EUH Morning Report: Can PE be ruled out with a D-Dimer of less than 1000?

The Bottom Line: The YEARS algorithm simultaneously assesses three items – clinical signs of DVT, hemoptysis, and whether PE is the most likely diagnosis – as well as a D-dimer test threshold of 500 ng/mL in presence, and 1000 ng/mL in absence of one of the YEARS items.

Van der Hulle et al (2017) safely excluded PE in patients with no YEARS items and a D-dimer concentration less than 1000 ng/ML. PE was also excluded in patients with one or more YEARS items and a D-dimer concentration less than 500 ng/mL.  Theirs is the first prospective outcome study to validate a D-dimer threshold of 1000 ng/mL in patients with a low clinical probability. The YEARS clinical decision tool also achieved a 14% decrease in the need for CTPA.

References: Konstantinides SV. Diagnosis of pulmonary embolism: progress after many YEARS. Lancet. 2017 July 15:390(10091):210-211. doi:10.1016/X0140-6736(17)31291-6.

van der Hulle T, Cheung WY, Kooij S, Beenen LFM, et al. Simplified diagnostic management of suspected pulmonary embolism (the YEARS study): a prospective, multicentre, cohort study. Lancet. 2017 Jul15;390(10091):289-297. doi:10.1016/S0140-6736(17)30885-1.

Summary:  Konstantinides (2017) highlights the strengths of the YEARS study by saying, the results of YEARS study are more than another technical refinement of existing algorithms: they address a true medical need in contemporary practice. Indeed, an increase in the use of CTPA has consistently been observed in population studies describing trends in the management of the disease in the past three decades (p.211).

Additionally, it is simple and easy to remember, it appears to work independently from the patient’s age, and the D-dimer tests are integrated into the clinical assessment right from the beginning, reflecting real world conditions. However, the YEARS algorithm has retained the most subjective and contentious element of the Wells’ rule—namely, “Alternative diagnosis less likely than PE [pulmonary embolism]”. In fact, it cannot be excluded that fulfillment of this criterion could now become even more vulnerable to bias and lead to over suspicion of pulmonary embolism, if physicians misinterpret the YEARS study data and start using D-dimer tests as the first screening tool (Konstantinides, 2017).

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