The Use of D-Dimer Testing and Impedance Plethysmographic Examination in Patients With Clinical Indications of Deep Vein Thrombosis

Ginsberg, Jeffrey S.

doi:10.1001/archinte.1997.00440310041004

Cited by 110 publications

(59 citation statements)

References 21 publications

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“…Several studies have shown that this assay has a high negative predictive value and is a relatively sensitive but nonspecific marker for DVT. [1][2][3] Brotman et al evaluated the utility and limitations of D-dimer testing for evaluation of VTE in hospitalized patients. 4 Four different methods of D-dimer testing were used in this study.…”

Section: D-dimer Assaymentioning

confidence: 99%

Laboratory Markers in the Diagnosis of Venous Thromboembolism

et al. 2004

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Abstract-Selected blood tests may be useful in the diagnosis of venous thromboembolism (VTE), or in the identification of a congenital or acquired defect associated with the development of VTE. Several studies have shown the D-dimer assay to have a high negative predictive value but poor specificity when used in the detection of VTE. Yet in the emergency room setting, the D-dimer test may be useful if a detailed risk factor analysis for each patient is included in the diagnosis. The presence of such genetic thrombophilia markers as factor V Leiden, prothrombin 20210A mutation, and antiphospholipid antibodies significantly increases a patient's risk of a thrombotic event. The relative risk of thrombosis in factor V heterozygotes is at least 3 times higher than in the general population, whereas the increased risk of thrombosis in homozygotes is estimated to be 50-to 80-fold greater than those without the defect. Thromboembolic events are reported in approximately one third of antiphospholipid-positive patients. Other markers such as hyperhomocysteinemia and deficiencies of antithrombin, protein C, or protein S, when combined with the previous mutations, significantly increase a patient's risk of a thrombotic event. We feel that it is important to identify these ultra-high-risk patients to provide adequate counseling about the risk of thrombosis before elective surgical procedures. Often, lifelong anticoagulation may be needed as these patients and family members may need testing before taking birth control pills or hormonal replacement.

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Section: D-dimer Assaymentioning

confidence: 99%

Laboratory Markers in the Diagnosis of Venous Thromboembolism

et al. 2004

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“…More recently, both DVT and PE management studies have been performed, basing therapeutic decisions in part on D-dimer results. Ginsberg and colleagues 45 evaluated the results of a bedside wholeblood agglutination D-dimer assay and impedance plethysmography in patients with suspected DVT. When both studies were negative, anticoagulation was withheld and the patients monitored for three months.…”

Section: D-dimersmentioning

confidence: 99%

A practical approach to the diagnosis of venothromboembolism

Corris

2001

Clinical Medicine

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A negative D-dimer result in a patient presenting with signs and symptoms in keeping with venous thromboembolism but with a low clinical probability is sufficient to exclude the diagnosis Ventilation perfusion isotope scanning, although widely available, should only be used in patients with suspected pulmonary embolism who have a normal chest radiograph or no previous chronic cardiopulmonary disease Studies suggest good sensitivity and specificity of spiral computerised tomography (CT) in the diagnosis of central or segmental pulmonary emboli All hospitals receiving acute medical emergencies should devise their own algorithm for diagnosis of venothromboembolism that reflects local expertise and availability of investigations Key Pointsare no absolute contraindications, although particular care should be exercised in patients with known sensitivity to contrast media and in those with severe pulmonary hypertension, renal impairment or following acute MI. The femoral vein approach is commonly used, but some prefer the internal jugular or subclavian approach because of the reduced risk of disturbing thrombi and the ability to maintain venous access for pressure monitoring and the administration of thrombolytic drugs where indicated. Good liaison between the radiologist and intensive care unit is recommended. Pigtail catheters of sufficient size (7F) to enable high-flow injections of non-ionic contrast media should be used. Volume and flow will depend on facilities available. Superselective injections may be necessary. A main PA injection may be sufficient when prior echocardiography suggests the possibility of a large centrally placed clot. Where prior V/Q scan is non-diagnostic, angiography can be confined to the more abnormal side 65 .Minor complications have been reported in 2% and major or fatal complications in 0.5-1.3% of investigations 66 using these techniques, mainly in patients already severely ill. The introduction of low osmolar non-ionic contrast media has led to a reduction in complications, a recent report finding only one major (non-fatal) complication in every 300 patients 67 .There may be difficulties in interpretation of PA results, even by experienced radiologists. The PIOPED study found 19% interobserver disagreement, varying from 2% for central to 34% for subsegmental abnormalities 68 , and 11% within-observer discrepancy. A recent study with consensus review in patients with non-diagnostic lung scans led to a change in initial diagnosis in 20%. There was better agreement when digital subtraction was used, but this is not widely available. RecommendationsThe algorithm shown in Fig 1 outlines one approach to the investigation of a patient presenting with suspected VTE. ConclusionsThe investigation of suspected VTE will continue to be refined by further evidence from prospective studies using D-dimers and spiral CT. Moreover, newer modalities such as magnetic resonance imaging (MRI) are beginning to demonstrate diagnostic value, particularly in North America. However, at present, routine use of M...

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“…Ginsberg and colleagues [34] also recently evaluated the probability of DVT in patients by using D-dimer to limit the need for serial testing. They reported that among 273 patients who had a single normal result with IPG and a negative SimpliRED D-dimer result, 269 (98.5%; 95% CI, 96.3-99.6%) had no venous thromboembolic complications during the 3-month follow-up period.…”

Section: Diagnostic-testing Algorithmsmentioning

confidence: 99%

Modern Approach to Diagnosis in Patients with Suspected Deep Vein Thrombosis

Wells

Anderson

1999

Pathophysiol Haemos Thromb

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Deep vein thrombosis is a relatively common disease, amenable to therapy but with a potentially fatal outcome if untreated. The diagnosis can be made in most patients with the non-invasive imaging procedure ultrasonography, but limitations exist. As with all tests, there is a potential for false-positive and false-negative results. The latter are especially an issue for calf vein thrombi, and this in part has led to the concept of serial testing of the proximal venous system rather than imaging the calf. The premise of the repeat (serial) test is that only thrombi that extend to the proximal system are clinically relevant and such thrombi will be detected on the repeat test. However, despite the safety of the serial-testing concept, it is inconvenient and expensive. In the last few years, the diagnostic process has been improved by the validation of a clinical model that accurately categorizes patients as having low, moderate or high probability of deep vein thrombosis. Among the improvements this provides is the elimination of serial testing if the ultrasound is normal and the clinical probability low. The fibrin degradation product D-dimer has been demonstrated to have a high negative predictive value and has also proven useful in diagnostic algorithms. The combination of the D-dimer with clinical model assessment will enable diagnostic-testing strategies that are more safe, effective and convenient for patients.

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The Use of D-Dimer Testing and Impedance Plethysmographic Examination in Patients With Clinical Indications of Deep Vein Thrombosis

Abstract: The results of the D-dimer assay and impedance plethysmographic examination on the day of presentation can be used to treat the majority of outpatients who present with clinical indications of deep vein thrombosis without further testing.

Cited by 110 publications

References 21 publications

Laboratory Markers in the Diagnosis of Venous Thromboembolism

Laboratory Markers in the Diagnosis of Venous Thromboembolism

A practical approach to the diagnosis of venothromboembolism

Modern Approach to Diagnosis in Patients with Suspected Deep Vein Thrombosis

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