CAN WE RELY ON THE D-DIMER ASSAY FOR PROGNOSTIC ASSESSMENT ACROSS ACUTE PULMONARY EMBOLISM?

Abstract

Background: Data is lacking over the prognostic importance of the D-dimer assay across acute pulmonary embolism (PE). Purpose: to assess PE prognosis stratified by the D-dimer assay. Population: Retrospective, longitudinal, continuous analysis of 135 patients admitted for an acute pulmonary embolism between 2000 and 2008 in a single center. The D-dimer was available for 113 patients. Two groups were created based on the D-dimer level: A (n=71) D-dimer ≤9.85 mg/ml; B (n=42) D-dimer >9.85 mg/ml. The primary endpoint was a composite of in-hospital mortality and the need for escalation of treatment defined by one of the following: catecholamine infusion, need for mechanical ventilation or cardiopulmonary resuscitation. A clinical follow up was performed targeting all-cause mortality and PE recurrence (median time follow up 764 days). Results: the mean D-dimer value for the population was 14.1 ±22.3 mg/ml. The area under the curve for the primary endpoint was 0.67 (p=0.046). A D-dimer of 9.85 had 61.5% sensitivity and 66.6% specificity for the primary outcome. There were no differences between groups with respect to demographics. Both groups had a similar rate of cancer, venous insufficiency, deep vein thrombosis, heart failure, known thrombophilia, and recent history of surgery. Groups were also similar with respect to clinical presentation and time of symptom duration. The rate of cardiogenic shock was similar between groups (21.3 vs 20.6%) but there were a higher rate of markers of right ventricular dysfunction and myocardial injury in group B (38.3 vs 64.7% p=0.027). Thrombolysis was performed in a similar rate for both groups (84.1 vs 82.7% p=0.18), and there were no differences between them regarding bleeding rate (14.1 vs 26.2%). Seven percent of group A versus 19.0% of group B patients (p=0.05) reached the primary endpoint. On a multivariate logistic regression analysis that included D-dimer, age, cardiogenic shock and thrombolysis, the D-dimer assay no longer remained significant for the primary endpoint. Conclusion: In our population d-dimer was weak prognostic marker for in-hospital events.