Pulmonary embolism laboratory findings
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Editor(s)-In-Chief: C. Michael Gibson, M.S., M.D. [1], The APEX Trial Investigators; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]
Overview
The results of routine laboratory tests including arterial blood gas analysis are non-specific in making the diagnosis of pulmonary embolism (PE). These laboratory studies can be obtained to rule out other cause of chest discomfort and tachypnea. In patients with acute PE, non-specific lab findings include: leukocytosis, elevated ESR with an elevated serum LDH and serum transaminase (especially AST or SGOT). A negative D-dimer in a patient with low to intermediate probability of PE strongly suggests PE is not present.
Laboratory Findings
D-dimer Test
Fore more information about D-dimer, click here.
- D-dimer is a cross-linked fibrin degradation product and a marker of endogenous fibrinolysis. In the setting of ongoing thrombosis, D-dimer's concentration is elevated in the blood and thus makes it a screening tool to rule out DVT.
- D-dimer is the test of choice in patients who are considered to be at low or intermediate risk of PE according to pre-test probability. D-dimer is more useful if its negative rather than positive. It has a great negative predictive value in low to moderate risk patients. If D-dimer is elevated, then DVT should be confirmed with ultrasound.[1][2]
- Plasma D-dimer > 500 ng/mL is the most commonly used cut-off concentration.[3]
- Plasma D-dimer>500 ng/ml, PE present (sensitivity: 84.8%; specificity:68.4%)[4]
- Plasma D-dimer<500 excludes PE (high negative predictive value)
- However, the use of the cut off value 500 ng/mL for abnormal D-dimer limits the diagnostic role of D-dimer in the elderly, among whom D-dimer increases with age in the absence of any ongoing venous thromboembolism (VTE) process. The age adjusted cut off value of D-dimer is the following:
Routine Blood Tests
- Leukocytosis[8]
- Elevated ESR[9]
- Elevated serum LDH[10]
- Elevated serum transaminase (especially AST or SGOT)[11]
Workup for Hypercoagulability
- Workup for hypercoagulation includes:
- Activated protein C resistance
- Factor V Leiden mutation
- Protein C
- Protein S (free and total)
- Antithrombin
- Lupus anticoagulant
- Anticardiolipin antibodies
- Plasma homocysteine values
- The hypercoagulability tests are not part of the routine workup for all patients who suffer from PE. The hypercoagulability workup should be considered in the case of unprovoked venous thrombosis at an early age (< 40 years), strong family history of more than 2 relatives who had VTE symptoms, and pregnant women who had a previous VTE episode in the absence of a significant trigger.[12]
- The hypercoagulability workup should not be performed in the cases of:[12]
- Upper limb thrombosis
- Central venous catheter related thrombosis
- Retinal vein occlusion
- Recent major surgery
- Recent trauma
- Recent immobilization
- Active cancer
The 2008 Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)[13]
Suspected Non High-risk PE Patients (DO NOT EDIT)[13]
| Class I |
| "1. Plasma D-dimer measurement is recommended in emergency department patients to reduce the need for unnecessary imaging and irradiation, preferably with the use of a highly sensitive assay. (Level of Evidence: A) " |
Low Clinical Probability (DO NOT EDIT)[13]
| Class I |
| "1. Normal D-dimer level using either a highly or moderately sensitive assay excludes pulmonary embolism. (Level of Evidence: A) " |
Intermediate Clinical Probability (DO NOT EDIT)[13]
| Class I |
| "1. Normal D-dimer level using a highly sensitive assay excludes pulmonary embolism. (Level of Evidence: A) " |
| Class IIa |
| "1. Further testing should be considered if D-dimer level is normal when using a less sensitive assay. (Level of Evidence: B) " |
High Clinical Probability (DO NOT EDIT)[13]
| Class III |
| "1. D-dimer measurement is not recommended in high clinical probability patients as a normal result does not safely exclude pulmonary embolism even when using a highly sensitive assay. (Level of Evidence: C) " |
References
- ↑ Wells PS, Anderson DR, Rodger M; et al. (2003). "Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis". N. Engl. J. Med. 349 (13): 1227–35. doi:10.1056/NEJMoa023153. PMID 14507948.
- ↑ Bates SM, Kearon C, Crowther M; et al. (2003). "A diagnostic strategy involving a quantitative latex D-dimer assay reliably excludes deep venous thrombosis". Ann. Intern. Med. 138 (10): 787–94. PMID 12755550.
- ↑ Stein PD, Hull RD, Patel KC, Olson RE, Ghali WA, Brant R, Biel RK, Bharadia V, Kalra NK (2004). "D-dimer for the exclusion of acute venous thrombosis and pulmonary embolism: a systematic review". Annals of Internal Medicine. 140 (8): 589–602. PMID 15096330. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ Ginsberg JS, Wells PS, Kearon C, Anderson D, Crowther M, Weitz JI; et al. (1998). "Sensitivity and specificity of a rapid whole-blood assay for D-dimer in the diagnosis of pulmonary embolism". Ann Intern Med. 129 (12): 1006–11. PMID 9867754.
- ↑ Douma RA, Tan M, Schutgens RE, Bates SM, Perrier A, Legnani C; et al. (2012). "Using an age-dependent D-dimer cut-off value increases the number of older patients in whom deep vein thrombosis can be safely excluded". Haematologica. 97 (10): 1507–13. doi:10.3324/haematol.2011.060657. PMC 3487551. PMID 22511491.
- ↑ Schouten HJ, Geersing GJ, Koek HL, Zuithoff NP, Janssen KJ, Douma RA; et al. (2013). "Diagnostic accuracy of conventional or age adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism: systematic review and meta-analysis". BMJ. 346: f2492. doi:10.1136/bmj.f2492. PMC 3643284. PMID 23645857.
- ↑ Righini M, Van Es J, Den Exter PL, et al. Age-Adjusted D-Dimer Cutoff Levels to Rule Out Pulmonary Embolism: The ADJUST-PE Study. JAMA. 2014;311(11):1117-1124. doi:10.1001/jama.2014.2135.
- ↑ Afzal A, Noor HA, Gill SA, Brawner C, Stein PD (1999). "Leukocytosis in acute pulmonary embolism". Chest. 115 (5): 1329–32. PMID 10334148.
- ↑ Kokturk N, Demir N, Oguzulgen IK, Demirel K, Ekim N (2005). "Fever in pulmonary embolism". Blood Coagul Fibrinolysis. 16 (5): 341–7. PMID 15970718.
- ↑ Hasegawa K, Sawayama T, Ibukiyama C, Muramatsu J, Ozawa Y, Kanemoto N; et al. (1993). "[Early diagnosis and management of acute pulmonary embolism: clinical evaluation those of 225 cases]". Kokyu To Junkan. 41 (8): 773–7. PMID 8351437.
- ↑ Hu ZJ, Zhou YQ, Zhang HB, Li L (2008). "[Clinical value of monitoring serum cardiac biomarkers in pulmonary thromboembolism-induced myocardial injury]". Nan Fang Yi Ke Da Xue Xue Bao. 28 (10): 1853–5. PMID 18971188.
- ↑ 12.0 12.1 Baglin T, Gray E, Greaves M, Hunt BJ, Keeling D, Machin S; et al. (2010). "Clinical guidelines for testing for heritable thrombophilia". Br J Haematol. 149 (2): 209–20. doi:10.1111/j.1365-2141.2009.08022.x. PMID 20128794.
- ↑ 13.0 13.1 13.2 13.3 13.4 Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P, Bengel F, Brady AJ, Ferreira D, Janssens U, Klepetko W, Mayer E, Remy-Jardin M, Bassand JP (2008). "Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)". Eur. Heart J. 29 (18): 2276–315. doi:10.1093/eurheartj/ehn310. PMID 18757870. Retrieved 2011-12-07. Unknown parameter
|month=ignored (help)