1. © Siemens 2013. All rights reserved. The Clinical Utility of D-dimer Assays Beth Phillips MT,SH (ASCP) Zone Technical Application Specialist Siemens Healthcare Diagnostics

2. © Siemens 2013. All rights reserved. Page 2 Objectives:  Define VTE as DVT and PE  Identify D-dimer assays and the role they play in DVT/PE  Explain Well’s pre-test probability scoring and clinical models  Describe evaluation of D-dimer assay results

3. © Siemens 2013. All rights reserved. Page 3 History of Fibrinolysis  4 th Century BC…Hippocratic school familiar with blood fluidity  1687 (300 years later) Malpighi noted blood clotted & reliquidfied after death  1893 Dastre coined term “fibrinolysis”  1905 Morawitz concluded process was probably enzymatic  1959 Sherry proved fibrinolysis due to activator converting plasminogen to plasmin  1960 five fragments of fibrinogen when treated with plasmin: A, B, C, D, & E  1983 Greenberg measured “fibrin d-dimer” to differential FDP derived from fibrinogen or fibrin

4. © Siemens 2013. All rights reserved. Page 4 Use of D-Dimer  30 years ago proposed as aid in suspect DVT  mid 1990’s focus on use as aid in ruling out VTE  DIC profile

5. © Siemens 2013. All rights reserved. Page 5 Venous Thromboembolism Epidemiology  Yearly in the USA: > 600,000 Deep Vein Thrombosis ~ 150,000 Pulmonary Embolism  Diagnostic Challenges with DVT/PE 90% of PE develop from DVT PE mortality 18%-30% without treatment VTE suspected…..15% - 25% actually positive  Clinical suspicion has increased  Prevalence has decreased, some statistics state only 10% of suspected VTE are positive

6. © Siemens 2013. All rights reserved. Page 6 VENOUS THROMBOEMBOLISM Venous Blood Clot Embolus Venous Thromboembolic Disease DVT PE  Distinct clinical entities  Manifestation of the same disease

7. © Siemens 2013. All rights reserved. Page 7 VENOUS THROMBOEMBOLISM  DVT-- thrombi form in deep veins of legs, pelvis or upper extremities  PE -- thrombi embolize to pulmonary arteries  elevate pulmonary vascular resistance  heart failure  cardiogenic shock  impairment of gas exchange

8. © Siemens 2013. All rights reserved. Page 8  DVT may occur without obvious symptoms and may be difficult to detect  Up to 50% of DVT incidents may produce minimal symptoms or are completely "silent”  85% are in the proximal venous system and 15% limited to the calf  20% to 30% of calf thrombi extend proximally  Symptoms: Pain, tenderness, or sudden swelling in the leg Discoloration or visibly large veins Skin that is warm to the touch Deep Vein Thrombosis (DVT)

9. © Siemens 2013. All rights reserved. Page 9  The highest incidence of recognized pulmonary embolism occurs in hospitalized patients  Approximately 10% of patients with diagnosed pulmonary embolism die within the first 60 minutes  Symptoms: Shortness of breath Anxiety or nervousness Rapid pulse Excessive sweating Sharp chest pain Cough that may produce a bloody discharge Very low blood pressure Fainting Pulmonary Embolism (PE)

10. © Siemens 2013. All rights reserved. Page 10 WHY IDENTIFY PATIENTS WITH VTE  Prevent mortality and morbidity associated with PE  Anticoagulant therapy reduces risk of fatal outcome 15 fold  Anticoagulant therapy related to high mortality and morbidity  Justification for risk of bleeding  Cost savings

11. © Siemens 2013. All rights reserved. Page 11 VTE Disease Predisposing Risk Factors  Clinical conditions  surgery, trauma, cancer  hormonal influences  Hereditary coagulapathies  Factor V Leiden  Protein C / S Deficiency  AT Deficiency  Prothrombin Gene Mutation  Acquired coagulapathies  Lupus Anticoagulant  Environment  air travel  smoking  age

12. © Siemens 2013. All rights reserved. Page 12 Diagnostic Challenges with DVT/PE  Only 15-25% of suspected VTE patients have disease  DVT mortality rate of 21% in elderly  PE mortality rate 30% without treatment  90% of PE develops from DVT  PE causes more deaths annually in the U.S. than breast cancer, highway fatalities and AIDS combined 

13. © Siemens 2013. All rights reserved. Page 13 DIAGNOSING DVT/PE History and Exam Determines Low Moderate High Clinical Probability Guides Choice Diagnostic Studies

14. © Siemens 2013. All rights reserved. Page 14 D-Dimer + Probability Score “…DD testing has gained wide acceptance for ruling out the disease, at least in the outpatient population referred to the emergency department.” “…ELISA DD assays and automated latex turbidimetric tests are associated with the highest sensitivity and with virtually no interobserver variability.” “…these tests should be used to rule out VTE only in non-high clinical probability patients.” D-Dimer for venous thromboembolism diagnosis: 20 years later; M. Righini, A. Perrier, P. De Mperloose amnd H. Bpima,eaix Journal of Thrombosis and Haemostasis, 2008, 6: 1059-1071

15. © Siemens 2013. All rights reserved. Page 15 Clinical Parameter Score Score Active cancer (treatment ongoing, or within 6 months or palliative) +1 Paralysis or recent plaster immobilization of the lower extremities +1 Recently bedridden for >3 d or major surgery <4 wk +1 Localized tenderness along the distribution of the deep venous system +1 Entire leg swelling +1 Calf swelling >3 cm compared to the asymptomatic leg +1 Pitting edema (greater in the symptomatic leg) +1 Previous DVT documented +1 Collateral superficial veins (nonvaricose) +1 Alternative diagnosis (as likely or > that of DVT) -2 Wells Pre-test Probability of DVT Score >3 High probability 1 or 2 Moderate probability <0 Low probability

16. © Siemens 2013. All rights reserved. Page 16 Clinical Parameter ScoreScore Suspected DVT 3.0 Alternate Dx is less likely than PE 3.0 Heart rate >100 1.5 Immobilized or surgery in last 4 wk 1.5 Previous DVT/PE 1.5 Hemoptysis 1.0 Malignancy (treated within 6 mo.) 1.0 Wells Pre-Test Probability of PE Wells, PS et al. Thromb Haemost. 83: 416, 2000 ScoreProbabilityRisk 0 – 2 Low 3.6% 3 – 6Moderate20.5% > 6High66.7%

17. © Siemens 2013. All rights reserved. Page 17 Implication of D-dimer Thrombin Fibrinogen Soluble Fibrin + FP A+B FXIII Fibrin Clot Plasminogen Activators (tissue PA, urokinase PA, FXII, etc) Plasmin Plasminogen D-dimer D=D D E D Clot + Fibrinolysis = D-dimer formation No Clot + Fibrinolysis =  D-dimer formation

18. © Siemens 2013. All rights reserved. Page 18 Elevated D-dimer  DIC  Fibrinolytic therapy within 7 days  Malignancies  Aortic aneurysm, MI  Sepsis, severe infection, pneumonia  Trauma, surgery  Liver cirrhosis  Pregnancy or obstetric complication  Age  Hospitalized patients in general  Stress  Excessive exercise  Lipemic samples  Hemolyzed samples

19. © Siemens 2013. All rights reserved. Page 19 Why Differences in D-dimer Assays  No D-dimer assay produces identical results to another D-dimer assay  D-dimer antigen is not homogenous but a mixture of fragments & compounds containing fragments of D & E of different molecular weight (HMW & LMW)  D-dimer assays use different antibodies, buffers, measuring technique, standards

20. © Siemens 2013. All rights reserved. Page 20 Comparability of D-Dimer Assays  Facts that effect assay comparability  No international standard for D-dimer  Different reporting units: D-dimer units (DDU) & Fibrinogen Equivalent Units (FEU)  Antibodies have different affinity to D-dimer compounds  Different reagents & assay methodologies result in different interferences and signals  Conclusions  Each manufacturer establishes its own standardization method  Various assays have different performance characteristics  Different standardizations typically result in different quantitative results on the same patient

21. © Siemens 2013. All rights reserved. Page 21 Goals of Diagnostic Studies  Provide reliable diagnosis  Shortest possible time  Least discomfort to patient  Reasonable cost

22. © Siemens 2013. All rights reserved. Page 22 PE / DVT Exclusion D-dimer Testing Algorithms

23. © Siemens 2013. All rights reserved. Page 23 Low Clinical Probability of embolism Highly sensitive D-dimer assay NegativePositive Diagnosis ruled outVentilation-perfusion scan or CT scan. Fedullo, P, Tapson, V. The Evaluation of Suspected Pulmonary Embolism. N Engl J Med 2003:1247-56. Algorithm for PE

24. © Siemens 2013. All rights reserved. Page 24 Algorithm for DVT Hirsh J, Lee AY How We Diagnose & Treat Deep Vein Thrombosis, Blood 2002; 99(9): 3102-3110

25. © Siemens 2013. All rights reserved. Page 25 Evaluating D-dimer Results

26. © Siemens 2013. All rights reserved. Page 26 D-dimer vs. Imaging…Why Results Do Not Agree  Age of Clot  Time of Initial Symptoms  Size of Clot  Where Clot Located  Anticoagulants before Draw  Patient Age  Cancer  Previous Thrombosis  Pregnant  In-patient Questions to Ask:

27. © Siemens 2013. All rights reserved. Page 27 Normal D-dimer with Abnormal Scan  Distal DVT  Subsegmental / peripheral PE  Presentation to ER > 7days after symptoms  Size of clot, small clot may produce minimal D-dimer levels  Anticoagulant therapy within 24 hours

28. © Siemens 2013. All rights reserved. Page 28 Age of Thrombus Patients who report greater than 14 days duration of symptoms demonstrate inactive fibrinolysis and D-dimer levels rapidly decrease, false negative Size of Thrombus Smaller thrombi produce minimal levels of D-dimer, false negative Position of Thrombus  Calf vein thrombi, false negative  Sub-segmental PE, false negative Anticoagulant Therapy  Reduces fibrin formation  D-dimer levels are reduced, false negative  Do Not perform D-dimer on anticoagulated patients D-dimer vs. Imaging…Why Results Do Not Agree

29. © Siemens 2013. All rights reserved. Page 29 D-dimer in Hospitalized Patients  Hospitalized patients usually have on-going disease process  D-dimer levels can be elevated in these patients due to disease state  Patients may be tested, but will likely have elevated levels in absence of clot  DO NOT perform D-dimer on hospitalized patients for DVT/PE rule-out  Utilize imaging methods for DVT/PE rule-out  D-dimer is used for DIC in hospitalized patients  Do not use hospitalized patients in a normal reference range study

30. © Siemens 2013. All rights reserved. Page 30 Summary for Clinical Utility of D-dimer Assay  Negative D-dimer with low pre-test probability can exclude VTE  D-dimer is cost effective, saving thousands of dollars in health care cost  D-Dimer test results should always be used in conjunction with the patient’s medical history, pre-test probability scoring and clinical presentation.

31. © Siemens 2013. All rights reserved. Page 31 Questions