title: An algorithm for the investigation and management of patients with suspected deep venous thrombosis at a district general hospital.
abstract: The aim was to show that clinical assessment and serial Dopplers could be used to exclude deep venous thrombosis (DVT), and also that clinical assessment in combination with D-dimers could be used to exclude DVT. This was a prospective trial. Patients underwent clinical assessment, colour flow Doppler, and D-dimer measurement. Patients with an equivocal first Doppler and patients with a moderate/high pre-test clinical score had a repeat Doppler. Follow up information was obtained to see if further thromboembolism developed. Outcome measures included the reliability of the clinical assessment, Doppler, and D-dimer in excluding DVT. One hundred and ninety four patients were enrolled. The negative predictive value of a low medical pre-test score in excluding DVT was 92%. Eighty eight patients underwent D-dimer measurement. The negative predictive value of a D-dimer <400 units was 96%. The negative predictive value of a low clinical pre-test score and D-dimer <400 units was 100%. The negative predictive value of a low clinical pre-test score and D-dimer <800 units was 97%. The negative predictive value of the combination of a low clinical pre-test score and D-dimer <400 units was 100%. Twenty three per cent of patients had a low clinical pre-test score and D-dimer <400 units. Thus, a DVT could be excluded in 23% of referred patients. This information could be used to reduce Doppler requests by 23%. No patient in whom clinical assessment and serial Dopplers had excluded a DVT suffered further thromboembolism on follow up. This study has thus shown that a low medical pre-test score and negative Doppler reliably exclude DVT; a low pre-test score and negative D-dimer would reliably exclude DVT.
authors.affiliation: Basildon & Thurrock NHS Hospitals Trust, Basildon, Essex, UK. kieran@kmwalsh.freeserve.co.uk
authors.forename: K
authors.initials: K
authors.lastname: Walsh
authors.forename: N
authors.initials: N
authors.lastname: Kelaher
authors.forename: K
authors.initials: K
authors.lastname: Long
authors.forename: P
authors.initials: P
authors.lastname: Cervi
mesh_terms: D000328:Adult; D000368:Aged; D000465:Algorithms; D015415:Biomarkers / Q000032:analysis; D015331:Cohort Studies; D005260:Female; D005338:Fibrin Fibrinogen Degradation Products / Q000032:analysis; D005500:Follow-Up Studies; D006767:Hospitals, District; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011446:Prospective Studies; D018615:Ultrasonography, Doppler, Color / Q000379:methods; D020246:Venous Thrombosis / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000628:therapy
chemical_list: D015415:Biomarkers; D005338:Fibrin Fibrinogen Degradation Products; C036309:fibrin fragment D