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Strategies for the safe and effective exclusion and diagnosis of deep vein thrombosis by the sequential use of clinical score, D-dimer testing, and compression ultrasonography.
Semin Thromb Hemost. 2000; 26(6):657-67.ST

Abstract

Patients with suspected deep vein thrombosis (DVT) are subjected to leg vein compression ultrasonography (CUS) that confirms DVT in only 20 to 30% of patients. A positive CUS is consistent with DVT irrespective of clinical score. The sequential use of a simple clinical score assessment, a rapid sensitive enzyme-linked immunosorbent assay (ELISA) D-dimer test and CUS to safely exclude DVT is promising. The clinical score is a validated clinical model of complaints, signs, and symptoms, on the basis of which a pretest clinical probability for DVT can be estimated as low, moderate, and high. The safe exclusion of DVT by a rapid sensitive D-dimer test in combination with clinical score or CUS necessitates a negative predictive value of more than 99%. The negative predictive value for DVT is determined by the sensitivity of the rapid ELISA D-dimer test and the prevalence of DVT in subgroups of outpatients with suspected DVT. The prevalence of DVT in outpatients with a low, moderate, and high clinical score varies widely from 3 to 10%, 15 to 30% and more than 70%, respectively. A negative rapid ELISA D-dimer and a low clinical score (prevalence DVT 3 to 5%) will have a very high negative predictive value of more than 99.5% to exclude DVT without the need of CUS testing. A negative ELISA D-dimer test and a first-negative CUS safely exclude DVT in patients with a moderate clinical score with a negative predictive value of more than 99.5%, therefore obviating the need to repeat CUS. The use of a rapid ELISA D-dimer testing in patients with a high clinical score is not recommended. A negative CUS, a low clinical score, and a positive ELISA D-dimer, even less than 1000 ng/mL exclude DVT with a nega tive predictive value of more than 99%. Patients with a negative CUS, but a positive ELISA D-dimer, and a moderate or high clinical score have a probability of DVT of 3 to 5% and 20 to 30%, respectively, and are thus candidates for repeated CUS testing. The proposed sequential use of the clinical score assessment, a rapid ELISA D-dimer test, and CUS will be the most cost-effective diagnostic strategy for DVT because of a significant reduction of CUS examinations and gain of time for the patient and physician in charge.

Authors+Show Affiliations

Clinical Hemostasis and Thrombosis, Department of Hematology, University Hospital Antwerp and the Goodheart Institute Center for Hemostasis, Thrombosis, and Vascular Pathology, Rotterdam, The Netherlands. postbus@goodheartcenter.demon.nlNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Review

Language

eng

PubMed ID

11140802

Citation

Michiels, J J., et al. "Strategies for the Safe and Effective Exclusion and Diagnosis of Deep Vein Thrombosis By the Sequential Use of Clinical Score, D-dimer Testing, and Compression Ultrasonography." Seminars in Thrombosis and Hemostasis, vol. 26, no. 6, 2000, pp. 657-67.
Michiels JJ, Freyburger G, van der Graaf F, et al. Strategies for the safe and effective exclusion and diagnosis of deep vein thrombosis by the sequential use of clinical score, D-dimer testing, and compression ultrasonography. Semin Thromb Hemost. 2000;26(6):657-67.
Michiels, J. J., Freyburger, G., van der Graaf, F., Janssen, M., Oortwijn, W., & van Beek, E. J. (2000). Strategies for the safe and effective exclusion and diagnosis of deep vein thrombosis by the sequential use of clinical score, D-dimer testing, and compression ultrasonography. Seminars in Thrombosis and Hemostasis, 26(6), 657-67.
Michiels JJ, et al. Strategies for the Safe and Effective Exclusion and Diagnosis of Deep Vein Thrombosis By the Sequential Use of Clinical Score, D-dimer Testing, and Compression Ultrasonography. Semin Thromb Hemost. 2000;26(6):657-67. PubMed PMID: 11140802.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Strategies for the safe and effective exclusion and diagnosis of deep vein thrombosis by the sequential use of clinical score, D-dimer testing, and compression ultrasonography. AU - Michiels,J J, AU - Freyburger,G, AU - van der Graaf,F, AU - Janssen,M, AU - Oortwijn,W, AU - van Beek,E J, PY - 2001/1/5/pubmed PY - 2001/4/6/medline PY - 2001/1/5/entrez SP - 657 EP - 67 JF - Seminars in thrombosis and hemostasis JO - Semin Thromb Hemost VL - 26 IS - 6 N2 - Patients with suspected deep vein thrombosis (DVT) are subjected to leg vein compression ultrasonography (CUS) that confirms DVT in only 20 to 30% of patients. A positive CUS is consistent with DVT irrespective of clinical score. The sequential use of a simple clinical score assessment, a rapid sensitive enzyme-linked immunosorbent assay (ELISA) D-dimer test and CUS to safely exclude DVT is promising. The clinical score is a validated clinical model of complaints, signs, and symptoms, on the basis of which a pretest clinical probability for DVT can be estimated as low, moderate, and high. The safe exclusion of DVT by a rapid sensitive D-dimer test in combination with clinical score or CUS necessitates a negative predictive value of more than 99%. The negative predictive value for DVT is determined by the sensitivity of the rapid ELISA D-dimer test and the prevalence of DVT in subgroups of outpatients with suspected DVT. The prevalence of DVT in outpatients with a low, moderate, and high clinical score varies widely from 3 to 10%, 15 to 30% and more than 70%, respectively. A negative rapid ELISA D-dimer and a low clinical score (prevalence DVT 3 to 5%) will have a very high negative predictive value of more than 99.5% to exclude DVT without the need of CUS testing. A negative ELISA D-dimer test and a first-negative CUS safely exclude DVT in patients with a moderate clinical score with a negative predictive value of more than 99.5%, therefore obviating the need to repeat CUS. The use of a rapid ELISA D-dimer testing in patients with a high clinical score is not recommended. A negative CUS, a low clinical score, and a positive ELISA D-dimer, even less than 1000 ng/mL exclude DVT with a nega tive predictive value of more than 99%. Patients with a negative CUS, but a positive ELISA D-dimer, and a moderate or high clinical score have a probability of DVT of 3 to 5% and 20 to 30%, respectively, and are thus candidates for repeated CUS testing. The proposed sequential use of the clinical score assessment, a rapid ELISA D-dimer test, and CUS will be the most cost-effective diagnostic strategy for DVT because of a significant reduction of CUS examinations and gain of time for the patient and physician in charge. SN - 0094-6176 UR - https://www.unboundmedicine.com/medline/citation/11140802/Strategies_for_the_safe_and_effective_exclusion_and_diagnosis_of_deep_vein_thrombosis_by_the_sequential_use_of_clinical_score_D_dimer_testing_and_compression_ultrasonography_ L2 - http://www.thieme-connect.com/DOI/DOI?10.1055/s-2000-13222 DB - PRIME DP - Unbound Medicine ER -