title: Combined use of pretest clinical probability score and latex agglutination D-dimer testing for excluding acute deep vein thrombosis.
abstract: OBJECTIVE
  Currently, the latex agglutination D-dimer assay is widely used for excluding deep vein thrombosis (DVT) but is considered less sensitive than the enzyme-linked immunosorbent assay-based D-dimer test. The purpose of the present study was to determine if a combination of different cutoff points, rather than a single cutoff point of 1.0 microg/mL, on the latex agglutination D-dimer assay and the pretest clinical probability (PTP) score would be able to reduce the use of venous duplex ultrasound (DU) scanning in patients with suspected DVT.
  
  
  METHODS
  The PTP score and D-dimer testing were used to evaluate 989 consecutive patients with suspected DVT before venous DU scanning. After calculating the clinical probability scores, patients were divided into low-risk (< or =0 points), moderate-risk (1-2 points), and high-risk (> or =3 points) pretest clinical probability groups. Receiver operating characteristic (ROC) curve analysis was used to determine the appropriate D-dimer cutoff point for each PTP with a negative predictive value of >98% for a positive DU scan.
  
  
  RESULTS
  There were 886 patients enrolled. The study group included 609 inpatients (68.7%) and 277 outpatients (31.3%). The prevalence of DVT in this series was 28.9%. There were 508 patients (57.3%) classified as low-risk, 237 (26.8%) as moderate-risk, and 141 (14.9%) as high-risk PTP. DVT was identified in 29 patients (5.7%) with low-risk, 118 (49.8%) with moderate-risk, and 109 (77.3%) with high-risk PTP scores. ROC curve analysis was used to select D-dimer cutoff points of 2.6, 1.1, and 1.1 microg/mL for the low-, moderate- and high-risk PTP groups, respectively. In the low-risk PTP group, specificity increased from 48.9% to 78.2% (P < .0001) with use of the different D-dimer cutoff value. In the moderate- and high-risk PTP groups, however, the different D-dimer levels did not achieve substantial improvement. Despite this, the overall use of venous DU scanning could have been reduced by 43.0% (381 of 886) if the different D-dimer cutoff points had been used.
  
  
  CONCLUSIONS
  Combination of a specific D-dimer level with the clinical probability score is most effective in low-risk PTP patients for excluding DVT. In moderate- and high-risk PTP patients, however, the recommended cutoff points of 1.0 microg/mL may be preferable. These results show that different D-dimer levels for patients differing in risk is feasible for excluding DVT using the latex agglutination D-dimer assay.
authors.affiliation: Department of Plastic and Reconstructive Surgery, Tokyo Women's Medical University, Tokyo, Japan. yamaki@prs.twmu.ac.jp
authors.forename: Takashi
authors.initials: T
authors.lastname: Yamaki
authors.forename: Motohiro
authors.initials: M
authors.lastname: Nozaki
authors.forename: Hiroyuki
authors.initials: H
authors.lastname: Sakurai
authors.forename: Yuji
authors.initials: Y
authors.lastname: Kikuchi
authors.forename: Kazutaka
authors.initials: K
authors.lastname: Soejima
authors.forename: Taro
authors.initials: T
authors.lastname: Kono
authors.forename: Atsumori
authors.initials: A
authors.lastname: Hamahata
authors.forename: Kaya
authors.initials: K
authors.lastname: Kim
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015415:Biomarkers / Q000097:blood; D005240:Feasibility Studies; D005260:Female; D005338:Fibrin Fibrinogen Degradation Products / Q000032:analysis*; D006305:Health Status Indicators; D006801:Humans; D007841:Latex Fixation Tests; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D012372:ROC Curve; D018570:Risk Assessment; D012307:Risk Factors; D018616:Ultrasonography, Doppler, Duplex; D020246:Venous Thrombosis / Q000097:blood / Q000175:diagnosis* / Q000000981:diagnostic imaging; D055815:Young Adult
chemical_list: D015415:Biomarkers; D005338:Fibrin Fibrinogen Degradation Products; C036309:fibrin fragment D