Combining clinical risk with D-dimer testing to rule out deep vein thrombosis

Ilkhanipour, Kaveh; Wolfson, Allan B.; Walker, Heather; Cillo, Jason; Rolniak, Susan; Cockley, Pamela; Mooradian, David; Kaplan, Sandra S.

doi:10.1016/j.jemermed.2004.04.010

Cited by 33 publications

(17 citation statements)

References 23 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…The sensitivities and specifi cities of the rule (at each cutoff) refl ect how correctly the rule predicts the presence or absence of disease. We identifi ed 19 studies that evaluated clinical prediction rules for the diagnosis of DVT, [16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34] and 8 studies evaluating clinical prediction rules for the diagnosis of pulmonary embolism, [35][36][37][38][39][40][41][42] although common patients were reported in 3 studies. [40][41][42] (Supplemental Appendix 1, available online at http://www.annfammed.org/cgi/content/full/5/1/63/DC1).…”

Section: Are Clinical Prediction Rules Valuable For Diagnosing Dvt Ormentioning

confidence: 99%

Review of the Evidence on Diagnosis of Deep Venous Thrombosis and Pulmonary Embolism

Segal

Eng

Tamariz

et al. 2007

The Annals of Family Medicine

139

View full text Add to dashboard Cite

PURPOSE This review summarizes the evidence regarding the effi cacy of techniques for diagnosis of deep venous thrombosis (DVT) and pulmonary embolism. METHODSWe searched for studies using MEDLINE, MICROMEDEX, the Cochrane Controlled Trials Register, and the Cochrane Database of Systematic Reviews through June 2006. We reviewed randomized controlled trials, systematic reviews of trials, and observational studies if no trials were available. Paired reviewers assessed the quality of each included article and abstracted the data into summary tables. Heterogeneity in study designs precluded mathematical combination of the results of the primary literature. RESULTSOur review found 22 relevant systematic reviews and 36 primary studies. The evidence strongly supports the use of clinical prediction rules, particularly the Wells model, for establishing the pretest probability of DVT or pulmonary embolism in a patient before ordering more defi nitive testing. Fifteen studies support that when a D-dimer assay is negative and a clinical prediction rule suggests a low probability of DVT or pulmonary embolism, the negative predictive value is high enough to justify foregoing imaging studies in many patients. The evidence in 5 systematic reviews regarding the use of D-dimer, in isolation, is strong and demonstrates sensitivities of the enzyme-linked immunosorbent assay (ELISA) and quantitative rapid ELISA, pooled across studies, of approximately 95%. Eight systematic reviews found that the sensitivity and specifi city of ultrasonography for diagnosis of DVT vary by vein; ultrasonography performs best for diagnosis of symptomatic, proximal vein thrombosis, with pooled sensitivities of 89% to 96%. The sensitivity of single-detector helical computed tomography for diagnosis of pulmonary embolism varied widely across studies and was below 90% in 4 of 9 studies; more studies are needed to determine the sensitivity of multidetector scanners.CONCLUSIONS While the strength of the evidence varies across questions, it is generally strong.

show abstract

Section: Are Clinical Prediction Rules Valuable For Diagnosing Dvt Ormentioning

confidence: 99%

Review of the Evidence on Diagnosis of Deep Venous Thrombosis and Pulmonary Embolism

Segal

Eng

Tamariz

et al. 2007

The Annals of Family Medicine

139

View full text Add to dashboard Cite

show abstract

“…Stein et al's meta-analysis of D-dimer assays for diagnosis of DVT or pulmonary embolism using ELISA found pooled specifi cities ranged from 40% to 50%. 34 In summary, the evidence suggests that a negative highly sensitive D-dimer test can help exclude the diagnosis of proximal DVT and pulmonary embolism * References 9,14,[15][16][17][18][19]22 ,23 ,26,27,29.…”

Section: Test Characteristics Of D-dimer Assays Alone For Diagnosis Omentioning

confidence: 99%

Current Diagnosis of Venous Thromboembolism in Primary Care: A Clinical Practice Guideline from the American Academy of Family Physicians and the American College of Physicians

Qaseem

Snow

Barry³

et al. 2007

The Annals of Family Medicine

128

View full text Add to dashboard Cite

This guideline summarizes the current approaches for the diagnosis of venous thromboembolism. The importance of early diagnosis to prevent mortality and morbidity associated with venous thromboembolism cannot be overstressed. This fi eld is highly dynamic, however, and new evidence is emerging periodically that may change the recommendations. The purpose of this guideline is to present recommendations based on current evidence to clinicians to aid in the diagnosis of lower extremity deep venous thrombosis and pulmonary embolism. RECOMMENDATIONS Recommendation 1 Validated clinical prediction rules should be used to estimate pretest probability of venous thromboembolism (VTE), both deep venous thrombosis (DVT) and pulmonary embolism, and for the basis of interpretation of subsequent tests.Good quality evidence supports the use of clinical prediction rules to establish pretest probability of disease. The Wells prediction rules for DVT and for pulmonary embolism (Tables 1 and 2) have been validated and are frequently used to estimate the probability of VTE before performing more defi nitive testing on patients. The Wells prediction rule performs better in younger patients without comorbidities or a history of VTE than it does in other patients. Physicians should use their clinical judgment in cases where a patient is older or presents with comorbidities. Recommendation 2In appropriately selected patients with low pretest probability of DVT or pulmonary embolism, obtaining a high-sensitivity D-dimer is a reasonable option, and if negative,

show abstract

“…It has a half-life of 48 h, and the assay has a high sensitivity for intravascular thrombi (7). The development of monoclonal antibodies specific for D-dimer has enabled accurate quantification of cross-linked fibrin degradation products.…”

Section: Discussionmentioning

confidence: 99%

“…The development of monoclonal antibodies specific for D-dimer has enabled accurate quantification of cross-linked fibrin degradation products. The role of the D-dimer assay in the diagnosis and prognosis of cardiovascular disease has been extensively studied (7,8). We have presented a case in which the D-dimer assay was used in the inclusion and exclusion of atrial thrombosis before cardioversion in a patient with AF who refused to undergo TEE.…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

The D-dimer assay: A possible tool in the evaluation of atrial thrombosis

Ibebuogu

Salah

Malhotra

et al. 2008

Canadian Journal of Cardiology

View full text Add to dashboard Cite

A trial fibrillation (AF) is the most common sustained arrhythmia seen in clinical practice, and affects more than 4% of the population older than 60 years of age (1,2). Peripheral thromboembolism and ischemic stroke contribute significantly to the observed mortality and morbidity rates. AF contributes to 15% to 20% of all strokes (1,3), and emboli arise predominantly from the left atrial appendage (LAA) (4). Hence, there is a need to exclude atrial thrombi before cardioversion in symptomatic AF. A recent large, randomized controlled trial has shown that negative transesophageal echocardiography (TEE) results may obviate the need for prolonged anticoagulation before cardioversion, with no significant difference in embolic events compared with conventional therapy (5). Because of the complex multilobed configuration of the LAA and the minute size of clinically significant thrombi, there are inherent limitations in using a nontomographic technique for visualization of the LAA. Using the two-dimensional beam of TEE in visualizing the three-dimensional anatomy of the LAA is analogous to using a searchlight to visualize the entire roof of a cave, which is technically difficult to achieve completely. Studies have shown that embolism may presumably occur after cardioversion of AF, despite apparent exclusion of a pre-existing atrial thrombus by TEE (6). Plasma D-dimer constitutes an antigen-antibody reaction to the dimeric final degradation product of a mature clot. An elevated fibrin D-dimer has a high sensitivity for intravascular thrombus (7) and may improve the evaluation of a patient with AF before cardioversion. CASE PRESENTATIONA 56-year-old man eight years post-renal transplant and four years post-coronary artery bypass surgery, as well as a history of adequately treated, methicillin-resistant Staphylococcus epidermidis bacteremia, CASE REPORT ©2008 Pulsus Group Inc. All rights reserved Atrial fibrillation (AF) is a common arrhythmia seen in clinical practice, and affects more than 4% of the population older than 60 years of age. Peripheral thromboembolism contributes significantly to the observed morbidity and mortality. Symptomatic AF, before cardioversion to normal sinus rhythm, requires either exclusion of atrial thrombi using transesophageal echocardiography (TEE) or the conventional use of three weeks of adequate anticoagulation. The exclusion of atrial thrombi by TEE, a nontomographic technique but comparable with conventional treatment of AF in outcomes, has inherent limitations due to the complex three-dimensional multilobed anatomy of the left atrial appendage, where the majority of atrial thrombi arise. Also, the conventional treatment of three weeks of therapeutic anticoagulation before cardioversion reportedly does not always eliminate atrial thrombi. Plasma D-dimer constitutes an antigen-antibody reaction to the dimeric final degradation product of a mature clot. An elevated fibrin D-dimer has a high sensitivity for intravascular thrombosis and, hence, may improve the evaluation of a patient with A...

show abstract

Combining clinical risk with D-dimer testing to rule out deep vein thrombosis

Cited by 33 publications

References 23 publications

Review of the Evidence on Diagnosis of Deep Venous Thrombosis and Pulmonary Embolism

Review of the Evidence on Diagnosis of Deep Venous Thrombosis and Pulmonary Embolism

Current Diagnosis of Venous Thromboembolism in Primary Care: A Clinical Practice Guideline from the American Academy of Family Physicians and the American College of Physicians

The D-dimer assay: A possible tool in the evaluation of atrial thrombosis

Contact Info

Product

Resources

About