key: cord-1011758-q6jhm30g
authors: Godon, Alexandre; Tacquard, Charles Ambroise; Mansour, Alexandre; Garrigue, Delphine; Nguyen, Philippe; Lasne, Dominique; Testa, Sophie; Levy, Jerrold H.; Albaladejo, Pierre; Gruel, Yves; Susen, Sophie; Godier, Anne
title: Reply to the authors of “Age-adjusted D-dimer cut-off levels to exclude venous thromboembolism in COVID-19 patients”
date: 2021-08-13
journal: Anaesth Crit Care Pain Med
DOI: 10.1016/j.accpm.2021.100940
sha: 7ca18be753541ab886e3950d809133026244bf6a
doc_id: 1011758
cord_uid: q6jhm30g

nan

We thank the authors for taking interest in the 2021 updated GIHP/GFHT proposals on thromboprophylaxis for COVID-19 patients. The authors proposed to consider an ageadjusted D-dimer cut-off to exclude venous thromboembolism (VTE) in COVID-19 patients.

We would like to clarify this misunderstanding regarding D-dimers during COVID-19.

In non-COVID-19 patients, D-dimers have a very high sensitivity and negative predictive value to rule out VTE, thus guidelines recommend their measurement and propose an ageadjusted cut-off as an alternative to the fixed D-dimer cut-off [1, 2] . Nevertheless, such guidelines concern outpatients or emergency department patients with low or intermediate clinical probability of having VTE. Guidelines also specify that D-dimer level cannot be used to rule out VTE in high-pretest probability patients. As a result, D-dimers cannot be used to exclude VTE in critically ill COVID-19 patients: they are not outpatients, their D-dimer levels are always increased and their probability of having VTE is high.

In our proposals, we suggested using D-dimer level and its dynamics not to exclude VTE but to define a subgroup of critically ill COVID-19 patients exposed to a very high thrombotic risk. Indeed, a D-dimer level greater than 5 µg/mL, or an abrupt rise in D-dimer level were associated with a high positive predictive value for the diagnosis of thrombosis, with thrombosis being diagnosed in more than 50% of these patients. We chose to consider these patients as having a thrombotic complication until proven otherwise, or about to have this complication, and suggested starting therapeutic dose anticoagulation. Based on data available in the literature, about 10-15% of all critically ill patients would be concerned by this proposal [3] [4] [5] .

The variation in D-dimer levels with age adds to the lack of standardisation between D-dimer assays. This highlights the value of regular biological monitoring in critically ill patients to detect a sudden increase in D-dimer levels.

In conclusion, we suggest using D-dimers as a dynamic tool to identify a small subset of critically ill COVID-19 patients with a very high risk of thrombosis, who may benefit from anticoagulation at therapeutic dose. Such a preventive anticoagulation should not go beyond 7 to 10 days without screening for thrombosis, to minimise the bleeding risk, which then becomes predominant [6] .

J o u r n a l P r e -p r o o f

Recommandations de bonne pratique pour la prise en charge de la maladie veineuse thromboembolique chez l'adulte. Version courte [Recommendations of good practice for the management of thromboembolic venous disease in adults

ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS)

Utility of D-dimers and intermediate-dose prophylaxis for venous thromboembolism in critically ill patients with COVID-19

Pulmonary embolism in hospitalised patients with COVID-19

Utility of D-dimer in predicting venous thromboembolism in non-mechanically ventilated COVID-19 survivors

Anticoagulation in COVID-19: not strong for too long? Anaesth Crit Care Pain Med