Diagnosis of venous thromboembolism using clinical pretest probability rules, D-dimer assays, and imaging techniques.
01 May 2021-Gender & Development (Ovid Technologies (Wolters Kluwer Health))-Vol. 46, Iss: 5, pp 15-22
TL;DR: In this article, the optimal approach to evaluating venous thromboembolism including pretest probability clinical decision rules and appropriate testing to ensure an accurate diagnosis is described, which is a significant clinical entity that includes deep vein thrombosis and pulmonary embolism.
Abstract: Venous thromboembolism is a significant clinical entity that includes two associated medical disorders: deep vein thrombosis and pulmonary embolism. The goal of this article is to describe the optimal approach to evaluating venous thromboembolism including pretest probability clinical decision rules and appropriate testing to ensure an accurate diagnosis.
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TL;DR: Follow-up and angiography together suggest pulmonary embolism occurred among 12% of patients with low-probability scans, and clinical assessment combined with the ventilation/perfusion scan established the diagnosis or exclusion of pulmonary emblism only for a minority of patients--those with clear and concordant clinical and ventilation-perfusions scan findings.
Abstract: To determine the sensitivities and specificities of ventilation/perfusion lung scans for acute pulmonary embolism, a random sample of 933 of 1493 patients was studied prospectively. Nine hundred thirty-one underwent scintigraphy and 755 underwent pulmonary angiography; 251 (33%) of 755 demonstrated pulmonary embolism. Almost all patients with pulmonary embolism had abnormal scans of high, intermediate, or low probability, but so did most without pulmonary embolism (sensitivity, 98%; specificity, 10%). Of 116 patients with high-probability scans and definitive angiograms, 102 (88%) had pulmonary embolism, but only a minority with pulmonary embolism had high-probability scans (sensitivity, 41%; specificity, 97%). Of 322 with intermediate-probability scans and definitive angiograms, 105 (33%) had pulmonary embolism. Follow-up and angiography together suggest pulmonary embolism occurred among 12% of patients with low-probability scans. Clinical assessment combined with the ventilation/perfusion scan established the diagnosis or exclusion of pulmonary embolism only for a minority of patients--those with clear and concordant clinical and ventilation/perfusion scan findings.
2,468 citations
TL;DR: Deep-vein thrombosis can be ruled out in a patient who is judged clinically unlikely to have deep-veIn thromBosis and who has a negative D-dimer test, and ultrasound testing can be safely omitted in such patients.
Abstract: background Several diagnostic strategies using ultrasound imaging, measurement of d -dimer, and assessment of clinical probability of disease have proved safe in patients with suspected deep-vein thrombosis, but they have not been compared in randomized trials. methods Outpatients presenting with suspected lower-extremity deep-vein thrombosis were potentially eligible. Using a clinical model, physicians evaluated the patients and categorized them as likely or unlikely to have deep-vein thrombosis. The patients were then randomly assigned to undergo ultrasound imaging alone (control group) or to undergo d -dimer testing ( d -dimer group) followed by ultrasound imaging unless the d -dimer test was negative and the patient was considered clinically unlikely to have deep-vein thrombosis, in which case ultrasound imaging was not performed. results Five hundred thirty patients were randomly assigned to the control group, and 566 to the d -dimer group. The overall prevalence of deep-vein thrombosis or pulmonary embolism was 15.7 percent. Among patients for whom deep-vein thrombosis had been ruled out by the initial diagnostic strategy, there were two confirmed venous thromboembolic events in the d -dimer group (0.4 percent; 95 percent confidence interval, 0.05 to 1.5 percent) and six events in the control group (1.4 percent; 95 percent confidence interval, 0.5 to 2.9 percent; P=0.16) during three months of follow-up. The use of d -dimer testing resulted in a significant reduction in the use of ultrasonography, from a mean of 1.34 tests per patient in the control group to 0.78 in the d -dimer group (P=0.008). Two hundred eighteen patients (39 percent) in the d- dimer group did not require ultrasound imaging. conclusions Deep-vein thrombosis can be ruled out in a patient who is judged clinically unlikely to have deep-vein thrombosis and who has a negative d -dimer test. Ultrasound testing can be safely omitted in such patients.
1,303 citations
TL;DR: The derived eight‐factor block rule reduced the pretest probability below the test threshold for d‐dimer in two validation populations, but the rule's utility was limited by low specificity.
375 citations
TL;DR: Treating an acute VTE on average appears to be associated with incremental direct medical costs of $12,000 to $15,000 among first-year survivors, controlling for risk factors, and subsequent complications are conservatively estimated to increase cumulative costs to $18,000-23,000 per incident case.
326 citations
McMaster University1, Ottawa Hospital Research Institute2, University of Geneva3, Geneva College4, Montefiore Medical Center5, Rockyview General Hospital6, University of Calgary7, Indiana University – Purdue University Indianapolis8, University of Illinois at Chicago9, University of Missouri–Kansas City10, Loyola University Medical Center11, University of Kansas12
TL;DR: These evidence-based guidelines are intended to support patients, clinicians, and health care professionals in VTE diagnosis by recommending using D-dimer as the initial test and research is needed on new diagnostic modalities and on clinical decision rules for patients with suspected recurrent VTE.
239 citations