pitié-Salpêtrière, Assistance-Publique Hôpitaux de Paris, Paris, France, 5Service of Anesthesiology, Hospital MD Anderson Cancer Center, Madrid, Spain, 6Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Thrombosis Research Group, Ottawa, Canada, 7Department of Medicine, Østfold Hospital Trust, Fredrikstad, Norway, 8Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, United States, 9Department of Oncology, McMaster University, Hamilton, Canada, 10Division of Angiology and Hemostasis, Department of Medical Specialties, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland, 11Department of Emergency, University of Angers, Angers, France, 12Department of Medicine, The Thrombosis and Atherosclerosis Research Institute, Mc Master University, Hamilton, Canada

Abstract Number: OC 73.2

Meeting: ISTH 2021 Congress

Theme: Venous Thromboembolism » VTE Diagnosis

Background: It is unknown how different diagnostic strategies for suspected pulmonary embolism (PE) perform in relevant patient subgroups defined by sex, age, cancer, and previous venous thromboembolism (VTE).

Aims: To evaluate the safety and efficiency of the Wells and revised Geneva scores in combination with fixed, age-adjusted, and pre-test probability adjusted D-dimer thresholds, as well as the YEARS algorithm, for ruling out acute PE in these patient subgroups.

Methods: MEDLINE was searched from 1 January 1995 until January 1st 2021 and studies which assessed at least one diagnostic strategy under evaluation were selected. Individual data from 20,564 patients was collected from 16 studies and analyzed. Primary outcomes were safety and efficiency. Safety was defined as the diagnostic failure rate, i.e. the estimated 3-month incidence of VTE in patients in whom PE was considered excluded without imaging. Efficiency was defined as the probability of being classified as ‘PE considered excluded’ without imaging tests.

Results: Across all strategies, efficiency was highest in patients <40 years old (48-68%) and lowest in patients ≥80 years old and in patients with active cancer. In these latter subgroups (elderly and cancer patients), efficiency estimates varied around 5-10% when using the fixed D-dimer threshold, but improved by up to 25% when a pre-test probability adjusted D-dimer was used (Table 1). This pre-test probability adjusted D-dimer approach increased the failure rate to 2-4% (Table 2), although increased heterogeneity around the estimates, potential misclassification bias and differential verification bias prevented definitive conclusions on the superiority of either of the different strategies in the predefined patient subgroups.

Table 1. Efficiency* of the CDRs and D-dimer testing in excluding PE overall and in important subgroups
Table 2. Failure rate* of the CDRs and D-dimer testing in excluding PE overall and in important subgroups​

Conclusions: The safety and efficiency of the studied diagnostic strategies varied across different patient subgroups. Overall, the strategies under study all might be considered safe across the predefined subgroups. From an efficiency perspective, this IPDMA supports the use of pre-test probability adjusted D-dimer thresholds.

To cite this abstract in AMA style:

Stals MAM, Takada T, Kraaijpoel N, van Es N, HR Büller , Y Freund , J Galipienzo , G Le Gal , W Ghanima , MV Huisman , JA Kline , KGM Moons , S Parpia , M Righini , P-M Roy , M van Smeden , PS Wells , K de Wit , GJ Geersing , FA Klok . Safety and Efficiency of Diagnostic Strategies for Ruling out Pulmonary Embolism in Important Patient Subgroups: A Systematic Review and Individual-patient Data Meta-analysis [abstract]. Res Pract Thromb Haemost. 2021; 5 (Suppl 2). https://abstracts.isth.org/abstract/safety-and-efficiency-of-diagnostic-strategies-for-ruling-out-pulmonary-embolism-in-important-patient-subgroups-a-systematic-review-and-individual-patient-data-meta-analysis/. Accessed November 29, 2023.

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