Management of patients with suspected deep vein thrombosis in the Emergency Department: Combining use of a clinical diagnosis model with D-dimer testing

Introduction: Diagnosing pulmonary embolism (PE) can be challenging because the signs and symptoms are often non-specific. Studies have shown that evidence-based algorithms are not always adhered to in the Emergency Department (ED) and are often not used correctly, which leads to unnecessary CT scanning. The YEARS diagnostic algorithm, consisting of three items (clinical signs of deep vein thrombosis, hemoptysis, and whether pulmonary embolism is the most likely diagnosis) and D-dimer, is a novel and simplified way to approach suspected acute PE. The purpose of this study was to 1) evaluate the use of the YEARS algorithm in the ED and 2) to compare the rates of testing for PE if the YEARS algorithm was used. Methods: This was a health records review of ED patients investigated for PE at two emergency departments over a two-year period (April 2013-March 2015). Inclusion criteria were ED physician ordered CT pulmonary angiogram, ventilation-perfusion scan, or D-dimer for investigation of PE. Patients under the age of 18 and those without a D-dimer test were excluded. PE was considered to be present during the emergency department visit if PE was diagnosed on CT or VQ (subsegmental level or above), or if the patient was subsequently found to have PE or deep vein thrombosis during the next 30 days. Trained researchers extracted anonymized data. The rate of CT/VQ imaging and the false negative rate was calculated. Results: There were 1,163 patients that were tested for PE and 1,083 patients were eligible for our analysis. Of the total, 317/1,083 (29.3%; 95%CI 26.6-32.1%) had CT/VQ imaging for PE, and 41/1,083 (3.8%; 95%CI 2.8-5.1%) patients were diagnosed with PE at baseline. Three patients had a missed PE, resulting in a false negative rate of 0.4% (95%CI 0.1-1.2%). If the YEARS algorithm was used, 211/1,083 (19.5%; 95%CI 17.2-22.0%) would have required imaging for PE. Of the patients who would not have required imaging according to the YEARS algorithm, 8/872 (0.9%; 95%CI 0.5-1.8%) would have had a missed PE. Conclusion: If the YEARS algorithm was used in all patients with suspected PE, fewer patients would have required imaging with a small increase in the false negative rate.

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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)

Journal of Thrombosis and Haemostasis ◽

10.1046/j.1538-7836.2003.00131.x ◽

2003 ◽

Vol 1 (4) ◽

pp. 645-651 ◽

Cited By ~ 81

Author(s):

D. R. Anderson ◽

M. J. Kovacs ◽

G. Kovacs ◽

I. Stiell ◽

M. Mitchell ◽

...

Keyword(s):

Emergency Department ◽

Deep Vein Thrombosis ◽

Clinical Assessment ◽

Vein Thrombosis ◽

Combined Use ◽

Deep Vein ◽

D Dimer

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D-Dimers, Thrombin Antithrombin III Complexes and Prothrombin Fragments 1 + 2: Diagnostic value in Clinically Suspected Deep Vein Thrombosis

Thrombosis and Haemostasis ◽

10.1055/s-0038-1647449 ◽

1991 ◽

Vol 65 (01) ◽

pp. 028-032 ◽

Cited By ~ 105

Author(s):

B Boneu ◽

G Bes ◽

H Pelzer ◽

P Sié ◽

H Boccalon

Keyword(s):

Deep Vein Thrombosis ◽

Antithrombin Iii ◽

High Sensitivity ◽

Diagnostic Value ◽

Predictive Values ◽

Vein Thrombosis ◽

High Negative Predictive Value ◽

Deep Vein ◽

D Dimer ◽

Mercury Strain Gauge

SummaryThis study was performed to determine the accuracy of D-Dimer fibrin derivatives, thrombin-antithrombin III (TAT) complexes and prothrombin fragments 1 + 2 (F 1 + 2) determinations for the diagnosis of deep vein thrombosis (DVT). One hundred and sixteen consecutive patients referred to the angiology unit of our hospital for a clinically suspected DVT were investigated. They were submitted to mercury strain gauge plethysmography and to ultrasonic duplex scanning examination; in cases of inconclusive results or of proximal DVT (n = 35), an ascending phlebography was performed. After these investigations were completed, the diagnosis of DVT was confirmed in 34 and excluded in 82. One half of the patients were already under anticoagulant therapy at the time of investigation. The 3 biological markers were assayed using commercially available ELISA techniques and the D-Dimer was also assayed with a fast latex method. The normal distribution of these markers was established in 40 healthy blood donors. The most accurate assay for the diagnosis of DVT was the D-Dimer ELISA which had both a high sensitivity (94%) and a high negative predictive value (95%). The D-Dirner latex, TAT complexes and F 1 + 2 were far less sensitive and provided negative predictive values which ranged between 78 and 85%. In spite of positive and significant correlations between the levels of ihe 3 markers, their association did not improve their overall accuracy for detecting D\/L Therefore, with the exception of the D-Dimer ELISA, these markers were of little value for the diagnosis of DVT in this specific population.

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Evaluation of a New Rapid Quantitative D-dimer Assay in Patients with Clinically Suspected Deep Vein Thrombosis

Thrombosis and Haemostasis ◽

10.1055/s-0038-1650288 ◽

1996 ◽

Vol 75 (03) ◽

pp. 412-416 ◽

Cited By ~ 70

Author(s):

Armando D’Angelo ◽

Gabriella D’Alessandro ◽

Loredana Tomassini ◽

Jean Louis Pittet ◽

G Dupuy ◽

...

Keyword(s):

Deep Vein Thrombosis ◽

Predictive Value ◽

Cost Savings ◽

Pretest Probability ◽

First Episode ◽

Consecutive Series ◽

Vein Thrombosis ◽

Baseline Testing ◽

Deep Vein ◽

D Dimer

SummaryThe sensitivity and specificity for deep vein thrombosis (DVT) of a new rapid, quantitative and precise (total imprecision < 10%) D-dimer assay suitable for individual measurements (VIDAS D-DIMER, bio-Merieux, France) were evaluated in a consecutive series of 103 in- and out-patients submitted to serial compression ultrasonography (C-US) for the clinical suspicion of DVT (n = 66) or of DVT recurrence (n = 37) and symptoms lasting from 1 to 15 days. DVT was found in 22 patients at baseline testing and no patient with an initially negative C-US developed vein incompressibility at follow up. The time elapsed from the onset of symptoms was negatively associated with D-dimer levels both in patients with and in those without DVT. In the entire series of patients, the sensitivity of a positive D-dimer test (≥1.0 Μg/ml) for the presence of DVT was 96% (21/22 patients, 95% confidence interval 75-100%) with a specificity of 75% (64-84%), a negative predictive value of 98% (90-100%), a positive predictive value of 51% (35-67%), and an overall accuracy of 80% (70-87%). A normal D-dimer value (0.22 Μg/ml) was observed in one patient with DVT and symptoms lasting from 15 days. The approach of withholding C-US testing in patients with symptoms lasting from less than 11 days and D-dimer levels below the cut-off value was compared to serial C-US testing alone in a cost-effectiveness analysis subdividing the 66 patients with a first episode according to their clinical pretest probability of DVT. Thrombosis was detected in 6.7% of the patients in the low probability group (n = 15), 16.7% of the patients in the moderate probability group (n = 24), 51.9% of the patients in the high probability group (n = 27) and 8.1% of patients with suspected DVT recurrence. Calculated cost-savings for each DVT diagnosed ranged from 5% in the high pretest probability group to 55% in the low pretest probability group and to 77% in patients with suspected DVT recurrence.The safety of avoiding C-US testing in symptomatic patients with a negative D-dimer test should be evaluated in clinical management studies.

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D-Dimer Test and Diagnosis of Deep Vein Thrombosis: A Comparative Study of 7 Assays

Thrombosis and Haemostasis ◽

10.1055/s-0038-1650615 ◽

1996 ◽

Vol 76 (04) ◽

pp. 518-522 ◽

Cited By ~ 44

Author(s):

A Elias ◽

I Aptel ◽

B Huc ◽

J J Chale ◽

F Nguyen ◽

...

Keyword(s):

Deep Vein Thrombosis ◽

Negative Predictive Value ◽

Predictive Value ◽

Latex Agglutination ◽

Lower Limbs ◽

First Episode ◽

Lower Sensitivity ◽

Vein Thrombosis ◽

Deep Vein ◽

D Dimer

SummaryThe current D-Dimer ELISA methods provide high sensitivity and negative predictive value for the diagnosis of deep vein thrombosis but these methods are not suitable for emergency or for individual determination. We have evaluated the performance of 3 newly available fast D-Dimer assays (Vidas D-Di, BioMerieux; Instant IA D-Di, Stago; Nycocard D-Dimer, Nycomed) in comparison with 3 classic ELISA methods (Stago, Organon, Behring) and a Latex agglutination technique (Stago). One-hundred-and-seventy-one patients suspected of presenting a first episode of deep vein thrombosis were investigated. A deep vein thrombosis was detected in 75 patients (43.8%) by ultrasonic duplex scanning of the lower limbs; in 11 of them the thrombi were distal and very limited in size (<2 cm). We compared the performance of the tests by calculating their sensitivity, specificity, positive and negative predictive value for different cut-off levels and by calculating the area under ROC curves. The concordance of the different methods was evaluated by calculating the kappa coefficient. The performances of the 3 classic ELISA and of the Vidas D-Di were comparable and kappa coefficients indicated a good concordance between the results provided by these assays. Their sensitivity slightly declined for detection of the very small thrombi. Instant IA D-Di had a non-significantly lower sensitivity and negative predictive value than the 4 previous assays; however its performance was excellent for out-patients. As expected, the Latex assay had too low a sensitivity and negative predictive value to be recommended. In our hands, Nycocard D-Dimer also exhibited low sensitivity and negative predictive value, which were significantly improved when the plasma samples were tested by the manufacturer. Thus significant progress has been made, allowing clinical studies to be planned to compare the safety and cost-effectiveness of D-Dimer strategy to those of the conventional methods for the diagnosis of venous thrombosis.

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Rapid Quantitative D-dimer Assay and Clinical Evaluation for the Diagnosis of Clinically Suspected Deep Vein Thrombosis

Thrombosis and Haemostasis ◽

10.1055/s-0038-1656013 ◽

1997 ◽

Vol 77 (03) ◽

pp. 602-603 ◽

Cited By ~ 12

Author(s):

J Y Borg ◽

H Lévesque ◽

N Cailleux ◽

C Franc ◽

M F Hellot ◽

...

Keyword(s):

Deep Vein Thrombosis ◽

Clinical Evaluation ◽

Vein Thrombosis ◽

Deep Vein ◽

D Dimer

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Performance of age-adjusted D-dimer values for predicting DVT before the knee and hip arthroplasty

Journal of Orthopaedic Surgery and Research ◽

10.1186/s13018-020-02172-w ◽

2021 ◽

Vol 16 (1) ◽

Author(s):

Jian Xiang Wu ◽

Jiang Hui Qing ◽

Yao Yao ◽

Dong Yang Chen ◽

Qing Jiang

Keyword(s):

Deep Vein Thrombosis ◽

Odds Ratio ◽

Joint Arthroplasty ◽

Receiver Operating Curve ◽

Multiple Logistic Regression ◽

Vein Thrombosis ◽

Specificity And Sensitivity ◽

Knee And Hip Arthroplasty ◽

Deep Vein ◽

D Dimer

Abstract Purpose To compare the specificity and sensitivity of preoperative D-dimer and age-adjusted D-dimer value for predicting the incidence of the DVT preoperatively in total joint arthroplasty (TJA) patients. Methods We enrolled 406 patients finally above 50 years old. Everyone had done ultrasonography bedside, and D-dimer concentrations were collected before surgery. The D-dimer and age-adjusted D-dimer cut-off was calculated by multiple logistic regression and receiver operating curve (ROC) analyses. Results A total of 39 patients had found asymptomatic deep vein thrombosis (DVT) by ultrasonography. The age (odds ratio [OR] 1.067; p = 0.003) and D-dimer (OR 1.331; p = 0.025) were related to the existence of DVT. For conventional D-dimer and age-adjusted D-dimer value, the area under the curves (AUCs) were 0.685 (0.499–0.696) and 0.795 (0.611–0.881), respectively. Conclusion Compared to traditional D-dimer, age-adjusted D-dimer showed better performance in screening DVT, which was useful clinically.

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