Age-Adjusted Prevalence of Diagnosed Diabetes Among U.S. Adults
2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off:...
Transcript of 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off:...
![Page 1: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/1.jpg)
![Page 2: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/2.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
2014 ESC Guidelines on the diagnosis and
management of acute pulmonary embolism Endorsed by the European Respiratory Society (ERS)
Chairpersons: Stavros Konstantinides (Germany/Greece), Adam Torbicki (Poland)
Authors/Task Force members: Giancarlo Agnelli (Italy), Nicolas Danchin (France), David Fitzmaurice (UK), Nazzareno Galiè (Italy), J. Simon R. Gibbs (UK), Menno Huisman (The Netherlands), Marc Humbert (France), Nils Kucher (Switzerland), Irene Lang (Austria), Mareike Lankeit (Germany), John Lekakis (Greece), Christoph Maack (Germany), Eckhard Mayer (Germany), Nicolas Meneveau (France), Arnaud Perrier (Switzerland), Piotr Pruszczyk (Poland), Lars H. Rasmussen (Denmark), Thomas H. Schindler (USA), Pavel Svitil (Czech Republic), Anton Vonk Noordegraaf (The Netherlands), Jose Luis Zamorano (Spain), Maurizio Zompatori (Italy)
![Page 3: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/3.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
Relevant new aspects 2014 – staging/management
(1) New predisposing factors
(2) Simplification of clinical prediction rules
(3) Age-adjusted D-dimer cut-offs
(4) Sub-segmental/incidental PE
(5) New stratification of mortality risk PE
(6) Enigma of thrombolytic treatment in intermediate risk PE
(7) Initiation of treatment with vitamin K antagonists
(8) PE treatment with non-Vitamin-K-dependent oral ACs
(9) Early discharge and home (outpatient) treatment of PE
(10) Current diagnosis and treatment of CTEPH
(11) Recommendations for PE in cancer/pregnancy
![Page 4: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/4.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
![Page 5: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/5.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
SBP < 90 mmHg
![Page 6: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/6.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
Initial risk stratification of acute PE
![Page 7: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/7.jpg)
Risk-adjusted management algorithm
RV Overload
![Page 8: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/8.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
Recommendations for acute phase treatment
![Page 9: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/9.jpg)
Risk-adjusted management algorithm
![Page 10: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/10.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
RV/LV - Echo or CT
NT-proBNP
Troponin
SBP < 90 mmHg
![Page 11: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/11.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
Original and simplified pulmonary embolism
severity index (PESI)
patient
related
PE
related
![Page 12: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/12.jpg)
Risk-adjusted management algorithm
![Page 13: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/13.jpg)
New strategies with new AC drugs
Heparin
Fondaparinux
AVK
Dabigatran, Edoxaban Heparin
Fondaparinux
Apixaban,
Rivaroxaban
Initial overlap between two standard Tx
Switch from standard parenteral Tx to new oral agent
One oral agent with dose modification for LT prevention
![Page 14: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/14.jpg)
New strategies with new AC drugs
Heparin
Fondaparinux
AVK
Dabigatran, Edoxaban Heparin
Fondaparinux
Apixaban,
Rivaroxaban
Initial overlap between two standard Tx
Switch from standard Tx to new oral agent
One agent with dose modification for LT prevention
![Page 15: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/15.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
Recommendations: acute phase treatment
![Page 16: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/16.jpg)
Risk-adjusted management algorithm
![Page 17: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/17.jpg)
Risk-adjusted management algorithm
![Page 18: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/18.jpg)
Tenecteplase (n=506)
Placebo (n=499) P value
n (%) n (%)
All-cause mortality within 7 days
6 (1.2) 9 (1.8) 0.43
Hemodynamic collapse within 7 days
8 (1.6) 25 (5.0) 0.002
ITT population The PEITHO Investigators
PEITHO: Secondary efficacy outcomes
![Page 19: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/19.jpg)
Tenecteplase (n=506)
Placebo (n=499) P value
n (%) n (%)
Non-intracranial bleeding
Major 32 (6.3) 6 (1.5) <0.001
Minor 165 (32.6) 43 (8.6) <0.001
ITT population The PEITHO Investigators
PEITHO: Safety outcomes (within 7 days of randomization)
Strokes by day 7 12 (2.4) 1 (0.2) 0.003
Hemorrhagic 10 1
Ischemic 2 0
![Page 20: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/20.jpg)
Tenecteplase (n=506)
Placebo (n=499) P value
n (%) n (%)
PE recurrence 1 (0.2) 5 (1.0) 0.12
Intubation / mechanical ventilation
8 (1.6) 15 (3.0) 0.13
Open-label thrombolysis 4 (0.8) 23 (4.6) <0.001
ITT population The PEITHO Investigators
PEITHO: Other clinical outcomes (within 7 days)
![Page 21: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/21.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
Recommendations: acute phase treatment
![Page 22: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/22.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
Risk-adjusted management algorithm
RV Overload
![Page 23: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/23.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
Recommendations: duration of treatment
![Page 24: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/24.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
Recommendations for CTEPH
![Page 25: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/25.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
Recommendations for PE in pregnancy
![Page 26: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/26.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
Recommendations for PE in cancer
![Page 27: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/27.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
![Page 28: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/28.jpg)
Beware of PE ...
Adam Torbicki Dept. Pulmonary Circulation & Th-E diseases Center of Postgraduate Medical Education ECZ-Otwock, Poland
![Page 29: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/29.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
RV/LV - Echo or CT
NT-proBNP
Troponin
![Page 30: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/30.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
Classification of early mortality risk
![Page 31: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/31.jpg)
RV/LV - Echo or CT
NT-proBNP
Increased HR
Troponin
TAPSE
LV exc index
SBP < 90 mmHg
ST-T on ECG
Troponin
SvO2, SaO2
Mortality Risk Markers in PE
![Page 32: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/32.jpg)
leg pain
oedema
angina
tachycardia
low BP
ST-T changes
TnT, BNP
pleural pain
fever
hemophtysis
pleural effusion
atelectasis
dyspnea
shock
hypotension
syncope
![Page 33: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/33.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
Algorithm for the
treatment of chronic
thromboembolic
pulmonary
hypertension
![Page 34: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/34.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
Recommendations for prognostic assessment
![Page 35: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/35.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
Recommendations for prognostic assessment
![Page 36: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/36.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
Recommendations for prognostic assessment
![Page 37: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/37.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
Thrombolytic treatment of PE
![Page 38: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/38.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
Parenteral anticoagulation for PE
![Page 39: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/39.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
Recommendations for acute phase treatment
![Page 40: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/40.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
Recommendations: Venous filters
![Page 41: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/41.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
Algorithm for the
diagnosis of chronic
of thromboembolic
pulmonary
hypertension
![Page 42: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/42.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
Recommendations for diagnosis
![Page 43: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/43.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
Recommendations for diagnosis
![Page 44: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/44.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
![Page 45: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/45.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
Recommendations for diagnosis
![Page 46: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/46.jpg)
D-dimer in elderly patients: variable cut-off?
• New cut-off value proposed based on retrospective analysis of 2 cohorts including 5132 consecutive patients with suspected PE
• New D-dimer cut-off value:
– < 50 years-old 500 ng/mL
– > 50 years-old Patient age X 10 (e.g. 78-year-old patient, cut-off 780 ng/mL)
• Age-adjusted cut-off would increase the diagnostic yield of D-dimer by
10% (from 25 to 35% of all patients tested)
Douma et al., BMJ 2010;340:c1475
![Page 47: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/47.jpg)
Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study
• Aim: prospectively validate whether an age-adjusted D-dimer cutoff (age × 10 in patients 50 years or older) is associated with an increased diagnostic yield of D-dimer in elderly patients with suspected PE.
• Setting: multicenter, prospective management outcome study in 19 centers in Belgium, France, the Netherlands, and Switzerland
• Diagnostic strategy:
– clinical probability assessed by simplified revised Geneva score or 2-level Wells score for PE combined with highly sensitive D-dimer measurement
– CT angiography in patients with D-dimer result above age-adjusted cut-off
• Outcome: failure rate of the diagnostic strategy
– Thromboembolic events during the 3-month follow-up in patients not treated with anticoagulants based on a negative age-adjusted D-dimer cutoff result
Righini et al. JAMA. 2014 (April 23-30 );311:1117-1124
![Page 48: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/48.jpg)
Incidental PE
• PE found on chest CT done for other reasons than suspected PE in the absence of symptoms of PE
• Metaanalysis of 12 studies (4 prospective, 8 retrospective) including 10289 patients
Incidental PE, % Incidental PE, %
OR
Outpatients vs. inpatients 1.2% (0.5,2.1) 4.0% (2.7-5.6) 4.3 (2.6,7.0)
Cancer vs. non cancer 3.1% (2.2,4.1) 2.5% (1.1-4.5) 1.8 (1.2,2.8)
> 5 mm slice CT vs. < 5 mm slice CT
2.0% (1.0,3.4) 3.0% (2.0,4.0) NA
Overall 2.6% (1.9,3.4)
Dentali et al., Thromb Res 2010;125:518-522
![Page 49: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/49.jpg)
Tenecteplase (n=506)
Placebo (n=499) P value
n (%) n (%)
All-cause mortality or hemodynamic collapse within 7 days of randomization
13 (2.6) 28 (5.6) 0.015
ITT population The PEITHO Investigators
PEITHO: Primary efficacy outcome
1.00 0
0.23 0.44
2.00
Odds ratio
Thrombolysis superior
0.88
![Page 50: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/50.jpg)
Tenecteplase (n=506)
Placebo (n=499) P value
n (%) n (%)
All-cause mortality within 7 days
6 (1.2) 9 (1.8) 0.43
Hemodynamic collapse within 7 days
8 (1.6) 25 (5.0) 0.002
Need for CPR 1 5
Hypotension / blood pressure drop
8 18
Catecholamines 3 14
Resulted in death 1 6
ITT population The PEITHO Investigators
PEITHO: Secondary efficacy outcomes
![Page 51: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/51.jpg)
Główne różnice
nomenklatura zatorowości płucnej
leczenie fibrynolityczne
nacisk na leczenie śródnaczyniowe
nowe zagadnienia
us
Th-ly
![Page 52: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/52.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
2014 ESC Guidelines on the Diagnosis & Management of
ACUTE PULMONARY EMBOLISM
2014 version
European Heart Journal
(2014):doi:10.1093/eurheartj/ehu283
Chairpersons: Stavros Konstantinides (Germany/Greece), Adam Torbicki (Poland)
![Page 53: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/53.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
Predisposing factors for venous thromboembolism
![Page 54: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/54.jpg)
Isolated subsegmental PE: metaanalysis
J Thromb Haemost 2010;8:1716-22
All MDCT (n=1534)
Single-detector CT (n=1123)
4-detector (n=461)
16-detector (n=207)
64-detector (n=100)
NB: Definition not uniform: single vs. multiple subsegmental clots
![Page 55: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/55.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
Diagnostic tests confirming PE: not high-risk /considering clinical probability
![Page 56: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/56.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
Original and simplified pulmonary embolism
severity index (PESI)
![Page 57: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/57.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
Diagnosis of PE in pregnancy
![Page 58: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/58.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
RV/LV>0.9 and cTnI>0,1ug/L.
Scridon T et al. Am J Cardiol 2005
![Page 59: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/59.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
HR < 110 bpm SBP > 100 mmHg
SaO2 > 90
![Page 60: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/60.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
Classification of early mortality risk
![Page 61: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/61.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
Suspected high-risk PE: diagnostic algorithm
CUS
TEE
![Page 62: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/62.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
Diagnostic algorithm: not high-risk PE
![Page 63: 2014 ESC Guidelines on the diagnosis and · Prospective validation of D-dimer age-adjusted cut-off: the ADJUST study • Aim: prospectively validate whether an age-adjusted D-dimer](https://reader034.fdocuments.in/reader034/viewer/2022052010/601f6747054cd1647f46ba4c/html5/thumbnails/63.jpg)
www.escardio.org/guidelines European Heart Journal (2014):doi:10.1093/eurheartj/ehu283
Diagnostic algorithm: not high-risk PE
Age-adjusted D-dimer cut-off:
< 50 years-old 500 ng/mL
> 50 years-old age X 10
e.g.78 years-old 780 ng/mL