What is the management approach for an elderly patient with elevated D-dimer (D-dimer), a history of aortic aneurysm and esophageal adenocarcinoma post radiotherapy?

From the Guidelines

The management approach for an elderly patient with elevated D-dimer, a history of aortic aneurysm, and esophageal adenocarcinoma post radiotherapy should prioritize immediate investigation for potential thromboembolism and aortic aneurysm expansion through imaging studies, followed by therapeutic or prophylactic anticoagulation as necessary, while balancing thrombotic and bleeding risks. The patient's elevated D-dimer level, as indicated in the study by 1, warrants a diagnostic multiparametric algorithm that combines the aortic dissection detection-risk score with D-dimer to rule out acute aortic syndrome (AAS). Given the patient's history of aortic aneurysm, a CT angiogram of the aorta should be performed to assess for aneurysm expansion, as recommended by 1. Additionally, the patient's cancer history increases thrombotic risk, so if thromboembolism is confirmed, therapeutic anticoagulation should be initiated, preferably with low molecular weight heparin, as it's preferred in cancer patients, according to general clinical guidelines. Some key points to consider in the management plan include:

• Immediate investigation for potential thromboembolism through imaging studies such as CT pulmonary angiography and duplex ultrasonography of the lower extremities
• Assessment for aneurysm expansion or acute aortic syndrome through a CT angiogram of the aorta
• Initiation of therapeutic anticoagulation if thromboembolism is confirmed, with consideration of low molecular weight heparin as the preferred option in cancer patients
• Prophylactic anticoagulation if no acute thrombosis is found but the patient has high thrombotic risk, with options including enoxaparin or apixaban
• Regular monitoring of the aortic aneurysm, with surgical consultation if the aneurysm exceeds size thresholds or shows rapid expansion, as generally recommended in clinical practice. The study by 1 provides additional context on the use of D-dimer levels in diagnosing acute aortic dissection, highlighting the importance of considering the patient's overall clinical presentation and risk factors in determining the appropriate management approach.

From the FDA Drug Label

The efficacy and safety of XARELTO for prophylaxis of venous thromboembolism in acutely ill medical patients at risk for thromboembolic complications not at high risk of bleeding was evaluated in the MAGELLAN study VTE risk factors included severe immobilization at study entry (99.9%), D-dimer > 2× ULN (43.7%), history of heart failure (35.6%), BMI ≥ 35 kg/m 2 (15. 2%), chronic venous insufficiency (14.9%), acute infectious disease (13.9%), severe varicosis (12.5%), history of cancer (16.2%), history of VTE (4.5%) Table 24 shows the overall results from the prespecified, modified intent-to-treat (mITT) analysis for the efficacy outcomes and their components.

The management approach for an elderly patient with elevated D-dimer, a history of aortic aneurysm, and esophageal adenocarcinoma post radiotherapy may involve the use of anticoagulants such as rivaroxaban or enoxaparin to prevent venous thromboembolism (VTE).

• Risk factors for VTE in this patient include history of cancer, immobilization, and elevated D-dimer.
• The MAGELLAN study 2 showed that rivaroxaban reduced the risk of VTE in acutely ill medical patients at risk for thromboembolic complications.
• Enoxaparin 3 has also been shown to reduce the risk of DVT in medical patients with severely restricted mobility during acute illness. However, the decision to use anticoagulants should be made on a case-by-case basis, taking into account the patient's individual risk factors and medical history.

From the Research

Management Approach for Elevated D-dimer in Elderly Patients

The management approach for an elderly patient with elevated D-dimer, a history of aortic aneurysm, and esophageal adenocarcinoma post radiotherapy involves several considerations:

• The patient's medical history, including the aortic aneurysm and esophageal adenocarcinoma, increases the risk of thromboembolic events 4.
• Elevated D-dimer levels are associated with an increased risk of incident venous thromboembolism (VTE), recurrent VTE, and mortality 4.
• The D-dimer assay is a valuable marker of activation of coagulation and fibrinolysis, but it has limitations, including elevation in various clinical scenarios such as age, pregnancy, and cancer 5.

Diagnostic Considerations

• Extremely elevated D-dimer levels are specific for serious illness, including VTE, sepsis, and cancer 6.
• A high D-dimer level in this patient may indicate an increased risk of thromboembolic events, and further diagnostic evaluation is warranted 4, 6.
• However, the presence of heterophilic antibodies can cause falsely elevated D-dimer levels, and this should be considered when the clinical evidence does not support the diagnosis of thromboembolic disease 7.

Treatment Considerations

• Antithrombotic therapy may be considered in patients with elevated D-dimer levels, but the efficacy and safety of this approach need to be evaluated prospectively 4.
• The administration of direct oral anticoagulants (DOACs) such as rivaroxaban may affect D-dimer levels, and the diagnostic performance of the test should be interpreted with caution in patients receiving these medications 8.
• The patient's history of aortic aneurysm and esophageal adenocarcinoma post radiotherapy should be taken into account when considering antithrombotic therapy, as these conditions may increase the risk of bleeding or other complications.