Pulmonary embolism rule-out strategies using D-dimer guided by the YEARS algorithm and an age-adjusted cutoff: systematic review

Abstract

Introduction: Safe diagnostic exclusion of pulmonary embolism (PE) in hemodynamically stable patients relies on integrating pretest clinical probability, D-dimer testing, and imaging. However, fixed D-dimer thresholds reduce operational efficiency—particularly in older adults—by increasing computed tomographic pulmonary angiography (CTPA) use. Age-adjusted D-dimer cutoffs and simplified algorithms such as YEARS have been proposed to optimize the trade-off between safety (low follow-up failure rates) and efficiency (less CTPA). Objective: to critically synthesize evidence on PE rule-out strategies using D-dimer guided by the YEARS algorithm and by an age-adjusted cutoff, focusing on clinical safety, diagnostic performance, and imaging utilization. Methods: systematic review conducted in accordance with PRISMA 2020, searching biomedical databases (e.g., PubMed/MEDLINE, Cochrane Library, and regional databases) using MeSH/DeCS terms related to PE, D-dimer, YEARS, age-adjustment, and clinical probability. Eligible studies included diagnostic management and/or accuracy studies applying YEARS and/or age-adjusted thresholds, with appropriate reference standards and/or clinical follow-up for thromboembolic events. Methodological quality was assessed using QUADAS-2. A narrative synthesis was performed without meta-analysis, extracting safety outcomes (follow-up events) and efficiency outcomes (CTPA avoidance). Conclusion: current evidence supports that adaptive D-dimer threshold strategies (YEARS, age-adjusted, and probability-adjusted approaches) can reduce CTPA utilization while maintaining acceptable safety in selected populations, with performance depending on the clinical setting, patient profile, and the acceptable residual-risk threshold.