Re: help with pt with elevated D-dimer please

[Guest guest]

Elevated levels of d dimer can also be found when fibrin is found and not cleared like heart disease, liver disease, Trauma, infection, surgery and pregnancy (not applicable to this pt I know). Interestingly you can also see higher levels in the elderly.My advice don't chase a lab value. It sounds like you have done the appropriate workup, and just monitor for any new issues that may warrant further testing.Soma

From:

Eads ;

To:

< >;

Subject:

help with pt with elevated D-dimer please

Sent:

Thu, Feb 9, 2012 4:27:41 AM

Ok

folks, I need to tap into the incredible collective wisdom of this group. I

have a 59yo healthy never smoker G4P4 WF with homozygous factor V Leiden

mutation and MTHFR mutation who has had no hx of thrombosis; takes ASA 325 and

is not on ERT/HRT. Checked annual D-dimer as recommended by heme, and

this time it was elevated at 610 (nl 100-400) and a week later (today) was 560.

Heme said to look for a clot as this is not nl for these pts. Pt has no

sxs, nl hx of recent trauma/extended travel/prolonged sitting, no recent surgery,

no known malignancy, and is very active. She had nl SaO2 at home (husband

has finger model) and in my office, even with ambulating. With detailed

questioning, was having intermittent nocturnal R upper arm discomfort, so

checked sono, and was nl from ear to R wrist. Normal exam, including no

bulging of vessels, no edema, no discomfort (even in R arm), etc. Any

idea how long D-dimer stays elevated? What

else should I look for? Not

finding the answers I need from UpToDate… Waiting

to feel enlightened (and humbled) with your suggestions… THANKS! Eads, MD Pinnacle Family Medicine Colorado Springs, CO www.PinnacleFamilyMedicine.com

[Guest guest]

,Here is some info about the D-Dimer test from LabTestsOnline.org:http://labtestsonline.org/understanding/analytes/d-dimer/tab/test-----What does the test result mean?A normal or negative D-dimer result means that it is most likely that the person tested does not have an acute condition or disease that is causing abnormal clot formation and breakdown. Most doctors agree that a negative D-dimer is most valid and useful when the test is done on people who are considered to be at low to intermediate risk for thrombosis. The test is used to help rule out clotting as the cause of symptoms.A positive D-dimer result may indicate the presence of an abnormally high level of fibrin degradation products. It tells the doctor that there may be significant blood clot (thrombus) formation and breakdown in the body, but it does not tell the location or cause. It may be due to, for example, a venous thromboembolism (VTE) or DIC. Typically, the D-dimer level is very elevated in DIC.However, an elevated D-dimer does not always indicate the presence of a clot because a number of other factors can cause an increased level. Elevated levels may be seen in conditions in which fibrin is formed and then broken down, such as recent surgery, trauma, infection, heart disease, and some cancers or conditions in which fibrin is not cleared normally, such as liver disease. Therefore, D-dimer is typically not used to rule out VTE in hospitalized patients (inpatient setting).Pregnancy is also a condition in which fibrin is formed and broken down and may result in an elevated D-dimer level. However, if DIC is suspected in a woman who is pregnant or is in the immediate postpartum period, then the D-dimer test may be used, along with a PT, PTT, fibrinogen, and platelet count to help diagnose her condition. If the woman has DIC, her D-dimer level will be very elevated.D-dimer is recommended as an adjunct test. It should not be the only test used to diagnose a disease or condition. Both increased and normal D-dimer levels may require followup and can lead to further testing.When used to monitor DIC treatment, decreasing levels indicate that treatment is effective while increasing levels may indicate that treatment is not working.Is there anything else I should know?D-dimer concentrations may rise in the elderly, and false positives may be seen with high levels of rheumatoid factor, a protein seen in patients with rheumatoid arthritis. Substances such as high triglycerides, lipemia, and bilirubin can also cause false positives as can hemolysis caused by improper sample collection and handling.----- SetoSouth Pasadena, CA

Elevated levels of d dimer can also be found when fibrin is found and not cleared like heart disease, liver disease, Trauma, infection, surgery and pregnancy (not applicable to this pt I know). Interestingly you can also see higher levels in the elderly.My advice don't chase a lab value. It sounds like you have done the appropriate workup, and just monitor for any new issues that may warrant further testing.Soma

From:

Eads ;

To:

< >;

Subject:

help with pt with elevated D-dimer please

Sent:

Thu, Feb 9, 2012 4:27:41 AM

Ok

folks, I need to tap into the incredible collective wisdom of this group. I

have a 59yo healthy never smoker G4P4 WF with homozygous factor V Leiden

mutation and MTHFR mutation who has had no hx of thrombosis; takes ASA 325 and

is not on ERT/HRT. Checked annual D-dimer as recommended by heme, and

this time it was elevated at 610 (nl 100-400) and a week later (today) was 560.

Heme said to look for a clot as this is not nl for these pts. Pt has no

sxs, nl hx of recent trauma/extended travel/prolonged sitting, no recent surgery,

no known malignancy, and is very active. She had nl SaO2 at home (husband

has finger model) and in my office, even with ambulating. With detailed

questioning, was having intermittent nocturnal R upper arm discomfort, so

checked sono, and was nl from ear to R wrist. Normal exam, including no

bulging of vessels, no edema, no discomfort (even in R arm), etc. Any

idea how long D-dimer stays elevated?What

else should I look for? Not

finding the answers I need from UpToDate… Waiting

to feel enlightened (and humbled) with your suggestions… THANKS! Eads, MDPinnacle Family MedicineColorado Springs, COwww.PinnacleFamilyMedicine.com

[Guest guest]

Seems to me the annual D-dimer as recommended by heme has no evidence behind it or real utility. Essentially it's being used as a screening test in this case which is not at all it's intended use. It's a diagnostic test. I agree with not chasing the lab and following clinically as always. Deborah Ginsburg, MDHealing Oceans Family Wellness Center Helping Families Thrivewww.healing-oceans.com Sent from my iPad

,Here is some info about the D-Dimer test from LabTestsOnline.org:http://labtestsonline.org/understanding/analytes/d-dimer/tab/test-----What does the test result mean?A normal or negative D-dimer result means that it is most likely that the person tested does not have an acute condition or disease that is causing abnormal clot formation and breakdown. Most doctors agree that a negative D-dimer is most valid and useful when the test is done on people who are considered to be at low to intermediate risk for thrombosis. The test is used to help rule out clotting as the cause of symptoms.A positive D-dimer result may indicate the presence of an abnormally high level of fibrin degradation products. It tells the doctor that there may be significant blood clot (thrombus) formation and breakdown in the body, but it does not tell the location or cause. It may be due to, for example, a venous thromboembolism (VTE) or DIC. Typically, the D-dimer level is very elevated in DIC.However, an elevated D-dimer does not always indicate the presence of a clot because a number of other factors can cause an increased level. Elevated levels may be seen in conditions in which fibrin is formed and then broken down, such as recent surgery, trauma, infection, heart disease, and some cancers or conditions in which fibrin is not cleared normally, such as liver disease. Therefore, D-dimer is typically not used to rule out VTE in hospitalized patients (inpatient setting).Pregnancy is also a condition in which fibrin is formed and broken down and may result in an elevated D-dimer level. However, if DIC is suspected in a woman who is pregnant or is in the immediate postpartum period, then the D-dimer test may be used, along with a PT, PTT, fibrinogen, and platelet count to help diagnose her condition. If the woman has DIC, her D-dimer level will be very elevated.D-dimer is recommended as an adjunct test. It should not be the only test used to diagnose a disease or condition. Both increased and normal D-dimer levels may require followup and can lead to further testing.When used to monitor DIC treatment, decreasing levels indicate that treatment is effective while increasing levels may indicate that treatment is not working.Is there anything else I should know?D-dimer concentrations may rise in the elderly, and false positives may be seen with high levels of rheumatoid factor, a protein seen in patients with rheumatoid arthritis. Substances such as high triglycerides, lipemia, and bilirubin can also cause false positives as can hemolysis caused by improper sample collection and handling.----- SetoSouth Pasadena, CA

Elevated levels of d dimer can also be found when fibrin is found and not cleared like heart disease, liver disease, Trauma, infection, surgery and pregnancy (not applicable to this pt I know). Interestingly you can also see higher levels in the elderly.My advice don't chase a lab value. It sounds like you have done the appropriate workup, and just monitor for any new issues that may warrant further testing.Soma

From:

Eads ;

To:

< >;

Subject:

help with pt with elevated D-dimer please

Sent:

Thu, Feb 9, 2012 4:27:41 AM

Ok

folks, I need to tap into the incredible collective wisdom of this group. I

have a 59yo healthy never smoker G4P4 WF with homozygous factor V Leiden

mutation and MTHFR mutation who has had no hx of thrombosis; takes ASA 325 and

is not on ERT/HRT. Checked annual D-dimer as recommended by heme, and

this time it was elevated at 610 (nl 100-400) and a week later (today) was 560.

Heme said to look for a clot as this is not nl for these pts. Pt has no

sxs, nl hx of recent trauma/extended travel/prolonged sitting, no recent surgery,

no known malignancy, and is very active. She had nl SaO2 at home (husband

has finger model) and in my office, even with ambulating. With detailed

questioning, was having intermittent nocturnal R upper arm discomfort, so

checked sono, and was nl from ear to R wrist. Normal exam, including no

bulging of vessels, no edema, no discomfort (even in R arm), etc. Any

idea how long D-dimer stays elevated?What

else should I look for? Not

finding the answers I need from UpToDate… Waiting

to feel enlightened (and humbled) with your suggestions… THANKS! Eads, MDPinnacle Family MedicineColorado Springs, COwww.PinnacleFamilyMedicine.com

[Guest guest]

D-dimer is not specific. It has a lot of false positives. Beyond thrombosis it also increases with infection. IF the physical exam and tests you have done are negative I would leave it at that. Izquierdo-Porrera MD PhDExecutive Director & Co-founderCare for Your Health, IncPhone " Don't ever let injustice go by unchallenged. " From: [mailto: ] On Behalf Of EadsSent: Wednesday, February 08, 2012 11:28 PMTo: Subject: help with pt with elevated D-dimer please Ok folks, I need to tap into the incredible collective wisdom of this group. I have a 59yo healthy never smoker G4P4 WF with homozygous factor V Leiden mutation and MTHFR mutation who has had no hx of thrombosis; takes ASA 325 and is not on ERT/HRT. Checked annual D-dimer as recommended by heme, and this time it was elevated at 610 (nl 100-400) and a week later (today) was 560. Heme said to look for a clot as this is not nl for these pts. Pt has no sxs, nl hx of recent trauma/extended travel/prolonged sitting, no recent surgery, no known malignancy, and is very active. She had nl SaO2 at home (husband has finger model) and in my office, even with ambulating. With detailed questioning, was having intermittent nocturnal R upper arm discomfort, so checked sono, and was nl from ear to R wrist. Normal exam, including no bulging of vessels, no edema, no discomfort (even in R arm), etc. Any idea how long D-dimer stays elevated?What else should I look for? Not finding the answers I need from UpToDate… Waiting to feel enlightened (and humbled) with your suggestions… THANKS! Eads, MDPinnacle Family MedicineColorado Springs, COwww.PinnacleFamilyMedicine.com

[Guest guest]

D-dimer is not specific. It has a lot of false positives. Beyond thrombosis it also increases with infection. IF the physical exam and tests you have done are negative I would leave it at that. Izquierdo-Porrera MD PhDExecutive Director & Co-founderCare for Your Health, IncPhone " Don't ever let injustice go by unchallenged. " From: [mailto: ] On Behalf Of EadsSent: Wednesday, February 08, 2012 11:28 PMTo: Subject: help with pt with elevated D-dimer please Ok folks, I need to tap into the incredible collective wisdom of this group. I have a 59yo healthy never smoker G4P4 WF with homozygous factor V Leiden mutation and MTHFR mutation who has had no hx of thrombosis; takes ASA 325 and is not on ERT/HRT. Checked annual D-dimer as recommended by heme, and this time it was elevated at 610 (nl 100-400) and a week later (today) was 560. Heme said to look for a clot as this is not nl for these pts. Pt has no sxs, nl hx of recent trauma/extended travel/prolonged sitting, no recent surgery, no known malignancy, and is very active. She had nl SaO2 at home (husband has finger model) and in my office, even with ambulating. With detailed questioning, was having intermittent nocturnal R upper arm discomfort, so checked sono, and was nl from ear to R wrist. Normal exam, including no bulging of vessels, no edema, no discomfort (even in R arm), etc. Any idea how long D-dimer stays elevated?What else should I look for? Not finding the answers I need from UpToDate… Waiting to feel enlightened (and humbled) with your suggestions… THANKS! Eads, MDPinnacle Family MedicineColorado Springs, COwww.PinnacleFamilyMedicine.com

[Guest guest]

,

What you are actually asking is in this patient with abnormal factor V leiden is does she have a reason for chronic anticoagulation?

I have several patients with factor abnomalities. One is a construction worker that had a DVT after trauma. We anticoagualted with warfarin for 6months to a year, but then he had another. He is now on chronic anticoagulation.

In this 59 y/o without a known DVT or PE, one is concerned about risk. Does she have any sign of occult PE or DVT, leg swelling or vericose veins, periodic shortness of breath, chronic intermittent cough or asthma. These could be sutle signs of ongoing occult thrombosis and thrombolysis. Clearly venous dopller and V/Q or CT for PE would be indicated. Echo to detect elevated right heart pressures form chronic micro PE.

If all looks well, and truely asymptomatic a consult with an experience hematologist might be the best course.

Subject: RE: help with pt with elevated D-dimer pleaseTo: Date: Thursday, February 9, 2012, 11:34 AM

D-dimer is not specific. It has a lot of false positives. Beyond thrombosis it also increases with infection. IF the physical exam and tests you have done are negative I would leave it at that.

Izquierdo-Porrera MD PhD

Executive Director & Co-founder

Care for Your Health, Inc

Phone

"Don't ever let injustice go by unchallenged."

From: [mailto: ] On Behalf Of EadsSent: Wednesday, February 08, 2012 11:28 PMTo: Subject: help with pt with elevated D-dimer please

Ok folks, I need to tap into the incredible collective wisdom of this group.

I have a 59yo healthy never smoker G4P4 WF with homozygous factor V Leiden mutation and MTHFR mutation who has had no hx of thrombosis; takes ASA 325 and is not on ERT/HRT. Checked annual D-dimer as recommended by heme, and this time it was elevated at 610 (nl 100-400) and a week later (today) was 560. Heme said to look for a clot as this is not nl for these pts. Pt has no sxs, nl hx of recent trauma/extended travel/prolonged sitting, no recent surgery, no known malignancy, and is very active. She had nl SaO2 at home (husband has finger model) and in my office, even with ambulating. With detailed questioning, was having intermittent nocturnal R upper arm discomfort, so checked sono, and was nl from ear to R wrist. Normal exam, including no bulging of vessels, no edema, no discomfort (even in R arm), etc.

Any idea how long D-dimer stays elevated?

What else should I look for?

Not finding the answers I need from UpToDate…

Waiting to feel enlightened (and humbled) with your suggestions…

THANKS!

Eads, MD

Pinnacle Family Medicine

Colorado Springs, CO

www.PinnacleFamilyMedicine.com

[Guest guest]

I would stop measuring d-dimers. There is no science behind that. Hematologist did not give you clear indication of why you were doing it and then what do you do with the result. I mean, why yearly? What about the other 51 weeks of the year? If that concerned she could clot at any second, then anticoagulate or run the tests weekly (not that I see any point in that but could at least rationalize that more than yearly). But since there is nothing you can do about a positive result in an asymptomatic person, then don’t run the test. Kathy Saradarian, MDBranchville, NJwww.qualityfamilypractice.comSolo 4/03, Practicing since 9/90Practice Partner 5/03Low staffing From: [mailto: ] On Behalf Of Izquierdo MD PhDSent: Thursday, February 09, 2012 12:35 PMTo: Subject: RE: help with pt with elevated D-dimer please D-dimer is not specific. It has a lot of false positives. Beyond thrombosis it also increases with infection. IF the physical exam and tests you have done are negative I would leave it at that. Izquierdo-Porrera MD PhDExecutive Director & Co-founderCare for Your Health, IncPhone " Don't ever let injustice go by unchallenged. " From: [mailto: ] On Behalf Of EadsSent: Wednesday, February 08, 2012 11:28 PMTo: Subject: help with pt with elevated D-dimer please Ok folks, I need to tap into the incredible collective wisdom of this group. I have a 59yo healthy never smoker G4P4 WF with homozygous factor V Leiden mutation and MTHFR mutation who has had no hx of thrombosis; takes ASA 325 and is not on ERT/HRT. Checked annual D-dimer as recommended by heme, and this time it was elevated at 610 (nl 100-400) and a week later (today) was 560. Heme said to look for a clot as this is not nl for these pts. Pt has no sxs, nl hx of recent trauma/extended travel/prolonged sitting, no recent surgery, no known malignancy, and is very active. She had nl SaO2 at home (husband has finger model) and in my office, even with ambulating. With detailed questioning, was having intermittent nocturnal R upper arm discomfort, so checked sono, and was nl from ear to R wrist. Normal exam, including no bulging of vessels, no edema, no discomfort (even in R arm), etc. Any idea how long D-dimer stays elevated?What else should I look for? Not finding the answers I need from UpToDate… Waiting to feel enlightened (and humbled) with your suggestions… THANKS! Eads, MDPinnacle Family MedicineColorado Springs, COwww.PinnacleFamilyMedicine.com

[Guest guest]

Thanks for all the advice!

Eads, MD

Pinnacle Family Medicine

Colorado Springs, CO

www.PinnacleFamilyMedicine.com

From:

[mailto: ] On Behalf Of Egly

Sent: Thursday, February 09, 2012 10:57 AM

To:

Subject: RE: help with pt with elevated D-dimer

please

,

What you are actually asking is in this patient with

abnormal factor V leiden is does she have a reason for chronic

anticoagulation?

I have several patients with factor abnomalities.

One is a construction worker that had a DVT after trauma. We

anticoagualted with warfarin for 6months to a year, but then he had

another. He is now on chronic anticoagulation.

In this 59 y/o without a known DVT or PE, one is concerned

about risk. Does she have any sign of occult PE or DVT, leg swelling or

vericose veins, periodic shortness of breath, chronic intermittent cough or

asthma. These could be sutle signs of ongoing occult thrombosis and

thrombolysis. Clearly venous dopller and V/Q or CT for PE would be

indicated. Echo to detect elevated right heart pressures form chronic

micro PE.

If all looks well, and truely asymptomatic a consult with

an experience hematologist might be the best course.

Subject: RE: help with pt with elevated D-dimer please

To:

Date: Thursday, February 9, 2012, 11:34 AM

D-dimer

is not specific. It has a lot of false positives. Beyond thrombosis it also

increases with infection. IF the physical exam and tests you have done

are negative I would leave it at that.

Izquierdo-Porrera MD PhD

Executive

Director & Co-founder

Care

for Your Health, Inc

Phone

" Don't ever let injustice go by

unchallenged. "

From:

[mailto: ] On Behalf Of

Eads

Sent: Wednesday, February 08, 2012 11:28 PM

To:

Subject: help with pt with elevated D-dimer

please

Ok folks, I need to tap into the incredible

collective wisdom of this group.

I have a 59yo healthy never smoker G4P4 WF

with homozygous factor V Leiden mutation and MTHFR mutation who has had no hx

of thrombosis; takes ASA 325 and is not on ERT/HRT. Checked annual

D-dimer as recommended by heme, and this time it was elevated at 610 (nl 100-400)

and a week later (today) was 560. Heme said to look for a clot as this

is not nl for these pts. Pt has no sxs, nl hx of recent trauma/extended

travel/prolonged sitting, no recent surgery, no known malignancy, and is very

active. She had nl SaO2 at home (husband has finger model) and in my

office, even with ambulating. With detailed questioning, was having

intermittent nocturnal R upper arm discomfort, so checked sono, and was nl

from ear to R wrist. Normal exam, including no bulging of vessels, no

edema, no discomfort (even in R arm), etc.

Any idea how long D-dimer stays elevated?

What else should I look for?

Not finding the answers I need from UpToDate…

Waiting to feel enlightened (and humbled) with

your suggestions…

THANKS!

Eads, MD

Pinnacle Family

Medicine

Colorado Springs,

CO

www.PinnacleFamilyMedicine.com