title: Management of patients with suspected deep vein thrombosis in the emergency department: combining use of a clinical diagnosis model with D-dimer testing.
abstract: The management of patients presenting to hospital Emergency Departments with suspected deep vein thrombosis is problematic since urgent diagnostic imaging is at times unavailable. We evaluated the accuracy of a rapidly available D-dimer test and the potential of combining D-dimer testing with an explicit clinical model to improve the management of patients with suspected deep vein thrombosis. Two hundred and fourteen patients with suspected deep vein thrombosis presenting to the Emergency Departments of two tertiary care institutions were enrolled in this prospective cohort study. Patients were evaluated by an Emergency Physician who determined the pre-test probability for deep vein thrombosis to be either low, moderate, or high using an explicit clinical model. Patients were managed according to their pre-test probability category by specific algorithms that in all cases included venous ultrasound imaging within 24 h and a 90-day follow-up for the development of thromboembolic complications. Patients also underwent fingerstick SimpliRED(R) whole blood agglutination D-dimer testing; however, D-dimer results did not influence subsequent patient management. D-dimer had a sensitivity of 82.5% and a specificity of 84.9% for the diagnosis of deep vein thrombosis. The observed negative predictive value of D-dimer was 96.9% (95% CI, 93.0% to 99.1%) overall, and 100% (95% CI, 96.3% to 100%) in low probability patients, 94.1% (95% CI, 83.8% to 98.8%) in moderate probability patients, and 86.7% (95% CI, 59.4% to 98.3%) in high probability patients. SimpliRED(R) D-dimer has a high negative predictive value and may be useful in excluding the diagnosis in patients at low pre-test probability for deep vein thrombosis.
authors.affiliation: Department of Medicine, QEII Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada.
authors.forename: D R
authors.initials: DR
authors.lastname: Anderson
authors.forename: P S
authors.initials: PS
authors.lastname: Wells
authors.forename: I
authors.initials: I
authors.lastname: Stiell
authors.forename: B
authors.initials: B
authors.lastname: MacLeod
authors.forename: M
authors.initials: M
authors.lastname: Simms
authors.forename: L
authors.initials: L
authors.lastname: Gray
authors.forename: K S
authors.initials: KS
authors.lastname: Robinson
authors.forename: J
authors.initials: J
authors.lastname: Bormanis
authors.forename: M
authors.initials: M
authors.lastname: Mitchell
authors.forename: B
authors.initials: B
authors.lastname: Lewandowski
authors.forename: G
authors.initials: G
authors.lastname: Flowerdew
mesh_terms: D000372:Agglutination Tests; D000465:Algorithms; D004636:Emergency Service, Hospital; D005260:Female; D005338:Fibrin Fibrinogen Degradation Products / Q000032:analysis*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009674:Nova Scotia; D019095:Point-of-Care Systems; D011237:Predictive Value of Tests; D011446:Prospective Studies; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D020246:Venous Thrombosis / Q000175:diagnosis*
chemical_list: D005338:Fibrin Fibrinogen Degradation Products