Practical diagnostic management of patients with clinically suspected deep vein thrombosis by clinical probability test, compression ultrasonography, and D-dimer test.
OBJECTIVE
To evaluate a new noninvasive diagnostic strategy for ruling out deep vein thrombosis consisting of either a combination of low clinical probability and normal ultrasonography or a combination of moderate-to-high clinical probability, normal ultrasonography, and a normal D-dimer test.


METHODS
We studied 811 patients with clinically suspected deep vein thrombosis using a diagnostic management strategy that combined clinical probability, ultrasonography, and measurement of D-dimers. The primary endpoint was venous thromboembolism occurring during a 3-month follow-up.


RESULTS
Of the 280 patients (35%) with a low clinical probability, 30 (11%) had an abnormal initial ultrasonography and were treated. Of the other 250 untreated patients with low clinical probability and a normal ultrasonography, 5 (2%; 95% confidence interval [CI]: 1% to 5%) developed a nonfatal venous thromboembolism during follow-up. Of the 531 patients (65%) with a moderate-to-high clinical probability, 300 (56%) had an abnormal ultrasonography. Of the remaining 231 patients with a normal ultrasonography, 148 had a normal D-dimer test; none of these patients developed deep vein thrombosis during follow-up (0%; 95% CI: 0% to 3%). Of the 83 patients with an abnormal D-dimer test, 77 underwent repeat ultrasonography about 1 week later; none of the 64 patients with a second normal ultrasound developed symptomatic deep vein thrombosis during follow-up (0%; 95% CI: 0% to 6%).


CONCLUSIONS
This management strategy, which combines clinical probability, ultrasonography, and D-dimer measurements, is practical and safe in ruling out deep vein thrombosis in patients with clinically suspected thrombosis and reduces the need for repeat ultrasonography.
Tick
Lidwine W
LW
Department of General Internal Medicine, Meander Medical Center, Amersfoort, The Netherlands. L.Tick@meandermc.nl
Ton
Evelien
E
van Voorthuizen
Theo
T
Hovens
Marcel M C
MM
Leeuwenburgh
Ivonne
I
Lobatto
Sacha
S
Stijnen
Pieter J
PJ
van der Heul
Cees
C
Huisman
Peter M
PM
Kramer
Mark H H
MH
Huisman
Menno V
MV
D000328:Adult; D000368:Aged; D015331:Cohort Studies; D016001:Confidence Intervals; D005260:Female; D005338:Fibrin Fibrinogen Degradation Products / Q000032:analysis*; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D010690:Phlebography / Q000379:methods; D011336:Probability; D011446:Prospective Studies; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D018608:Ultrasonography, Doppler / Q000379:methods*; D020246:Venous Thrombosis / Q000097:blood* / Q000000981:diagnostic imaging*
D005338:Fibrin Fibrinogen Degradation Products; C036309:fibrin fragment D