The IMPROVEDD VTE Risk Score: Incorporation of D-Dimer into the IMPROVE Score to Improve Venous Thromboembolism Risk Stratification
C. Michael Gibson,
Alex C. Spyropoulos,
Alexander T. Cohen,
Russell D. Hull,
Samuel Z. Goldhaber,
Roger D. Yusen,
Adrian F. Hernandez,
Serge Korjian,
Yazan Daaboul,
Alex Gold,
Robert A. Harrington,
Gerald Chi
Affiliations
C. Michael Gibson
Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
Alex C. Spyropoulos
Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Hofstra Northwell School of Medicine, Northwell Health System, Manhasset, New York, United States
Alexander T. Cohen
Department of Haematological Medicine, Guy's and St Thomas' Hospitals, King's College, London, United Kingdom
Russell D. Hull
Division of Cardiology, Faculty of Medicine, University of Calgary, Alberta, Canada
Samuel Z. Goldhaber
Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
Roger D. Yusen
Divisions of Pulmonary and Critical Care Medicine and General Medical Sciences, Washington University School of Medicine, St. Louis, Missouri, United States
Adrian F. Hernandez
Department of Medicine, Duke University and Duke Clinical Research Institute, Durham, North Carolina, United States
Serge Korjian
Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
Yazan Daaboul
Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
Alex Gold
Portola Pharmaceuticals, Inc., South San Francisco, California, United States
Robert A. Harrington
Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, United States
Gerald Chi
Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
Abstract Background The IMPROVE score is a validated venous thromboembolism (VTE) assessment tool to risk stratify hospitalized, medically ill patients based on clinical variables. It was hypothesized that addition of D-dimer measurement to derive a new IMPROVEDD score would improve identification of at risk of VTE. Methods The association of the IMPROVE score and D-dimer ≥ 2 × the upper limit of normal (ULN) with the risk of symptomatic deep vein thrombosis, nonfatal pulmonary embolism, or VTE-related death was evaluated in 7,441 hospitalized, medically ill patients randomized in the APEX trial. Based on the Cox regression analysis, the IMPROVEDD score was derived by adding two points to the IMPROVE score if the D-dimer was ≥ 2 × ULN. Results Baseline D-dimer was independently associated with symptomatic VTE through 77 days (adjusted HR: 2.22 [95% CI: 1.38–1.58], p = 0.001). Incorporation of D-dimer into the IMPROVE score improved VTE risk discrimination (ΔAUC: 0.06 [95% CI: 0.02–0.09], p = 0.0006) and reclassification (continuous NRI: 0.34 [95% CI: 0.17–0.51], p = 0.001; categorical NRI: 0.13 [95% CI: 0.03–0.23], p = 0.0159). Patients with an IMPROVEDD score of ≥2 had a greater VTE risk compared with those with an IMPROVEDD score of 0 to 1 (HR: 2.73 [95% CI: 1.52–4.90], p = 0.0007). Conclusion Incorporation of D-dimer into the IMPROVE VTE risk assessment model further improves risk stratification in hospitalized, medically ill patients who received thromboprophylaxis. An IMPROVEDD score of ≥2 identifies hospitalized, medically ill patients with a heightened risk for VTE through 77 days.
