• Wim A M Lucassen, Marlous Kuijs-Augustijn, Petra M G Erkens, Geert-Jan Geersing, Harry R Büller, and Henk C P M van Weert.
• Academic Medical Centre, Department of General Practice , Amsterdam , The Netherlands.
• Eur J Gen Pract. 2013 Sep 1;19(3):143-9.

BackgroundAfter excluding pulmonary embolism (PE) with an unlikely Wells-decision rule and a negative D-dimer test, the general practitioner still has to differentiate between clinically relevant and clinically non-relevant diseases accounting for the presented symptoms. A negative D-dimer test makes clinically relevant disease less likely. The C-reactive protein (CRP) test could be of additional value to make this differentiation.ObjectivesTo assess whether an unlikely Wells-decision rule in combination with a negative point of care D-dimer test not only can safely exclude PE but also, in combination with a negative CRP-test, any other clinically relevant disease.MethodsWe used data of a prospective study including 598 primary care patients suspected of pulmonary embolism. We included all patients, referred to secondary care for reference testing, with an unlikely Wells-decision rule and a negative point of care D-dimer test. We included 191 patients and imputed the CRP-test results in 60 patients. Alternative diagnoses were divided in clinically relevant diseases and clinically non-relevant diseases. A ROC-curve was constructed to determine the optimal CRP-cut-off.ResultsThe optimal CRP cut-off value appeared to be 10 mg/l. A total of 116 patients had a CRP < 10 mg/l of whom 12 patients (10%) had a clinically relevant disease. Two patients (2%) needed hospital admission. A total of 75 patients had a CRP ≥ 10 mg/l of whom 32 patients (43%) had a clinically relevant disease. Fifteen patients (20%) were admitted to hospital.ConclusionThe CRP-test is enhancing diagnostic decision making in patients in whom the general practitioner excluded PE.

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