A new pre-test probability score for diagnosis of deep vein thrombosis in patients before surgery

The Wells score had shown weak performance to determine pre-test probability of deep vein thrombosis (DVT) for inpatients. So, we evaluated the impact of thromboprophylaxis on the utility of the Wells score for risk stratification of inpatients with suspected DVT. This bicentric cross-sectional study from February 1, 2018 to January 31, 2019 included consecutive medical and surgical inpatients who underwent lower limb ultrasound study for suspected DVT. Wells score clinical predictors were assessed by both ordering and vascular physicians within 24 h after clinical suspicion of DVT. Primary outcome was the Wells score’s accuracy for pre-test risk stratification of suspected DVT, accounting for anticoagulation (AC) treatment (thromboprophylaxis for ⩾ 72 hours or long-term anticoagulation). We compared prevalence of proximal DVT among the low, moderate and high pre-test probability groups. The discrimination accuracy was defined as area under the receiver operating characteristics (ROC) curve. Of the 415 included patients, 30 (7.2%) had proximal DVT. Prevalence of proximal DVT was lower than expected in all pre-test probability groups. The prevalence in low, moderate and high pre-test probability groups was 0.0%, 3.1% and 8.2% ( p = 0.22) and 1.7%, 4.2% and 25.8% ( p < 0.001) for inpatients with or without AC, respectively. Area under ROC curves for discriminatory accuracy of the Wells score, for risk of proximal DVT with or without AC, was 0.72 and 0.88, respectively. The Wells score performed poorly for discrimination of risk for proximal DVT in hospitalized patients with AC but performed reasonably well among patients without AC; and showed low inter-rater reliability between physicians. ClinicalTrials.gov Identifier: NCT03784937.

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Combined use of pretest clinical probability score and latex agglutination D-dimer testing for excluding acute deep vein thrombosis

Journal of Vascular Surgery ◽

10.1016/j.jvs.2009.06.059 ◽

2009 ◽

Vol 50 (5) ◽

pp. 1099-1105 ◽

Cited By ~ 19

Author(s):

Takashi Yamaki ◽

Motohiro Nozaki ◽

Hiroyuki Sakurai ◽

Yuji Kikuchi ◽

Kazutaka Soejima ◽

...

Keyword(s):

Deep Vein Thrombosis ◽

Latex Agglutination ◽

Probability Score ◽

Vein Thrombosis ◽

Clinical Probability ◽

Combined Use ◽

Acute Deep Vein Thrombosis ◽

Deep Vein ◽

D Dimer

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Imaging for venous thrombosis

ESC CardioMed ◽

10.1093/med/9780198784906.003.0670 ◽

2018 ◽

pp. 2806-2810

Author(s):

Frederikus A. Klok ◽

Charlotte E. A. Dronkers ◽

Menno V. Huisman

Keyword(s):

Deep Vein Thrombosis ◽

Venous Thrombosis ◽

Imaging Techniques ◽

Clinical Decision ◽

Cerebral Vein ◽

Vein Thrombosis ◽

Diagnostic Work ◽

Deep Vein ◽

Work Up ◽

Test Probability

The diagnostic work-up of upper and of lower extremity deep vein thrombosis starts with the assessment of the pre-test probability by using a validated clinical decision rule, followed by imaging if deep vein thrombosis cannot reliably be rule out. For splanchnic vein thrombosis and cerebral vein thrombosis, the diagnostic assessment starts with imaging. Currently, the imaging techniques most widely used in clinical practice are compression ultrasonography, computed tomography, and magnetic resonance imaging, with a diagnostic standard dependent on the specific site of the venous thrombosis. This chapter provides an overview of the diagnostic accuracy and potential pitfalls of imaging techniques for the different sites of venous thrombosis.

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Impact of gender on the clinical presentation and diagnosis of deep-vein thrombosis

Thrombosis and Haemostasis ◽

10.1160/th09-10-0705 ◽

2010 ◽

Vol 103 (04) ◽

pp. 710-717 ◽

Cited By ~ 20

Author(s):

Hanno Riess ◽

Viola Hach-Wunderle ◽

Horst Gerlach ◽

Heike Carnarius ◽

Sonja Eberle ◽

...

Keyword(s):

Deep Vein Thrombosis ◽

Clinical Presentation ◽

Risk Groups ◽

Pretest Probability ◽

Probability Score ◽

Vein Thrombosis ◽

Diagnostic Work ◽

Deep Vein ◽

Work Up ◽

Diagnostic Work Up

SummaryIt is uncertain whether gender influences the clinical presentation of deep-vein thrombosis (DVT) and the discriminative value of the Wells diagnostic pretest probability score. The aim of the study was to determine whether gender impacts the clinical presentation and diagnosis of DVT. The study analysed a cohort of 4,976 outpatients with clinically suspected DVT of the leg prospectively recruited by 326 vascular medicine physicians in the German ambulatory care sector between October and December 2005. The diagnosis of DVT was based on compression ultrasonography in 96% of patients. Among 4,777 patients who had a diagnostic work-up for DVT there were more women (n=2,998) than men (n=1,779). However, the prevalence of confirmed DVT was 37.0% (658/1779) in men vs. 24.3% (730/2,998) in women (p<0.001). Among patients with confirmed DVT, proximal DVT was more common in men (59.6% vs. 44.5% in women, p<0.001). Swelling of the leg, pitting oedema and dilated superficial veins were more frequently reported by men (p<0.001). The percentage of patients with a high probability Wells clinical pretest score was higher in men than in women (67.0% vs. 57.0%, p<0.001). However, overall, the score equally discriminated risk groups for DVT in both sexes. In conclusion, women were more frequently referred for a diagnostic work-up for DVT than men, but the prevalence of DVT was higher in men and their thrombotic events were more severe. Nevertheless, the Wells clinical pretest probability score correctly identified low- and high-risk groups in both genders.

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A new pretest probability score for diagnosis of lower limb deep vein thrombosis in unselected population of outpatients and inpatients

Phlebology The Journal of Venous Disease ◽

10.1177/0268355516630469 ◽

2016 ◽

Vol 32 (2) ◽

pp. 107-114 ◽

Cited By ~ 1

Author(s):

Nuttawut Sermsathanasawadi ◽

Trakarn Chaivanit ◽

Pinyo Suparatchatpun ◽

Khamin Chinsakchai ◽

Chumpol Wongwanit ◽

...

Keyword(s):

Deep Vein Thrombosis ◽

Characteristic Curve ◽

Pretest Probability ◽

Leg Pain ◽

Probability Score ◽

Vein Thrombosis ◽

Unselected Population ◽

Low Probability ◽

Deep Vein ◽

Limb Deep Vein Thrombosis

Objective To develop a new pretest probability score for deep vein thrombosis (DVT) in unselected population of outpatients and inpatients. Methods The new score was developed using independent factors from 500 patients clinically suspected of leg DVT. The new score was validated in a second group of 315 patients. Results The score consists of four components: unilateral leg pain, confinement to bed, calf enlargement >3 cm compared with the other side, and previous venous thromboembolism. A score ≥2 indicated a high probability while a score <2 indicated low probability. The sensitivity and specificity of the new score were 71.60% and 79.49%, respectively. The area under the receiver operating characteristic curve for the new score was 0.79. The combination of a new score <2 and D-dimer level <500 µg/L had a negative predictive value of 96.43%. Conclusions Our new score was valid in an unselected population of outpatients and inpatients.

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Comparison of clinical prediction scores for the diagnosis of deep vein thrombosis in unselected population of outpatients and inpatients

Phlebology The Journal of Venous Disease ◽

10.1177/0268355514541981 ◽

2014 ◽

Vol 30 (7) ◽

pp. 469-474 ◽

Cited By ~ 4

Author(s):

N Sermsathanasawadi ◽

P Suparatchatpun ◽

T Pumpuang ◽

K Hongku ◽

K Chinsakchai ◽

...

Keyword(s):

Deep Vein Thrombosis ◽

Lower Limb ◽

Clinical Prediction ◽

Probability Score ◽

Vein Thrombosis ◽

Wells Score ◽

Unselected Population ◽

Deep Vein ◽

Compression Ultrasonography

Objectives The aim of this research was to compare the accuracy of the modified Wells, the Wells, the Kahn, the St. André, and the Constans score for the diagnosis of deep vein thrombosis of the lower limb in unselected population of outpatients and inpatients. Method The pretest of probability score was employed in consecutive 500 outpatients and inpatients with suspicion of deep vein thrombosis. All patients were examined with compression ultrasonography. Results Deep vein thrombosis was confirmed in 26.4%. In the unselected population of outpatients and inpatients, the accuracy of the modified Wells score and the Constans score was higher than other scores. Both scores were more accurate for the outpatients. There was no accurate score for the inpatient subgroup. Conclusions The modified Wells and the Constans score appear to be useful in the unselected population of outpatients and inpatients and particularly in the outpatient subgroup.

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Safety of D-Dimer As a Stand-Alone Test for the Exclusion of Deep Vein Thrombosis Compared to Other Strategies

Blood ◽

10.1182/blood-2018-99-113831 ◽

2018 ◽

Vol 132 (Supplement 1) ◽

pp. 2517-2517

Author(s):

Synne Fronas ◽

Hilde Skuterud Wik ◽

Anders EA Dahm ◽

Camilla Tøvik Jørgensen ◽

Jostein Gleditsch ◽

...

Keyword(s):

Deep Vein Thrombosis ◽

Financial Support ◽

Probability Assessment ◽

Regional Health ◽

Vein Thrombosis ◽

Wells Score ◽

Deep Vein ◽

Eastern Norway ◽

Test Probability ◽

D Dimer

Abstract Background Together with clinical decision rules, D-dimer testing has long been the mainstay of diagnostic work-up of suspected deep vein thrombosis (DVT). Advantages of D-dimer measurement include wide availability, low costs and high sensitivity. Age-adjusted D-dimer cut-off values have been suggested to improve specificity of D-dimer testing, defining a positive D-dimer as age multiplied by 0.01 mg/L at or over fifty years of age. Age-adjusted cut-off values have been found to increase specificity without compromising safety in the setting of acute pulmonary embolism, but have not been extensively evaluated in DVT. In this study, we aimed to evaluate and compare the diagnostic performance of fixed versus age-adjusted D-dimer thresholds in patients with suspected DVT, as a stand-alone test or in combination with pre-test probability assessment. Methods We included 973 consecutive outpatients referred to Østfold Hospital, Norway, with suspected first or recurrent lower extremity DVT, between 2015 and 2017. STA®-Liatest® Plus D-Dimer assay was performed and Wells clinical score assessed in all patients. Patients with positive fixed D-dimer (≥0.5 mg/L) were referred for whole-leg compression ultrasonography (CUS), whereas patients with negative D-dimer were not, irrespective of the clinical pre-test probability. Failure rate was defined as patients with negative D-dimer at baseline remaining untreated and diagnosed with symptomatic venous thromboembolism during 3-month follow-up. We compared diagnostic indices of both D-dimer thresholds with or without initial pre-test probability assessment. Results DVT was diagnosed in 177 out of 973 patients (18%).The fixed D-dimer cut-off was associated with a sensitivity of 99.4% (95% CI 96.9 to 99.9%) for one diagnostic failure (0.3%) (not adjudicated as of print). Adding the Wells score would have detected this one case at a cost of 90 additional CUS examinations. Age-adjusted D-dimer as a stand-alone test was associated with 6 diagnostic failures (1.5%) for a sensitivity of 96.6% (95% CI 92.8 to 98.8%). Age-adjusted D-dimer combined with Wells score yielded a sensitivity of 99.4% (95% CI 96.9 to 99.9%), with one diagnostic failure (0.4%) and 714 patients referred for CUS. Conclusion Our results suggest that the fixed D-dimer as a stand-alone test without Wells score is a safe and efficient diagnostic strategy. Combining age-adjusted D-dimer with Wells score was equally safe, but was not associated with a lower number of necessary CUS examinations. Disclosures Fronas: Bayer AG: Other: Bayer AG contributed with financial support in conducting the study; South-Eastern Norway Regional Health Authority: Other: Grant in conducting the study. Tøvik Jørgensen:Bayer AG: Other: Bayer AG contributed with financial support in conducting the study; South-Eastern Norway Regional Health Authority: Other: Grant for conducting the study. Ghanima:Bayer, BMS, Novartis: Research Funding; Amgen, Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees.

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Prospective Evaluation of a Screening Protocol to Exclude Deep Vein Thrombosis on the Basis of a Combination of Quantitative D-Dimer Testing and Pretest Clinical Probability Score

Journal of the American College of Surgeons ◽

10.1016/j.jamcollsurg.2005.06.267 ◽

2005 ◽

Vol 201 (5) ◽

pp. 701-709 ◽

Cited By ~ 10

Author(s):

Takashi Yamaki ◽

Motohiro Nozaki ◽

Hiroyuki Sakurai ◽

Masaki Takeuchi ◽

Kazutaka Soejima ◽

...

Keyword(s):

Deep Vein Thrombosis ◽

Prospective Evaluation ◽

Probability Score ◽

Vein Thrombosis ◽

Clinical Probability ◽

Screening Protocol ◽

Deep Vein ◽

D Dimer

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Reduced efficacy of clinical probability score and d-dimer assay in elderly subjects suspected of having deep vein thrombosis

British Journal of Haematology ◽

10.1111/j.1365-2141.2005.05515.x ◽

2005 ◽

Vol 129 (5) ◽

pp. 653-657 ◽

Cited By ~ 29

Author(s):

Roger E. G. Schutgens ◽

Fred J. L. M. Haas ◽

Douwe H. Biesma

Keyword(s):

Deep Vein Thrombosis ◽

Elderly Subjects ◽

Probability Score ◽

Vein Thrombosis ◽

Clinical Probability ◽

Deep Vein ◽

D Dimer

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Could a D-dimer/fibrinogen ratio have a role in ruling-out venous thromboembolism?

Emergency Medicine Journal ◽

10.1136/emermed-2020-210688 ◽

2021 ◽

pp. emermed-2020-210688

Author(s):

Teodoro Marcianò ◽

Stefano Franchini

Keyword(s):

Pulmonary Embolism ◽

Deep Vein Thrombosis ◽

Venous Thromboembolism ◽

Chart Review ◽

Chest Ct ◽

Low Risk ◽

Vein Thrombosis ◽

Deep Vein ◽

Test Probability ◽

D Dimer

BackgroundDiagnosis of venous thromboembolism (VTE) requires chest CT angiography for pulmonary embolism and venous ultrasound for deep vein thrombosis. To reduce imaging, guidelines recommend D-dimer levels to rule-out VTE in patients with a low pre-test probability. The most widely used D-dimer cut-off is 500 ng/mL. This cut-off has low specificity, meaning many patients without disease require imaging.MethodsIn this retrospective chart review, we evaluated the diagnostic performance of the D-dimer/fibrinogen ratio (DFR) for identifying thromboembolism and compared it to the performance of two different D-dimer cut-offs (500 ng/mL and 1000 ng/mL) in patients who underwent a chest CT angiography or a venous ultrasound in the ED of San Raffaele Hospital, Italy, in 2017. Patients had a retrospective Wells score calculated after chart review, identifying both high-risk and low-risk pre-test probability patients for this study and low probability patients were further stratified into low-risk of deep vein thrombosis or pulmonary embolism.ResultsEnrolled patients included 92 with suspected pulmonary embolism and 154 with suspected deep vein thrombosis; of whom 67 (27%) were diagnosed with VTE. The most accurate cut-off for DFR in terms of discriminative power was 2.65. In the whole sample and in low-risk patients, this cut-off had the same sensitivity values of the 500 ng/mL D-dimer cut-off (97% (95% CI: 89.8% to 99.2%)), while slightly lower sensitivity values were found for the 1000 ng/mL D-dimer cut-off (95.5% (95% CI: 87.6% to 98.5%)). Specificity was higher for the 2.65 DFR cut-off (55.3% (95% CI: 48.0% to 62.4%)) in the whole sample compared with both 500 ng/mL D-dimer cut-off (22.9% (95% CI: 17.4% to 29.6%)) and 1000 ng/mL D-dimer cut-off (45.8% (95% CI: 38.7% to 53.1%)). Similar results were found in all subgroups.ConclusionA DFR, with a cut-off of 2.65, may improve the specificity for VTE patients when compared with D-dimer alone in high-risk VTE emergency medicine populations. This is exploratory information only, needing evaluation in prospective, multicentre studies, prior to consideration for use in routine clinical work.

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