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Review
. 2013 May 3:346:f2492.
doi: 10.1136/bmj.f2492.

Diagnostic accuracy of conventional or age adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism: systematic review and meta-analysis

Henrike J Schouten  1 , G J Geersing, H L Koek, Nicolaas P A Zuithoff, Kristel J M Janssen, Renée A Douma, Johannes J M van Delden, Karel G M Moons, Johannes B Reitsma
Affiliations
Review

Diagnostic accuracy of conventional or age adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism: systematic review and meta-analysis

Henrike J Schouten et al. BMJ. .

Abstract

Objective: To review the diagnostic accuracy of D-dimer testing in older patients (>50 years) with suspected venous thromboembolism, using conventional or age adjusted D-dimer cut-off values.

Design: Systematic review and bivariate random effects meta-analysis.

Data sources: We searched Medline and Embase for studies published before 21 June 2012 and we contacted the authors of primary studies.

Study selection: Primary studies that enrolled older patients with suspected venous thromboembolism in whom D-dimer testing, using both conventional (500 µg/L) and age adjusted (age × 10 µg/L) cut-off values, and reference testing were performed. For patients with a non-high clinical probability, 2 × 2 tables were reconstructed and stratified by age category and applied D-dimer cut-off level.

Results: 13 cohorts including 12,497 patients with a non-high clinical probability were included in the meta-analysis. The specificity of the conventional cut-off value decreased with increasing age, from 57.6% (95% confidence interval 51.4% to 63.6%) in patients aged 51-60 years to 39.4% (33.5% to 45.6%) in those aged 61-70, 24.5% (20.0% to 29.7% in those aged 71-80, and 14.7% (11.3% to 18.6%) in those aged >80. Age adjusted cut-off values revealed higher specificities over all age categories: 62.3% (56.2% to 68.0%), 49.5% (43.2% to 55.8%), 44.2% (38.0% to 50.5%), and 35.2% (29.4% to 41.5%), respectively. Sensitivities of the age adjusted cut-off remained above 97% in all age categories.

Conclusions: The application of age adjusted cut-off values for D-dimer tests substantially increases specificity without modifying sensitivity, thereby improving the clinical utility of D-dimer testing in patients aged 50 or more with a non-high clinical probability.

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Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: all authors had financial support from the Netherlands Organization for Scientific Research (ZonMw project No 17088-2502, 917-46-360, and 945-04-009) for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

Figures

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Fig 1 Diagnostic investigations in patients with suspected venous thrombembolism. Adapted from Wells 2007, Le Gal et al 2006, and Wells et al 2001
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Fig 2 Number of extra patients per 1000 patients with non-high clinical probability in whom venous thromboembolism would be correctly or falsely excluded by application of age adjusted D-dimer cut-off values instead of conventional cut-off values
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