Diagnostic Strategy Using an Elevated Age-Adjusted D-Dimer Threshold and Thromboembolic Events

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First, it should be clarified that this study’s results mainly apply to patients with an intermediate probability of PE because patients with a high subjective probability of PE (>50%)and a low subjective probability of PE with a PERC score of 0 were excluded from the study.Second, the theory that unstructured clinician gestalt has a PE risk stratification performance similar to structured scores remains controversial. A previous study suggested that clinicians should use explicit clinical models for the diagnostic strategy of suspected PE, given the inadequate interobserver reliability of pretest probability assessment by gestalt. In addition,the revised Geneva score, which does not incorporate the subjective criterion of “pulmonary embolism is the most likely diagnosis,” is favored over the Wells score and the YEARS strategy and is highly recommended in European Society of Cardiology guidelines for PE. Third, for the measurement of a primary outcome of VTE at 3 months, patients were instructed to return to the same hospital if they developed worsening or recurrent symptoms after the index emergency department visit.However, no scheduled trial visits or return visits due to worsening or recurrent symptoms were performed at any time during follow-up.Therefore, thromboembolic events among participants may have been missed. Fourth, patients taking anticoagulants were excluded from this study. However, patients enrolled in this study may have started treatment with anticoagulation for cardiovascular, cerebrovascular, or other diseases during follow-up, which may have affected the rate of thromboembolic events. Use of anticoagulant therapy during the follow-up period of this study was not reported. Fifth, clinical applicability and predictive accuracy are 2 important factors to consider when valuating a VTE risk assessment score.5 The new diagnostic strategy proposed in this study had similar diagnostic efficiency and moderately reduced image testing (10%) compared with conventional management. However, this study’s VTE assessment tool involved calculating PERC and YEARS scores and using an age-adjusted D-dimer threshold, making this strategy less user-friendly than the conventional one.

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