Hemostasis assessment in patients suspected of venous thrombosis and pulmonary embolism in the emergency setting: challenges for clinicians

Venous thromboembolism (VTE), which most especially includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is a major cause of morbidity and mortality worldwide and represents a time-sensitive clinical condition where diagnostic delay increases unfavorable outcomes. Among the various laboratory biomarkers investigated to support he diagnosis of VTE, D-dimer has emerged as the reference test for excluding acute thrombosis when interpreted within an appropriate clinical framework. D-dimer is a fibrin degradation product generated during plasmin-mediated breakdown of cross-linked fibrin, reflecting concurrent activation of coagulation and fibrinolysis. Modern diagnostic strategies integrate D-dimer testing with structured assessment of pre-test probability using validated clinical decision tools such as the Wells score, the Revised Geneva Score, and the Pulmonary Embolism Rule-out Criteria (PERC). In patients with low or intermediate clinical probability, a negative D-dimer result can safely exclude VTE and avoid unnecessary imaging, whereas elevated values or high clinical suspicion require confirmatory imaging. Recent developments, including age-adjusted D-dimer thresholds and probability-adapted algorithms such as YEARS and Pulmonary Embolism Graduated D-dimer (PEGeD), have improved diagnostic specificity and reduced reliance on imaging techniques without compromising patient safety. Nevertheless, the clinical reliability of D-dimer testing is influenced by pre-analytical variables, assay-related differences, and presence of physiological or pathological conditions associated with elevated or low fibrin turnover. Accordingly, optimal use of D-dimer requires strict laboratory supervision and integration with clinical probability assessment to ensure accurate and timely diagnosis of VTE.