title: Combined use of clinical assessment and d-dimer to improve the management of patients presenting to the emergency department with suspected deep vein thrombosis (the EDITED Study).
abstract: Suspected deep vein thrombosis (DVT) is a common problem facing emergency physicians. Timely diagnostic testing must be performed to accurately identify patients with DVT. The purpose of this study was to evaluate the safety and effectiveness of a management strategy that combined consideration of clinical pretest probability and a d-dimer test to evaluate patients presenting to the emergency department with suspected deep vein thrombosis (DVT). A prospective cohort study was performed in the emergency departments of four tertiary care institutions involving 1075 patients with suspected DVT. An emergency physician determined the pretest probability for DVT to be low, moderate, or high using an explicit clinical model. A blood sample was taken for d-dimer testing. Subsequent investigations (compression ultrasound, venography) were performed based upon the pretest probability and the d-dimer result. Patients considered at low pretest probability with negative d-dimer had no further diagnostic testing performed. All patients in whom the diagnosis of DVT was excluded by the algorithm did not receive anticoagulant therapy and were followed up for 90 days for the development of proximal DVT or pulmonary embolism. Overall, 195 (18.1%; 95% CI 15.9% to 20.6%) of 1075 patients were confirmed to have proximal DVT. Of the 882 patients who had proximal DVT excluded during the initial evaluation period using the algorithms, four (0.5%; 95% CI 0.1% to 1.2%) were subsequently diagnosed with proximal DVT in the follow-up period, including three patients in the low pretest probability group (1.0%; 95% CI 0.2% to 2.1%) who had normal d-dimer and no additional diagnostic testing performed. None of the 882 patients (0%: 95% CI 0% to 0.5%) developed pulmonary embolism in the follow-up period. A diagnostic strategy for the evaluation of patients with suspected DVT based on pretest probability and d-dimer is safe and feasible in the emergency department setting.
authors.affiliation: Department of Medicine, QEII Health Sciences Center, Dalhousie University, Halifax, Nova Scotia, Canada. david.anderson@dal.ca
authors.forename: D R
authors.initials: DR
authors.lastname: Anderson
authors.forename: M J
authors.initials: MJ
authors.lastname: Kovacs
authors.forename: G
authors.initials: G
authors.lastname: Kovacs
authors.forename: I
authors.initials: I
authors.lastname: Stiell
authors.forename: M
authors.initials: M
authors.lastname: Mitchell
authors.forename: V
authors.initials: V
authors.lastname: Khoury
authors.forename: J
authors.initials: J
authors.lastname: Dryer
authors.forename: J
authors.initials: J
authors.lastname: Ward
authors.forename: P S
authors.initials: PS
authors.lastname: Wells
mesh_terms: D000328:Adult; D000368:Aged; D000465:Algorithms; D019468:Disease Management; D004632:Emergency Medical Services; D005260:Female; D005338:Fibrin Fibrinogen Degradation Products / Q000032:analysis*; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011336:Probability; D018570:Risk Assessment; D014463:Ultrasonography; D020246:Venous Thrombosis / Q000175:diagnosis* / Q000453:epidemiology / Q000517:prevention & control
chemical_list: D005338:Fibrin Fibrinogen Degradation Products; C036309:fibrin fragment D