Diagnostic Approach for Elevated D-dimer Levels

Introduction to Diagnostic Approach

The American College of Chest Physicians recommends that when D-dimer levels are elevated, further investigations should be directed toward ruling out venous thromboembolism (VTE), particularly deep vein thrombosis (DVT) or pulmonary embolism (PE), as these are the most common serious conditions associated with elevated D-dimer levels 1, 2

For patients with high clinical probability of DVT, the European Society of Cardiology recommends proceeding directly to proximal compression ultrasonography (CUS) or whole-leg ultrasonography regardless of D-dimer result 2, 3
If proximal CUS is positive in patients with high clinical probability of DVT, the American College of Chest Physicians recommends treating for DVT without confirmatory venography 2
If isolated distal DVT is detected on whole-leg US in patients with high clinical probability of DVT, the American College of Chest Physicians recommends considering serial testing to rule out proximal extension 2

For patients with non-high risk pulmonary embolism (without shock or hypotension), the European Society of Cardiology recommends proceeding with CT pulmonary angiography (CTPA) 3
For patients with high risk pulmonary embolism (with shock or hypotension), the European Society of Cardiology recommends proceeding directly to CTPA if available and patient is stable 3
For patients with high risk pulmonary embolism (with shock or hypotension), the European Society of Cardiology recommends considering bedside echocardiography in unstable patients 3

For patients with suspected aortic dissection, the American Heart Association recommends that D-dimer has high sensitivity (94%) but variable specificity (40-100%) for acute aortic dissection 4, 5
For patients with suspected aortic dissection, the American Heart Association recommends proceeding directly to definitive imaging (CT angiography, MRI, or transesophageal echocardiography) regardless of D-dimer result 4, 5
D-dimer should not be used to rule out aortic dissection in high-risk individuals, as recommended by the American Heart Association 4, 5

The Society of Critical Care Medicine recommends that D-dimer should not be used as the sole guide for anticoagulation management decisions 6, 7, 8
The American College of Chest Physicians recommends that initial testing with ultrasonography may be preferred over D-dimer in patients with comorbid conditions likely to cause elevated D-dimer levels even in the absence of VTE 1, 2
For patients with suspected upper extremity DVT and negative initial ultrasound but high clinical suspicion, the American College of Chest Physicians recommends considering further testing with D-dimer, serial ultrasound, or venographic-based imaging 9