• Henrike J Schouten, G J Geersing, H L Koek, Nicolaas P A Zuithoff, Kristel J M Janssen, Renée A Douma, Johannes J M van Delden, Karel G M Moons, and Johannes B Reitsma.
• Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, PO Box 85500, 3508GA Utrecht, Netherlands.
• BMJ. 2013 Jan 1;346:f2492.

ObjectiveTo review the diagnostic accuracy of D-dimer testing in older patients (>50 years) with suspected venous thromboembolism, using conventional or age adjusted D-dimer cut-off values.DesignSystematic review and bivariate random effects meta-analysis.Data SourcesWe searched Medline and Embase for studies published before 21 June 2012 and we contacted the authors of primary studies.Study SelectionPrimary studies that enrolled older patients with suspected venous thromboembolism in whom D-dimer testing, using both conventional (500 µg/L) and age adjusted (age × 10 µg/L) cut-off values, and reference testing were performed. For patients with a non-high clinical probability, 2 × 2 tables were reconstructed and stratified by age category and applied D-dimer cut-off level.Results13 cohorts including 12,497 patients with a non-high clinical probability were included in the meta-analysis. The specificity of the conventional cut-off value decreased with increasing age, from 57.6% (95% confidence interval 51.4% to 63.6%) in patients aged 51-60 years to 39.4% (33.5% to 45.6%) in those aged 61-70, 24.5% (20.0% to 29.7% in those aged 71-80, and 14.7% (11.3% to 18.6%) in those aged >80. Age adjusted cut-off values revealed higher specificities over all age categories: 62.3% (56.2% to 68.0%), 49.5% (43.2% to 55.8%), 44.2% (38.0% to 50.5%), and 35.2% (29.4% to 41.5%), respectively. Sensitivities of the age adjusted cut-off remained above 97% in all age categories.ConclusionsThe application of age adjusted cut-off values for D-dimer tests substantially increases specificity without modifying sensitivity, thereby improving the clinical utility of D-dimer testing in patients aged 50 or more with a non-high clinical probability.

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