Nurdan KÖKTÜRK Ayhan VAROL Hatice KILIÇ Numan EKİM

1. The Role of D-Dimer Levels in Follow-up and Differential Diagnosis of Pulmonary Thromboembolism (PTE) and Community Acquired Pneumonia (CAP) Nurdan KÖKTÜRK Ayhan VAROL Hatice KILIÇ Numan EKİM GAZİ UNİVERSITY FACULTY OF MEDICINE PULMONARY DISEASES DEPARTMENT

2. INTRODUCTION • Pulmonary thromboembolism is responsible from 10% of hospital deaths • Among the patients; • 22 % of them die in first few hours (in 30 min) • 25 % of them die in first 7 days • 70 % of the massive pulmonary embolism cases die in first one hour Sirius study,Arch Inter Med. 2000; 160:3415-3420. ICOPER study, Lancet 1999; 353:1386-1389.

3. INTRODUCTION • Diagnostic tool; Chest X-ray Arterial Blood Gas (ABG) ECG D Dimer Spiral Thorax CT/ Lung V/Q Scintigraphy Bilateral Lower Extremity Doppler USG Pulmonary Angiography

4. - - - - - + + + + + Determine Clinical Probability Low probability Moderate and high probability D dimer D dimer Heparinisation (Standard, LMWH) Exclude PTE V/Q scintigraphy or Spiral CT Nondiagnostic (Low-moderate) / Normal CT 3 months follow up High probability / pozitive CT Normal Exclude PTE PTE: continue treatment Bilateral lower extremity USG DVT diagnosed DVT not identified Behave according to clinical probability Low clinical probabilty Moderate clinic probability High clinic probability Behave according to initial D-dimer level Angiography or repeat USG with in a week Exclude PTE Repeat USG within a week 3 months follow up PTE: continue treatment PTE: continue treatment Wells PS, Rodger M. Diagnosis of Pulmonary Embolism: When is imaging needed. Clin In Chest Med 2003; 13-28 Exclude PTE

5. D – Dimer-1

6. D – Dimer-2 • High D- dimer levels can be found in various conditions; • Acute thrombosis • Infections • Malignancies • Chronic Renal Failure • Pregnancy • Elderly patients • Stroke • Hepatic Disease • Major trauma Kelly J. Arch Intern Med.162;2000 Andersen DR.J.Emerg Med 2000

7. D – Dimer-3 • D – Dimer Measurement Techniques • ELISA ( NPV= % 91-100) • LATEX Agglutination (NPV= % 67-97 ) • Immunofiltration assay • Immunoturbidometric assay • Simple RED D- dimer test (Sensitivity ~ % 85 ) • VIDAS, Liatest (Rapid tests) Wells SP, Rodger M. Clin Chest Med. 2003; 24: 13-25

8. AIM • To evaluate the role of D-Dimer quantitative levels in differentiating PTE from CAP • To observe the variations in D-Dimer quantitative levels in PTE patients treated with anticoagulant therapy and to determine whether there is a relationship between these variations and disease prognosis, severity and recurrence

9. MATERIAL AND METHOD-1 Patient population • 20 PTE patient; mean age: 58 ± 18.19 years. • 17 CAP patient; mean age: 68 ± 14 years. PTE diagnosis • In 10 patient High Probability V/Q • In 4 patient Moderate Probability V/Q + Doppler USG • In 6 patient Thorax CT CAP diagnosis • Turkish Thorasic Society CAP criteria

10. MATERIAL AND METHOD-2 • Exclusion criteria from the study; Active hepatic failure Active malignancy Pregnancy Renal failure Sepsis Not accepting to be included in the study

11. MATERIAL AND METHOD-3 • Among the patients with the diagnosis of PTE and CAP, serum D-Dimer levels were measured in their first admission before anticoagulant or antibiotic therapy; and at the 3rd, 10th and 30th days after initiating therapy

12. MATERIAL AND METHOD-4 • D-Dimer levels were measured with latex added immunoturbidometric method named as D-Dimer Plus. LATEX PARTICULE Antibody against D-DİMER Antigen in the medium

13. MATERIAL AND METHOD-5 Statistical Analysis • p<0.05 was accepted as statistically significant • SPSS 11.5 version was used • Mann Whitney U • Friedman Test

14. RESULTS-1

15. RESULTS-2

16. RESULTS-3 • When the difference between the D-dimer levels were evaluated at different measurement days in PTE group; • D Dimer at day 0> D Dimer at 3rd day= D Dimer at 10th day > D Dimer at 1st month (p=0.000) • When the difference in D-dimer levels were evaluated at different measurement days in PTE group; • D Dimer at day 0 > D Dimer at 1st month • D Dimer at 3rd day > D Dimer 1st month (p=0.009) • D-Dimer level was still high at 30th day in patient with MODS • Except one case who died due to MODS; symptoms were improved completely in the other 19 patients.

17. CONCLUSION This longitudinal preliminary study indicated that; • Serum D-Dimer quantitative levels can be useful in differential diagnosis of PTE and CAP • D-Dimer levels decrease with treatment in PTE • Patient number must be increased in order to make a comment that a defective decrease in D-dimer levels with treatment may indicate recurrence or ineffective treatment in PTE