Predictive Value of the Wells Score Combined with D-Dimer Level in Identifying Acute Pulmonary Embolism in Patients with Coronary Heart Disease Presenting with Chest Pain
Acute pulmonary embolism (APE) is a life-threatening condition often associated with diagnostic delays or misdiagnosis, particularly in patients with coronary heart disease (CHD). In emergency settings, overlapping clinical features between APE and acute coronary syndrome (ACS) pose significant challenges. Patients with CHD and chest pain are frequently misdiagnosed with ACS, leading to unnecessary interventions such as coronary angiography or prolonged emergency department stays. The 2008 European Society of Cardiology (ESC) guidelines recommend using the Wells score for clinical risk stratification of APE. However, its application in emergency departments, especially for CHD patients, remains limited. This study evaluates the predictive value of combining the Wells score with D-dimer levels to improve the identification of APE in CHD patients presenting with chest pain.
Study Design and Patient Population
This retrospective study analyzed 247 consecutive CHD patients who presented to the emergency department with chest pain and underwent computed tomography pulmonary angiography (CTPA) between May 2008 and July 2016. Patients were stratified into two groups: those with CHD and confirmed APE (n=104) and those with CHD alone (n=143). Clinical data, including demographics, vital signs, laboratory results, imaging findings, and Wells scores, were collected and compared. Statistical analyses included chi-square tests for categorical variables, Student’s t-tests or Mann-Whitney U tests for continuous variables, and logistic regression to identify independent risk factors. Receiver operating characteristic (ROC) curves were generated to compare the diagnostic performance of the Wells score, D-dimer levels, and their combination.
Key Clinical and Laboratory Findings
Patients with CHD and APE were younger (61 ± 5 years vs. 66 ± 12 years, P=0.002) and exhibited distinct clinical profiles compared to those with CHD alone. The APE group had lower systolic (118.3 ± 22.4 mmHg vs. 125.9 ± 20.4 mmHg, P=0.006) and diastolic blood pressure (71.8 ± 12.8 mmHg vs. 75.4 ± 12.3 mmHg, P=0.028), higher heart rates (100.9 ± 18.5 vs. 91.5 ± 15.6 beats/minute, P<0.001), and a greater prevalence of unilateral lower limb swelling (51.0% vs. 17.5%, P<0.001), deep vein thrombosis (DVT; 19.2% vs. 7.0%, P=0.004), and shock (16.3% vs. 6.3%, P=0.011). The median D-dimer level was higher in the APE group (2148 ng/mL [interquartile range (IQR): 1121–3503] vs. 1771 ng/mL [IQR: 885–1896], P=0.051), approaching statistical significance.
Echocardiography revealed a higher incidence of the “D sign” (7.7% vs. 1.4%, P=0.013) and pulmonary arterial widening (4.8% vs. 0.7%, P=0.034) in the APE group. Electrocardiogram (ECG) findings showed significantly more sinus tachycardia (69.2% vs. 39.2%, P<0.001) and SIQIIITIII patterns (40.4% vs. 22.4%, P=0.002) in APE patients.
Independent Risk Factors for APE
Univariate and multivariate logistic regression identified three independent predictors of APE in CHD patients:
- Unilateral lower limb swelling (odds ratio [OR]=5.634, 95% CI: 1.257–13.463, P=0.037).
- Tachycardia (OR=1.194, 95% CI: 0.569–8.846, P=0.043).
- Deep vein thrombosis (OR=1.657, 95% CI: 0.338–12.850, P<0.001).
These findings underscore the importance of integrating clinical signs (e.g., limb swelling) and hemodynamic parameters (e.g., heart rate) into risk assessment for APE in CHD patients.
Diagnostic Performance of Wells Score and D-Dimer
The D-dimer level demonstrated a sensitivity of 88.46% and specificity of 83.22% at a cutoff of 1090 ng/mL, with a Youden index (YI) of 0.717. The Wells score alone had lower sensitivity (75.96%) and specificity (70.63%) at a cutoff >1 (YI=0.466). However, combining the Wells score with D-dimer levels improved diagnostic accuracy, achieving a sensitivity of 88.46%, specificity of 90.21%, and YI of 0.787. ROC curve analysis confirmed the superiority of the combined approach, with an area under the curve (AUC) of 0.949 (95% CI: 0.913–0.973), significantly higher than D-dimer alone (AUC=0.898, P<0.0001) or the Wells score alone (AUC=0.784, P<0.0001).
Clinical Implications and Limitations
The study highlights the diagnostic challenges in differentiating APE from ACS in CHD patients, particularly given the nonspecific ECG findings. Emergency physicians often rely on D-dimer testing to exclude APE, but this approach may delay diagnosis in CHD patients due to elevated baseline D-dimer levels in cardiovascular diseases. The Wells score provides a rapid, cost-effective clinical assessment tool, and its integration with D-dimer testing enhances diagnostic precision. This strategy could reduce unnecessary imaging and expedite appropriate management.
However, the study has limitations. Its retrospective design and single-center enrollment may limit generalizability. The sample size, though adequate for preliminary analysis, warrants validation in larger, multicenter cohorts. Additionally, the study excluded low-risk outpatients, potentially underestimating the utility of the combined approach in broader populations.
Conclusion
In CHD patients presenting with chest pain, the combination of the Wells score and D-dimer level significantly improves the identification of APE compared to either method alone. This approach addresses diagnostic uncertainties in emergency settings, reduces reliance on invasive procedures, and optimizes resource utilization. Future studies should explore the integration of these tools into standardized protocols for emergency departments, particularly in high-risk populations with overlapping cardiovascular pathologies.
doi.org/10.1097/CM9.0000000000000988
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