Nurdan KÖKTÜRK Ayhan VAROL Hatice KILIÇ Numan EKİM

The Role of D-Dimer Levels in Follow-up and Differential Diagnosis

of Pulmonary Thromboembolism (PTE) and Community Acquired Pneumonia (CAP)

Nurdan KÖKTÜRK Ayhan VAROL Hatice KILIÇ Numan EKİM

GAZİ UNİVERSITY FACULTY OF MEDICINE

PULMONARY DISEASES DEPARTMENT

INTRODUCTION•Pulmonary thromboembolism is responsible from 10% of hospital deaths

•Among the patients;22 % of them die in first few hours (in 30 min)25 % of them die in first 7 days

•70 % of the massive pulmonary embolism cases die in first one hour

Sirius study,Arch Inter Med. 2000; 160:3415-3420.

ICOPER study, Lancet 1999; 353:1386-1389.

• Diagnostic tool;

Chest X-ray

Arterial Blood Gas (ABG)

ECG

D Dimer

Spiral Thorax CT/ Lung V/Q Scintigraphy

Bilateral Lower Extremity Doppler USG

Pulmonary Angiography

INTRODUCTION

Low probability Low probability

D dimer

- +

Exclude PTE

3 months follow up

Exclude PTE

Moderate and high probabilityModerate and high probability

D dimer

Heparinisation (Standard, LMWH)

V/Q scintigraphy or Spiral CT

Nondiagnostic (Low-moderate) / Normal CT Normal High probability / pozitive CT

Bilateral lower extremity USGPTE: continue treatment

DVT diagnosed

DVT not identifiedBehave according to clinical probability

Low clinical probabilty Moderate clinic probability High clinic probability

Exclude PTE Repeat USG within a weekAngiography or repeat

USG with in a week

3 months follow up

PTE: continue treatment PTE: continue treatment

Exclude PTE

- + - +

Behave according to initial D-dimer level

- + - +

Wells PS, Rodger M. Diagnosis of Pulmonary Embolism: When is imaging needed. Clin In Chest Med 2003; 13-28

Determine Clinical Probability

D – Dimer-1

D – Dimer-2

• High D- dimer levels can be found in various conditions;– Acute thrombosis– Infections– Malignancies– Chronic Renal Failure– Pregnancy– Elderly patients– Stroke– Hepatic Disease– Major trauma Kelly J. Arch Intern Med.162;2000

Andersen DR.J.Emerg Med 2000

• D – Dimer Measurement Techniques

– ELISA ( NPV= % 91-100)– LATEX Agglutination (NPV= % 67-97 )– Immunofiltration assay– Immunoturbidometric assay– Simple RED D- dimer test (Sensitivity ~ % 85 )– VIDAS, Liatest (Rapid tests)

D – Dimer-3

Wells SP, Rodger M. Clin Chest Med. 2003; 24: 13-25

1. To evaluate the role of D-Dimer quantitative levels in differentiating PTE from CAP

2. To observe the variations in D-Dimer quantitative levels in PTE patients treated with anticoagulant therapy and to determine whether there is a relationship between these variations and disease prognosis, severity and recurrence

AIM

Patient population• 20 PTE patient; mean age: 58 ± 18.19 years. • 17 CAP patient; mean age: 68 ± 14 years.PTE diagnosis • In 10 patient High Probability V/Q• In 4 patient Moderate Probability V/Q +

Doppler USG• In 6 patient Thorax CTCAP diagnosis• Turkish Thorasic Society CAP criteria

MATERIAL AND METHOD-1

MATERIAL AND METHOD-2

• Exclusion criteria from the study;

Active hepatic failure Active malignancy

Pregnancy

Renal failure Sepsis

Not accepting to be included in the study

• Among the patients with the diagnosis of PTE and CAP, serum D-Dimer levels were measured in their first admission before anticoagulant or antibiotic therapy; and at the 3rd, 10th and 30th days after initiating therapy

MATERIAL AND METHOD-3

• D-Dimer levels were measured with latex added immunoturbidometric method named as D-Dimer Plus.

MATERIAL AND METHOD-4

LATEX PARTICULE

Antibody against D-DİMER

Antigen in the medium

Statistical Analysis

• p<0.05 was accepted as statistically significant

• SPSS 11.5 version was used

• Mann Whitney U

• Friedman Test

MATERIAL AND METHOD-5

RESULTS-1

D-Dimer levels in different days

PTE Pneumonia p

Day 0 3195,30 ± 476,38 1211,41± 297,49 0.004

3rd Day 650,35 ± 161,63 863,76 ± 289,44 0.004

10th Day 639,95 ± 195,63 451,64 ± 112,33 0.626

30th Day 234,40 ± 74.27 428,41 ± 178,76 0.363

RESULTS-2

• When the difference between the D-dimer levels were evaluated at different measurement days in PTE group;

• D Dimer at day 0> D Dimer at 3rd day= D Dimer at 10th day > D Dimer at 1st month (p=0.000)

• When the difference in D-dimer levels were evaluated at different measurement days in PTE group;

• D Dimer at day 0 > D Dimer at 1st month• D Dimer at 3rd day > D Dimer 1st month (p=0.009) • D-Dimer level was still high at 30th day in patient with MODS

• Except one case who died due to MODS; symptoms were improved completely in the other 19 patients.

RESULTS-3

CONCLUSION

This longitudinal preliminary study indicated that;

• Serum D-Dimer quantitative levels can be useful in differential diagnosis of PTE and CAP

• D-Dimer levels decrease with treatment in PTE • Patient number must be increased in order to

make a comment that a defective decrease in D-dimer levels with treatment may indicate recurrence or ineffective treatment in PTE