Combination of a Normal D-Dimer Concentration and a Non-High Pretest Clinical Probability Score Is a Safe Strategy to Exclude Deep Venous Thrombosis

Abstract

Background-Serial ultrasonography is reliable for the diagnosis of deep venous thrombosis in symptomatic patients, but the low prevalence of thrombosis in this group renders the approach costly and inconvenient to patients. We studied the clinical validity of the combination of a pretest clinical probability score and a D-dimer test in the initial evaluation of patients suspected of deep venous thrombosis. Methods and Results-Patients with a normal D-dimer concentration (Ͻ500 fibrin equivalent units [FEU] g/L) and a non-high probability score (Ͻ3) had no further testing. Patients with a normal D-dimer concentration and a high probability score (Ն3) underwent one ultrasonogram. Serial ultrasonography was performed in patients with an abnormal D-dimer concentration. Patients were followed for 3 months. A total of 812 patients were evaluable for efficacy. Only 1 of 176 patients (0.6%; 95% CI, 0.02% to 3.1%) with a normal D-dimer concentration and a non-high probability score developed thrombosis during follow-up. A normal D-dimer concentration and a high probability score were found in 39 patients; 3 of them (7.7%; 95% CI, 1.6% to 20.9%) had thrombosis at presentation, and one (2.8%; 95% CI, 0.07% to 14. 5%) developed pulmonary embolism during follow-up. In 306 of 597 patients (51.3%) with an abnormal D-dimer concentration, thrombosis was detected by serial ultrasonography. Six patients (2.1%; 95% CI, 0.8% to 4. 4%) developed thrombosis during follow-up. No deaths due to thromboembolism occurred during follow-up. The total need for ultrasonography was reduced by 29%. Conclusion-The combination of a non-high pretest clinical probability score and a normal D-dimer concentration is a safe strategy to rule out deep venous thrombosis and to withhold anticoagulation. (Circulation. 2003;107:593-597.)

Combined D‐dimer and clinical probability are useful for exclusion of recurrent deep venous thrombosis

“…These conclusions are similar to those reported for outpatients without any previous history of DVT by other research groups [6][7][8]; only one false negative DD result was elicited in a patient scored as likely for the diagnosis of DVT, consistent with the higher rate of false negative DD results previously described in that group [8].…”

“…Diagnostic algorithms using combined DD and clinical evaluation have proved to be useful and safe for exclusion of DVT in outpatients with a suspected first episode of venous thrombosis [6][7][8]. Whether this approach can be applied to outpatients with symptoms of recurrent DVT is currently unknown.…”

Using an age-dependent D-dimer cut-off value increases the number of older patients in whom deep vein thrombosis can be safely excluded

“…The diagnosis of DVT can be safely excluded based on the combination of a low or intermediate clinical probability combined with a negative D-dimer blood test, in which case imaging studies can be avoided. [2][3][4][5] With increasing age, however, the specificity of the D-dimer test decreases, resulting in more false positive test results in older patients than in younger ones. 6,7 In clinical practice, this means that VTE can less often be excluded based on the clinical probability/D-dimer combination in older patients than in younger patients, hence older patients more often need additional testing (i.e.…”

Deep venous thrombosis - diagnostic

“…In aktuellen Studien erzielten die Beschränkung der sonographischen Diagnostik auf Patienten mit positivem D-Dimer-Test und/oder hoher Vortestwahrscheinlichkeit und die routinemä-ßige vollständige Kompressionssonographie bezüglich der symptomatischen thromboembolischen Ereignisse in den folgenden Monaten vergleichbare Effektivitäten (5,7,12,14). Es gilt jedoch zu bedenken, dass die Patienten in den genannten Studien nur bei auffallender Anamnese (z.T.…”