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D-Dimer/Fibrinogen Ratio and Radiological Severity Scores in Acute Pulmonary Embolism: Is There Room for a New
Francesco Tiralongo1, Lorenzo Musmeci1, Stefania Tamburrini2
1Radiology Unit 1, Department of Medical Surgical Sciences and Advanced Technologies "GF Ingrassia", University Hospital Policlinico "G. Rodolico-San Marco", University of Catania, 95123 Catania, Italy.
Insights
The D-dimer/fibrinogen ratio (D-d/F) shows modest correlation with thrombus burden and right ventricular dysfunction (RVD) in acute pulmonary embolism (PE), similar to D-dimer alone. CT imaging markers, especially the RV/LV ratio, are more effective in assessing PE severity.
Area of Science:
- Cardiology
- Radiology
- Hematology
Background:
- The D-dimer/fibrinogen ratio (D-d/F) is a proposed composite marker for fibrinolysis-coagulation balance.
- Its ability to reflect CT-quantified thrombus burden and right ventricular dysfunction (RVD) in acute pulmonary embolism (PE) requires further investigation.
Purpose of the Study:
- To evaluate the association between the D-d/F ratio and CT-quantified thrombus burden and RVD in patients with acute PE.
- To compare the performance of D-d/F with D-dimer and CT-derived markers in reflecting PE severity.
Main Methods:
- Retrospective cohort study of 112 patients with CTPA-confirmed PE.
- Thrombus burden assessed using Qanadli and Mastora indices; RVD evaluated by RV/LV ratio, septal bowing, and IVC reflux.
- Statistical analyses included Spearman correlations, ROC analysis, and logistic regression models.
Main Results:
- D-d/F showed modest correlations with thrombus burden indices (Qanadli, Mastora) and RVD markers (RV/LV ratio, IVC reflux), comparable to D-dimer alone.
- CT-derived indices, particularly the RV/LV ratio, demonstrated stronger associations with disease severity.
- In logistic models, RV/LV significantly improved prediction of high clot burden, while D-d/F did not add incremental value.
Conclusions:
- The D-d/F ratio offers a modest reflection of thrombus burden and RVD in acute PE, with performance similar to D-dimer.
- CT-based markers, especially the RV/LV ratio, are superior in reflecting PE severity and predicting high clot burden.
- Further prospective studies are needed to assess the risk prediction and incremental utility of the D-d/F ratio.
Abstract:
Background/Objectives: The D-dimer/fibrinogen ratio (D-d/F) has been proposed as a composite marker of fibrinolysis-coagulation balance. Whether D-d/F reflects CT-quantified thrombus burden and right ventricular dysfunction (RVD) in acute pulmonary embolism (PE) remains uncertain. Methods: Single-center retrospective cohort of consecutive adults with CTPA-confirmed PE (January 2022-October 2024). D-d/F = D-dimer (µg/mL)/fibrinogen (mg/dL). Thrombus burden: Qanadli and Mastora indices. RVD: RV/LV ratio, septal bowing, and IVC reflux. Associations: Spearman's ρ with Steiger's Z for between-marker comparisons. Discrimination for Qanadli ≥ 40% and RV/LV ≥ 1.0 by ROC. Two exploratory logistic models predicted Qanadli ≥ 40%: Model-1 (age, sex, D-d/F) and Model-2 adding RV/LV. Results: Among 112 patients (mean age 65.4 ± 15.6; 60% men), D-d/F correlated modestly with Qanadli (ρ = 0.233, p = 0.013) and Mastora (ρ = 0.274, p = 0.0034); strengths were similar to D-dimer (no between-marker difference: Steiger's Z both p > 0.5). D-d/F correlated with RV/LV (ρ = 0.335, p < 0.001) and with IVC reflux (ρ = 0.247, p = 0.0085). CT indices related more strongly to hemodynamic markers (e.g., Qanadli with RV/LV ρ = 0.571, p < 0.0001; Mastora with RV/LV ρ = 0.620, p < 0.0001). Patients with septal bowing had higher D-dimer (median 4.65 vs. 2.74 µg/mL, p = 0.0037), higher D-d/F (1.04 vs. 0.61, p = 0.0018), and higher clot-burden scores (both p < 0.0001). For Qanadli ≥ 40%, AUCs were 0.621 for D-d/F (cut-off > 0.795; sens 58.8%, spec 62.3%) and 0.618 for D-dimer (>1.894 µg/mL; 84.3%, 37.7%); AUCs did not differ (p = 0.93). For RV/LV ≥ 1.0, AUCs were 0.693 for D-d/F (>0.607; 83.8%, 52.0%) and 0.684 for D-dimer (>2.849 µg/mL; 75.7%, 54.7%); p = 0.72. In Model-1, D-d/F predicted Qanadli ≥ 40% (OR = 1.43 per unit, p = 0.043; AUC = 0.64). After adding RV/LV (Model-2), discrimination improved (AUC = 0.796), RV/LV remained a strong predictor (p < 0.0001), and D-d/F was not retained (p = 0.287). Conclusions: In acute PE, D-d/F tracks thrombus burden and RVD to a degree comparable to D-dimer, but effects are modest. CT-based markers-particularly RV/LV-better reflect disease severity and are more predictive of high clot burden. Risk prediction and incremental utility of D-d/F were not assessed and warrant prospective evaluation.
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