A clinical decision rule and D-dimer testing to rule out upper extremity deep vein thrombosis in high-risk patients.
BACKGROUND
In a management study, a diagnostic algorithm consisting of a clinical decision rule, D-dimer, and ultrasonography was shown to safely exclude upper extremity deep vein thrombosis (UEDVT). Efficiency may be lower in high-risk subgroups: those with a central venous catheter or pacemaker, inpatients, cancer, and elderly patients.


METHODS
Data of 406 patients with suspected UEDVT enrolled in a prospective management study were used for the present analysis. The aim was to evaluate the efficiency of the algorithm in subgroups, defined as the proportion of patients in whom imaging could be safely withheld based on the combination of a decision rule result indicating "UEDVT unlikely" and a normal D-dimer result.


RESULTS
The strategy excluded UEDVT in 87 of 406 patients (21%); ultrasonography was withheld in these patients and none developed UEDVT during 3months of follow-up. In contrast, ultrasonography could be withheld in only 4 of 92 patients with a catheter or pacemaker (4.3%; 95% CI: 1.7% to 11%) and in 4 of 83 inpatients (4.8%; 95% CI: 1.9% to 12%). The efficiency was 11% in patients with cancer and 13% in those older than 75years.


CONCLUSIONS
Although the combination of a decision rule and D-dimer testing is safe in excluding UEDVT in the overall population of patients with suspected UEDVT, its efficiency appears limited in some subgroups, in particular those with a central venous catheter or pacemaker, and inpatients.
Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands. Electronic address: n.vanes@amc.nl.
Nick
N
van Es
Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands.
Suzanne M
SM
Bleker
Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands; Department of Medical, Oral and Biotechnological Sciences, G. D'Annunzio University, Chieti, Italy.
Marcello
M
Di Nisio
Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands.
Ankie
A
Kleinjan
Center for Vascular Diseases; Division "Angiology", Thrombosis Research Unit, Dresden University Clinic, Dresden, Germany.
Jan
J
Beyer-Westendorf
Unit of Angiology, University Hospital of Padua, Padua, Italy.
Giuseppe
G
Camporese
Department of Vascular Medicine, University Medical Center Groningen, Groningen, The Netherlands.
Pieter W
PW
Kamphuisen
Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands.
Harry R
HR
Büller
Department of Clinical Epidemiology and Biostatistics, Academic Medical Center, Amsterdam, The Netherlands.
Patrick M
PM
Bossuyt
D000368:Aged; D000465:Algorithms; D000066491:Clinical Decision-Making; D005260:Female; D005338:Fibrin Fibrinogen Degradation Products / Q000032:analysis*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D014463:Ultrasonography; D056824:Upper Extremity Deep Vein Thrombosis / Q000097:blood / Q000175:diagnosis*
D005338:Fibrin Fibrinogen Degradation Products; C036309:fibrin fragment D
Clinical decision rule; D-dimer; Diagnosis; Upper extremity deep vein thrombosis; Venous thromboembolism