Prospective diagnostic accuracy assessment of the HemosIL HS D-dimer to exclude pulmonary embolism in emergency department patients.

INTRODUCTION: Chest pain and shortness of breath are among the most common symptoms requiring immediate evaluation. Testing for pulmonary embolism (PE) has become easier and widespread due to D-dimer blood tests. Safe use of these tests is only possible if sensitivity is high and they are used in non-high probability patients. We evaluated diagnostic performance of the HemosIL HS D-dimer, which despite FDA approval in 2005, has been minimally reported in prospective standard clinical care. MATERIALS AND METHODS: We used a prospective observational study design to follow patients in a single center with the HemosIL HS ordered for symptoms of possible PE with positive test result if >243 ng/ml. The outcome was PE or deep venous thrombosis (DVT) at the time of presentation or subsequent 45 days determined by structured evaluation of imaging tests, phone, or medical record follow-up in all patients. RESULTS: 529 patients received a D-dimer and 4.7% were ultimately diagnosed with PE or DVT. The sensitivity of the HemosIL HS was 96.0% (95% CI; 79.6 to 99.9%) specificity was 65.7% (95% CI; 61.4 to 69.8%) and likelihood ratio negative was 0.06 (95% CI; 0.01 to 0.42). The probability of PE in patients with a negative D-dimer was 1/332 or 0.3% (95% CI; 0.01% to 1.67%). The receiver operator curve had an area under the curve of 0.87 and supported the current cut-point as optimal. CONCLUSIONS: The HemosIL HS D-dimer had high sensitivity, very low negative post-test probability and is useful in excluding PE in the acute care setting.

Increased blood pressure in the emergency department: pain, anxiety, or undiagnosed hypertension?

STUDY OBJECTIVE: We determine the proportion of patients with increased emergency department (ED) blood pressure and no history of hypertension who have persistently increased blood pressure at home, describe characteristics associated with sustained blood pressure increase, and examine the relationship between pain and anxiety and the change in blood pressure after ED discharge. METHODS: This was a prospective cohort study. Patients with no history of hypertension and 2 blood pressure measurements of at least 140/90 mm Hg who were treated in an urban ED were enrolled, provided with home blood pressure monitors, and asked to take their blood pressure twice a day for 1 week. Outcome measures were increased mean home blood pressure (140/90 mm Hg or greater), and correlations between ED anxiety (Spielberger State Anxiety Scale) or pain (10-point scale) and the change in blood pressure after discharge. Potential relevant predictors were recorded and a multivariate model was constructed to assess the relationship between these predictors and increased home blood pressure. RESULTS: 189 patients were enrolled and 156 returned the monitors and completed the protocol. Increased mean home blood pressure was present in 79 of 156 (51%) patients and was associated with older age and being black. Of patients with ED blood pressures meeting criteria for stage I hypertension, 6% had home blood pressures meeting stage II hypertension, 36% stage I, and 52% prehypertension, and 6% had normal blood pressure For patients with ED blood pressures meeting stage II criteria, the corresponding percentages were 28%, 31%, 33%, and 8%, respectively. The difference between home and ED systolic blood pressures was not associated with anxiety (r=-.03; P=.69) and showed a slight association with pain in the opposite direction from what was expected (r=.18; P=.03). CONCLUSION: Patients without diagnosed hypertension and increased ED blood pressures often have persistently increased home blood pressures, which does not appear to be related to pain or anxiety in the ED.