The combination of four different clinical decision rules and an ageadjustedd-dimer cut-off increases the number of patients in whomacute pulmonary embolism can safely be excluded

Four clinical decision rules (CDRs) (Wells score, Revised Geneva Score(RGS), simplified Wells score and simplified RGS) safely exclude pulmonaryembolism (PE), when combined with a normal D-dimer test. Recently,an age-adjusted cut-off of the D-dimer (patient's age x 10 μg/l)safely increased the number of patients above 50 years in whom PEcould safely be excluded. We validated the age-adjusted D-dimer testand assessed its performance in combination with the four CDRs in patientswith suspected PE. A total of 414 consecutive patients with suspectedPE who were older than 50 years were included. The proportionof patients in whom PE could be excluded with an 'unlikely' clinicalprobability combined with a normal age-adjusted D-dimer test was calculatedand compared with the proportion using the conventionalD-dimer cut-off. We assessed venous thromboembolism (VTE) failurerates during three months follow-up. In patients above 50 years, a normalage-adjusted D-dimer level in combination with an 'unlikely' CDRsubstantially increased the number of patients in whom PE could besafely excluded: from 13-14% to 19-22% in all CDRs similarly. In patientsover 70 years, the number of exclusions was nearly four-foldhigher, and the original Wells score excluded most patients, with an increasefrom 6% to 21% combined with the conventional and age-adjustedD-dimer cut-off, respectively. The number of VTE failures was alsocomparable in all CDRs. In conclusion, irrespective of which CDR isused, the age-adjusted D-dimer substantially increases the number of patients above 50 years in whom PE can be safely excluded.

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