Nurdan KÖKTÜRK Ayhan VAROL Hatice KILIÇ Numan EKİM
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Transcript of 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