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  • Title: Diagnosis of pulmonary embolism in the elderly: adherence to guidelines and age-adjusted D-dimer concentration values.
    Author: Lozano-Polo L, Puig-Campmany M, Herrera-Mateo S, Mateo-Roca M, Santos-Rodríguez JA, Benito-Vales S.
    Journal: Emergencias; 2018 Oct; 30(5):321-327. PubMed ID: 30260116.
    Abstract:
    OBJECTIVES: . The main purpose was to assess our emergency department's level of adherence to clinical practice guidelines (CPGs) for the diagnosis of pulmonary embolism in different age groups. The secondary aims were to study the utility and estimated the number of avoidable CT angiography with this approach of age-adjusted D-dimer concentrations in combination with the Wells score in the diagnosis of pulmonary embolism. MATERIAL AND METHODS: Retrospective observational study of a series of hemodynamically stable patients suspected of having pulmonary embolism in the emergency department of a tertiary care university hospital in 2012. Cases were identified in hospital discharge records on the basis of orders for D-dimer assays and computed tomography (CT) angiography of pulmonary arteries justified by suspicion of pulmonary embolism. We analyzed the degree of adherence to CPGs according to age groups, calculated the specificity and sensitivity of combining age-adjusted D-dimer test results and the Wells score, and estimated the number of potentially avoidable CT angiography procedures. RESULTS: We found a total of 785 patients (mean age, 69 years; range, 18-97 years) suspected of having pulmonary embolism; 403 (51.3%) were women. Significant differences were detected in adherence to CPGs, depending on which clinical prediction models were used and patient age (50 years or younger, 69.7%-76.5% adherence; 65-74 years, 32.3%-53.2%; 75-84 years, 29.1%-46.8%; 85-89 years, 32.7%-41.8%; and 90 years or older, 24.4%-46.7%). Adherence was increased when D-dimer test result and the simplified Wells score were combined (increments of 10.4%, 8.0%, 13.6%, 11.1%, respectively in the following age groups: 65-74 years, 75-84 years, 85-89 years, and 90 years or older). Using an ageadjusted D-dimer cut-point increased diagnostic specificity (34.2% without such a cut-point vs 45.8% with one). The positive predictive value of the test also increased when an age-adjusted D-dimer cut-point was used (to 11.4%, from 9.6% without age adjustement). Seventy CT angiograph procedures (12.5%) could have been avoided by using age-adjusted cut-points. CONCLUSION: We observed different degrees of age-related adherence to CPGs in cases in which pulmonary embolism was suspected. Using the simplified Wells score combined with an age-adjusted cut-point for D-dimer assay positivity improved the specificity and positive predictive value of the D-dimer assessment in comparison with standard practice. Using age-adjusted D-dimer cut-points could decrease the number of pulmonary artery CT angiograms required. OBJETIVO: El objetivo principal fue estudiar la adherencia a las guías de práctica clínica (GPC) para el diagnóstico de embolismo pulmonar (EP) según la edad del paciente. Los objetivos secundarios fueron investigar las características del dímero-D corregido por edad (DDc) en combinación con la Escala de Wells para el diagnóstico de EP y el número de angio-TC pulmonares potencialmente evitables con dicha estrategia. METODO: Estudio observacional retrospectivo de una serie de casos de pacientes con sospecha de EP con estabilidad hemodinámica en un servicio de urgencias de un hospital universitario de tercer nivel durante el año 2012. Los casos se obtuvieron a partir de las solicitudes de dímero-D, las angio-TC pulmonares realizadas por sospecha de EP y el registro de altas hospitalarias. Se realizó un análisis del grado de adherencia a las GPC según grupos de edad y se calculó las características del DDc en combinación con la Escala de Wells y el número de angio-TC potencialmente evitables con dicha estrategia. RESULTADOS: Se incluyeron 785 pacientes con sospecha de EP con una edad mediana de 69 años (rango 18-97), de los cuales 403 (51,3%) fueron mujeres. Se observaron diferencias significativas del grado de adherencia a las GPC en función del grupo de edad de los pacientes para las diferentes escalas de probabilidad clínica (EPC) ( 50 años: 69,7%-76,5%; 65-74 años: 32,3%-53,2%; 75-84 años: 29,1%-46,8%; 85-89 años: 32,7%-41,8%; 90 años: 24,4%-46,7%). La combinación del DDc y la Escala de Wells simplificada aumentó la adherencia (incrementos del 10,4%, 8,0%, 13,6%, 11,1%, en cada grupo de edad, respectivamente). El punto de corte del DDc aumentó la especificidad (34,2% vs 45,8%) y el valor predictivo positivo (9,6% vs 11,4%), y hubiera evitado 70 (12,5%) angio-TC pulmonares. CONCLUSIONES: Se hallaron diferencias de adherencia a las GPC en las sospechas de EP en función de la edad. La Escala de Wells simplificada combinada con el punto de corte del DDc obtuvo una mayor especificidad y valor predictivo positivo que con el DD estándar, lo que podría disminuir el número de angio-TC pulmonares.
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