D-dimer: Well beyond diagnosis!

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Reference

D-dimer: Well beyond diagnosis!

ROBERT-EBADI, Helia, RIGHINI, Marc Philip

ROBERT-EBADI, Helia, RIGHINI, Marc Philip. D-dimer: Well beyond diagnosis! Journal de médecine vasculaire , 2020, vol. 45, no. 5, p. 239-240

DOI : 10.1016/j.jdmv.2020.06.006 PMID : 32862979

Available at:

http://archive-ouverte.unige.ch/unige:155644

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JMV—JournaldeMédecineVasculaire(2020)45,239—240

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EDITORIAL

D-dimer: Well beyond diagnosis!

H. Robert-Ebadi

^∗

, M. Righini

Divisionofangiologyandhemostasis,GenevaUniversityHospitalsandFacultyofMedicine,Geneva, Switzerland

Rec¸ule3juin2020 ;acceptéle3juin2020 DisponiblesurInternetle9July2020

Plasma D-dimer are measurable degradation products of cross-linkedﬁbrin,whose levelsincrease inpresence of a blood clot but also in various other situations associated withactivatedcoagulation.Overthelast30years,D-dimer have revealed their main strength as a diagnostic toolin venousthromboembolicdiseases(VTE).Theircentralclini- calusefulness indeedresidesin their roleasan exclusion test in patients with suspected VTE [1,2]. Multiple large scaleprospectivemanagementoutcometrialshaveconﬁr- medthesafetyofexcluding pulmonaryembolism(PE)and deepveinthrombosis(DVT)byanegativeD-dimertestasso- ciatedwithanon-highpretestclinicalprobability[3].Some morerestrictedevidencealsosuggeststhatD-dimercould allowruling outaortic dissectionin associationwithalow AAD-RSscore[4].Finally,D-dimerareusedasadiagnostic toolinthesettingofdisseminatedintravascularcoagulation (DIC),andhavebeenintegratedinthelatestISTHovert-DIC diagnosticcriteria[5].

D-dimer have alsobeen studied asa predictiontoolin differentsettings suchaspredictionof VTEoccurrencein acutelyillhospitalizedmedicalpatientstoguidethrombo- prophylaxis prescription, or prediction of VTE recurrence afteraﬁrstepisodeofunprovokedVTEtotailordurationof anticoagulanttreatment. Inacutelyillmedicalinpatients, apost-hocanalysisoftheMAGELLANtrial(n=7581)showed thataD-dimerlevel>2timestheupperlimitofnormalrange

∗Correspondingauthor.

Adressee-mail:helia.robert-ebadi@hcuge.ch (H.Robert-Ebadi).

wasan independent predictor of VTE events (OR compa- redtopatientswithD-dimer≤2timesupperlimitofnormal range2.29;95%CI1.75—2.98)[6].ForVTErecurrencepre- dictionafterafew monthsofanticoagulanttreatment for aﬁrstidiopathicVTE,D-dimerlevels—onanticoagulation orafteranticoagulationcessation—havebeenextensively exploredandincludedinallpredictivemodelssuchasthe ViennaPredictionModel,theHERDOO2score,theDASHtool andtheDAMOVESscore[1].

Finally, the role of D-dimer as a prognostic tool has also been assessed, mainly in the setting of acute VTE.

Ina retrospective study publishedin 2006, Aujesky etal.

showed that among patients with confirmed PE (n=366), those who died had higher median D-dimer levels than patientswhosurvived(4578versus2946␮g/L;p=0.005).All- causemortality increased withincreasing D-dimer levels, risingfrom1.1%inthefirstquartile(<1500␮g/L)to9.1%in thefourth quartile(>5500␮g/L)(p=0.049)[7].These fin- dingswererecentlyconfirmedintheCOMMAND-VTEregistry (n=2852): D-dimerlevelswereagain anindependentpre- dictor of all-cause mortality in patients with acute VTE.

Indeed,mortalityat30dayswasof1.2%intheﬁrstquartile (<4900␮g/L),2.2%inthesecondquartile(5000—9900␮g/L), 3.4%inthethirdquartile(10,000—19,900␮g/L)and8.4%in thefourthquartile(DD≥20,000␮g/L)[8].

Inthisissue,Frèreetal.present theresultsofasyste- maticreviewandpooledanalysisof availabledataonthe association between D-dimer levelsand mortalityin 1355 hospitalizedpatientswithcoronavirusdisease2019(COVID- 19).As inthe setting ofacuteVTE, higherD-dimer levels

https://doi.org/10.1016/j.jdmv.2020.06.006

creativecommons.org/licenses/by-nc-nd/4.0/).

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240 H.Robert-Ebadi,M.Righini were shown to be associated withan increasedall-cause

mortalityinthepresentedcohorts ofpatientswithCOVID- 19.Ofnote,theincreaseinD-dimerlevelsdidnotseemto betheresultofovert-DICinthesepatients.

Ahigh riskof VTEhasbeen reportedover thelastfew weeks in patients with severe COVID-19 (around 20—40%

depending on the local systematic screening strategy) [9,10],which promptedphysicianstoempirically increase prophylactic anticoagulant dosing. Whether an intensi- ﬁedanticoagulant treatment— partlytailored toD-dimer levels — will impact mortality in these patients is cur- rentlyunderinvestigationinatleastfourrandomisedtrials (COVID-HEP NCT04345848; IMPROVE NCT04367831; COVI- DOSENCT04373707;RAPIDCOVIDCOAGNCT04362085).

Altogether,therecentdataincludingthosepresentedby Frèreetal.inthisissuehighlightonceagainthegreatinter- estofD-dimerasabiomarkerinclinicalpractice,notonly asadiagnostictoolbutalsoasaprognostictool[11].

Disclosure of interest

Theauthorsdeclarethattheyhavenocompetinginterest.

This manuscript represents original work, and it is not underconsideration for publication elsewhere. It has never been neither submitted nor published in another scientificjournal. Allauthors meet criteriafor authorship and none of the authors have any conflict of interest. All read and approved the final manuscript, and held responsibility for the decision to submit it for publication.

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