Reassessment strategy to reduce chest imaging in patients with suspected pulmonary embolism and elevated D-dimer: an exploratory cohort study

Background: Patients referred by community physicians to the emergency department (ED) for suspected pulmonary embolism (PE) with an elevated D-dimer result often undergo chest imaging, although the appropriate diagnostic strategy in this setting remains unclear.] as per style before objectives. Objectives: This study evaluated whether a standardized 3-step reassessment strategy could reduce chest imaging in these patients. Methods: Using data from an observational cohort study conducted in 2 French EDs between May 2022 and May 2023, a standardized 3-step reassessment strategy was retrospectively applied. The strategy combined (1) clinical probability reassessment, (2) adjustment of community laboratory D-dimer thresholds, and (3) repeat D-dimer testing in the ED using the VIDAS assay when indicated. Adult patients referred for suspected PE with a community D-dimer level of >500 ng/mL were included. The primary outcome was the proportion of chest imaging studies that would have been avoided. Results: Seventy-five patients were analyzed (median age, 59 years; 57% women). Application of the reassessment strategy would have avoided chest imaging in 37 patients, corresponding to an absolute reduction of 49 percentage points (95% CI, 37-60). Imaging avoidance occurred at step 1 in 11 patients (absolute reduction, 15 percentage points; 95% CI, 7-24), at step 2 in 14 patients (19 percentage points; 95% CI, 10-29), and at step 3 in 12 patients (16 percentage points; 95% CI, 8-26). The failure rate was 1% (95% CI, 0-7). Conclusion: In patients referred to the ED for suspected PE with an elevated community D-dimer result, application of a standardized reassessment strategy could reduce chest imaging by approximately half. The safety and generalizability of this approach warrant evaluation in larger, prospectively designed studies.