scholarly journals Diagnosis of suspected venous thromboembolism

Hematology ◽  
2016 ◽  
Vol 2016 (1) ◽  
pp. 397-403 ◽  
Author(s):  
Clive Kearon
Keyword(s):  
Venous Thromboembolism ◽  
Anticoagulant Therapy ◽  
Diagnostic Testing ◽  
Pulmonary Angiography ◽  
Test Results ◽  
Computed Tomography Pulmonary Angiography ◽  
Vein Thrombosis ◽  
Imaging Test ◽  
Deep Vein ◽  
D Dimer

Abstract The primary goal of diagnostic testing for venous thromboembolism (VTE) is to identify all patients who could benefit from anticoagulant therapy. Test results that identify patients as having a ≤2% risk of VTE in the next 3 months are judged to exclude deep vein thrombosis (DVT) or pulmonary embolism (PE). Clinical evaluation, with assessment of: (1) clinical pretest probability (CPTP) for VTE; (2) likelihood of important alternative diagnoses; and (3) the probable yield of D-dimer and various imaging tests, guide which tests should be performed. The combination of nonhigh CPTP and negative D-dimer testing excludes DVT or PE in one-third to a half of outpatients. Venous ultrasound of the proximal veins, with or without examination of the distal veins, is the primary imaging test for leg and upper-extremity DVT. If a previous test is not available for comparison, the positive predictive value of ultrasound is low in patients with previous DVT. Computed tomography pulmonary angiography (CTPA) is the primary imaging test for PE and often yields an alternative diagnosis when there is no PE. Ventilation-perfusion scanning is associated with less radiation exposure than CTPA and is preferred in younger patients, particularly during pregnancy. If DVT or PE cannot be “ruled-in” or “ruled-out” by initial diagnostic testing, patients can usually be managed safely by: (1) withholding anticoagulant therapy; and (2) doing serial ultrasound examinations to detect new or extending DVT.

scholarly journals Highly Elevated Quantitative D-Dimer Assay Values Increase the Likelihood of Venous Thromboembolism

TH Open ◽  
2019 ◽  
Vol 03 (01) ◽  
pp. e2-e9 ◽  
Author(s):  
Samuel Francis ◽  
Alexander Limkakeng ◽  
Hui Zheng ◽  
Judd Hollander ◽  
Gregory Fermann ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
Prospective Observational Study ◽  
Secondary Analysis ◽  
Pulmonary Angiography ◽  
Ct Pulmonary Angiography ◽  
Vein Thrombosis ◽  
Ultrasound Computed Tomography ◽  
Deep Vein ◽  
Work Up ◽  
D Dimer

Objectives In patients with suspected venous thromboembolism (VTE), the D-dimer assay is commonly utilized as part of the workup. The assay is primarily used to determine whether to proceed with radiographic imaging. We compared D-dimer levels in patients suspected of having VTE. We hypothesized that higher D-dimer values predict a higher likelihood of subsequent VTE diagnosis. Methods We conducted a secondary analysis of a multinational, prospective observational study of low- to intermediate-risk adult patients presenting to the emergency department with suspicion of VTE. Demographic and clinical data were collected in a structured manner. Advanced imaging including ultrasound, computed tomography (CT) pulmonary angiography, and ventilation/perfusion scanning was obtained at the discretion of the treating physicians. Imaging was evaluated by board-certified radiologists in real time. D-dimer values' bins were evaluated using a logistic regression model. Results We evaluated 1,752 patients for suspected deep vein thrombosis (DVT), with 191 (10.4%) DVT positive. We evaluated 1,834 patients for suspected pulmonary embolism (PE), with 108 (5.9%) PE positive. Higher D-dimer values in both groups were associated with higher likelihood of subsequent VTE diagnosis, with D-dimer values > 3,999 ng/mL in both groups having the highest incidence of VTE. More than 50% of those patients were VTE positive. Conclusions Increasing D-dimer values predict increased likelihood of being found VTE positive in this patient population. Among those in the highest D-dimer category, > 3,999 ng/mL, over half of patients were VTE positive. Further research could determine additional nuance in D-dimer as a tool to work up suspected VTE.

Deep Vein Thrombosis Diagnosis with D-Dimer Adjusted to Clinical Probability

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 20-20
Author(s):  
Kerstin de Wit ◽  
Sameer Papira ◽  
Sam Schulman ◽  
Fred Spencer ◽  
Sangita Sharma ◽  
...  
Keyword(s):  
Ultrasound Imaging ◽  
Anticoagulant Therapy ◽  
Diagnostic Testing ◽  
Diagnostic Algorithm ◽  
Advisory Board ◽  
Vein Thrombosis ◽  
Wells Score ◽  
Deep Vein ◽  
D Dimer

Introduction Diagnostic testing for deep vein thrombosis (DVT) is a multi-step and time-consuming process. Testing starts with clinical pretest probability (C-PTP) assessment. A negative D-dimer in combination with low C-PTP is widely used to exclude DVT; otherwise ultrasound imaging is required. When proximal vein ultrasound is used, a repeat ultrasound after a week is usually required to exclude DVT in moderate or high C-PTP patients. Ultrasound imaging is costly and can introduce delays. The goal of this study was to evaluate the safety and efficiency of a diagnostic algorithm for DVT that was designed to minimize the need for ultrasound imaging by using C-PTP-based D-dimer thresholds to exclude DVT (the 4D algorithm), rather than a standard fixed D-dimer cut-off value. Methods Consenting patients were enrolled in a Canadian prospective multicentre management study. Outpatients with symptoms or signs of DVT were eligible to be included in this study. Physicians used the 9-item Wells score to categorize the patient's C-PTP as low (Wells score, -2 to 0), moderate (1 or 2), or high (≥3). Patients with low C-PTP and a D-dimer <1,000 ng/mL or with a moderate C-PTP and a D-dimer <500 ng/mL underwent no further diagnostic testing for DVT and did not receive anticoagulant therapy. All other patients underwent proximal vein ultrasound. Patients with a single negative ultrasound but very high D-dimer (low or moderate C-PTP with D-dimer ≥3000 ng/mL, high C-PTP with D-dimer ≥1500 ng/mL) had a second proximal venous ultrasound one week later. The primary outcome was symptomatic, objectively verified, venous thromboembolism (VTE), which included proximal DVT or pulmonary embolism. All patients were followed for 90 days. A sample size of 1500 was required to establish 4D algorithm safety (90-day post-test probability of VTE <2%). Results From April 2014 through March 2020, a total of 1512 patients were enrolled and analyzed. The mean age was 60 years and 58% were female. Overall, 173 (11%) had DVT on initial or serial diagnostic testing (168 had DVT on ultrasound imaging on the day of presentation and 5 had DVT on repeat ultrasound imaging at one week). Of all 1298 patients (86% of total) who did not have DVT (at either initial presentation or at scheduled repeat ultrasound imaging) and who did not receive anticoagulant therapy, 7 had VTE during follow-up (0.5%, 95% confidence interval (CI): 0.3 to 1.1%). In the 579 patients who had low (378 patients) or moderate (201 patients) C-PTP and negative D-dimer results (i.e. <1000 or <500 ng/mL respectively) and who did not receive anticoagulant therapy, 2 had VTE during follow-up (0.4%, 95% CI: 0.1 to 1.3%). In the 572 patients with a single negative ultrasound who were low or moderate C-PTP with D-dimer <3000 ng/mL (423 patients), or high C-PTP with D-dimer <1500 ng/mL (149 patients) and who did not receive anticoagulant therapy, 3 had VTE during follow-up (0.5%, 95% CI: 0.2 to 1.5%). The difference in the mean number of ultrasound examinations with the 4D algorithm (0.72) compared with the conventional algorithm (1.36) was -0.64 (95% CI, -0.68 to -0.61), corresponding to a 47% relative reduction (1083 ultrasound scans performed with the 4D algorithm compared with 2053 ultrasound scans required for the conventional algorithm). Conclusions The 4D diagnostic algorithm ruled out DVT safely while substantially reducing the requirement for ultrasound imaging. Disclosures Wu: BMS-pfizer: Honoraria, Other: advisory board; leo pharma: Other: advisory board; Pfizer: Honoraria; Servier: Other: advisory board.

Evaluation of the Diagnostic Value of Bedside Transthoracic Ultrasonography (TTUS) and Lower Extremity Three-Points Compression Duplex in the Diagnosis of the Pulmonary Embolism

2020 ◽  
Vol 36 (5) ◽  
pp. 423-430
Author(s):  
Keihan Golshani ◽  
Mohammad Sharafsaleh
Keyword(s):  
Lower Extremity ◽  
Sensitivity And Specificity ◽  
Diagnostic Value ◽  
Pulmonary Angiography ◽  
Computed Tomography Pulmonary Angiography ◽  
Vein Thrombosis ◽  
Lung Sonography ◽  
Study Results ◽  
Deep Vein ◽  
D Dimer

Background: The present study aimed at evaluating the diagnostic value of lung transthoracic ultrasonography (TTUS) and lower extremity sonography versus computed tomography pulmonary angiography (CTPA) in the diagnosis of pulmonary embolus (PE). Materials and Methods: This study was performed on 104 patients with clinically suspected PE. CTPA and D-dimer was performed on all patients. Wells’ deep vein thrombosis criteria (WDVTC) was evaluated and recorded at the patient’s admission. Finally, the results of adding venous and lung sonography scores to the WDVTC with and without the results of D-dimer test were analyzed for predicting the diagnosis of PE. Results: There were 104 patients clinically suspected of having a PE and enrolled in the study. A PE was confirmed in 37.5% of this cohort. WDVTC had a sensitivity and specificity of 94.87% and 80.00%, respectively, to predict PE. When adding D-dimer to the WDVTC for patients unlikely to have a PE (WDVTC≤4), the sensitivity and specificity of positive D-dimer in diagnosis of PE were 94.87% and 56.92%, respectively ( P < .001). Conclusion: According to these study results, the modification of the WDVTC along with the results of lung TTUS and lower extremity venous sonogram significantly increase the diagnostic power for PE.

Venous Thromboembolism

2020 ◽  
Author(s):  
Samuel Z. Goldhaber
Keyword(s):  
Risk Factors ◽  
Pulmonary Embolism ◽  
Venous Thromboembolism ◽  
Venous Thrombosis ◽  
Antithrombotic Agents ◽  
Vein Thrombosis ◽  
Recurrent Venous Thrombosis ◽  
Deep Vein ◽  
D Dimer ◽  
In Pregnancy

Venous thromboembolism, which involves venous thrombosis and pulmonary embolism, is a leading cause of morbidity and mortality in hospitalized patients and is being seen with increasing frequency in outpatients. This chapter discusses the risk factors, etiology, classification, pathophysiology, natural history, prognosis, diagnosis (including venous thrombosis, recurrent venous thrombosis, and pulmonary embolism), prophylaxis, and treatment of venous thromboembolism (including the pharmacology of antithrombotic agents), as well as venous thromboembolism in pregnancy and miscellaneous thromboembolic disorders (including thrombosis of unusual sites).  This review contains 8 figures, 16 tables, and 79 references. Keywords: Venous thromboembolism, pulmonary embolism, deep vein thrombosis, embolectomy, thrombolysis, hypercoagulability, duplex ultrasonography, D-dimer, anticoagulation

scholarly journals Advances in the Diagnosis of Venous Thromboembolism: A Literature Review

Diagnostics ◽  
2020 ◽  
Vol 10 (6) ◽  
pp. 365 ◽  
Author(s):  
Harish Patel ◽  
Haozhe Sun ◽  
Ali N. Hussain ◽  
Trupti Vakde
Keyword(s):  
Pulmonary Embolism ◽  
Venous Thromboembolism ◽  
Valsalva Maneuver ◽  
Imaging Modality ◽  
Diagnostic Algorithm ◽  
Pulmonary Angiography ◽  
Vein Thrombosis ◽  
Compression Ultrasound ◽  
Test Probability ◽  
D Dimer

The incidence of venous thromboembolism (VTE), including lower extremity deep vein thrombosis (DVT) and pulmonary embolism (PE) is increasing. The increase in suspicion for VTE has lowered the threshold for performing imaging studies to confirm diagnosis of VTE. However, only 20% of suspected cases have a confirmed diagnosis of VTE. Development of pulmonary embolism rule-out criteria (PERC) and update in pre-test probability have changed the paradigm of ruling-out patient with low index of suspicion. The D-dimer test in conjunction to the pre-test probability has been utilized in VTE diagnosis. The age appropriate D-dimer cutoff and inclusion of YEARS algorithm (signs of the DVT, hemoptysis and whether PE is the likely diagnosis) for the D-dimer cutoff have been recent updates in the evaluation of suspected PE. Multi-detector computed tomography pulmonary angiography (CTPA) and compression ultrasound (CUS) are the preferred imaging modality to diagnose PE and DVT respectively. The VTE diagnostic algorithm do differ in pregnant individuals. The prerequisite of avoiding excessive radiation has recruited planar ventilation-perfusion (V/Q) scan as preferred in pregnant patients to evaluate for PE. The modification of CUS protocol with addition of the Valsalva maneuver should be performed while evaluating DVT in pregnant individual.

scholarly journals Outcomes beyond the Third Month of Anticoagulation in Patients Aged >75 Years with a First Episode of Unprovoked Venous Thromboembolism

TH Open ◽  
2018 ◽  
Vol 02 (04) ◽  
pp. e428-e436 ◽  
Author(s):  
Amaia Iñurrieta ◽  
José Pedrajas ◽  
Manuel Núñez ◽  
Luciano López-Jiménez ◽  
Alba Velo-García ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
Anticoagulant Therapy ◽  
Major Bleeding ◽  
Multivariable Analysis ◽  
First Episode ◽  
Vein Thrombosis ◽  
The Third ◽  
Fatal Bleeding ◽  
Increased Risk ◽  
Deep Vein

Background The ideal duration of anticoagulant therapy in elderly patients with unprovoked venous thromboembolism (VTE) has not been consistently evaluated. Methods We used the RIETE (Registro Informatizado Enfermedad TromboEmbólica) registry to compare the rate and severity of pulmonary embolism (PE) recurrences versus major bleeding beyond the third month of anticoagulation in patients >75 years with a first episode of unprovoked VTE. Results As of September 2017, 7,830 patients were recruited: 5,058 (65%) presented with PE and 2,772 with proximal deep vein thrombosis (DVT). During anticoagulant therapy beyond the third month (median, 113 days), 44 patients developed PE recurrences, 36 developed DVT recurrences, 101 had major bleeding, and 241 died (3 died of recurrent PE and 19 of bleeding). The rate of major bleeding was twofold higher than the rate of PE recurrences (2.05 [95% confidence interval, CI: 1.68–2.48] vs. 0.90 [95% CI: 0.66–1.19] events per 100 patient-years) and the rate of fatal bleeding exceeded the rate of fatal PE events (0.38 [95% CI: 0.24–0.58] vs. 0.06 [95% CI: 0.02–0.16] deaths per 100 patient-years). On multivariable analysis, patients who had bled during the first 3 months (hazard ratio [HR]: 4.32; 95% CI: 1.58–11.8) or with anemia at baseline (HR: 1.87; 95% CI: 1.24–2.81) were at increased risk for bleeding beyond the third month. Patients initially presenting with PE were at increased risk for PE recurrences (HR: 3.60; 95% CI: 1.28–10.1). Conclusion Prolonging anticoagulation beyond the third month was associated with more bleeds than PE recurrences. Prior bleeding, anemia, and initial VTE presentation may help decide when to stop therapy.

scholarly journals Treatment Decision-Making of Secondary Prevention After Venous Thromboembolism: Data From the Real-Life START2-POST-VTE Register

2020 ◽  
Vol 26 ◽  
pp. 107602962094579
Author(s):  
Emilia Antonucci ◽  
Ludovica Migliaccio ◽  
Maria Abbattista ◽  
Antonella Caronna ◽  
Sergio De Marchi ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
Real Life ◽  
Treatment Decision ◽  
Anticoagulant Treatment ◽  
Vein Thrombosis ◽  
Treatment Decision Making ◽  
Residual Thrombus ◽  
The Moment ◽  
Deep Vein ◽  
D Dimer

Patients with venous thromboembolism (VTE) should receive a decision on the duration of anticoagulant treatment (AT) that is often not easy to make. Sixteen Italian clinical centers included patients with recent VTE in the START2-POST-VTE register and reported the decisions taken on duration of AT in each patient and the reasons for them. At the moment of this report, 472 (66.9%) of the 705 patients included in the registry were told to stop AT in 59.3% and to extend it in 40.7% of patients. Anticoagulant treatment lasted ≥3 months in >90% of patients and was extended in patients with proximal deep vein thrombosis because considered at high risk of recurrence or had thrombophilic abnormalities. d-dimer testing, assessment of residual thrombus, and patient preference were also indicated among the criteria influencing the decision. In conclusion, Italian doctors stuck to the minimum 3 months AT after VTE, while the secondary or unprovoked nature of the event was not seen as the prevalent factor influencing AT duration which instead was the result of a complex and multifactorial evaluation of each patient.

Comparison of clinical probability-adjusted D-dimer and age-adjusted D-dimer interpretation to exclude venous thromboembolism

2017 ◽  
Vol 117 (10) ◽  
pp. 1937-1943 ◽  
Author(s):  
Jim Julian ◽  
Lori-Ann Linkins ◽  
Shannon Bates ◽  
Clive Kearon ◽  
Sarah Takach Lapner
Keyword(s):  
Pulmonary Embolism ◽  
Deep Vein Thrombosis ◽  
Venous Thromboembolism ◽  
Diagnostic Accuracy ◽  
Blood Samples ◽  
Vein Thrombosis ◽  
Clinical Probability ◽  
Deep Vein ◽  
New Strategies ◽  
D Dimer

SummaryTwo new strategies for interpreting D-dimer results have been proposed: i) using a progressively higher D-dimer threshold with increasing age (age-adjusted strategy) and ii) using a D-dimer threshold in patients with low clinical probability that is twice the threshold used in patients with moderate clinical probability (clinical probability-adjusted strategy). Our objective was to compare the diagnostic accuracy of age-adjusted and clinical probability-adjusted D-dimer interpretation in patients with a low or moderate clinical probability of venous thromboembolism (VTE). We performed a retrospective analysis of clinical data and blood samples from two prospective studies. We compared the negative predictive value (NPV) for VTE, and the proportion of patients with a negative D-dimer result, using two D-dimer interpretation strategies: the age-adjusted strategy, which uses a progressively higher D-dimer threshold with increasing age over 50 years (age in years × 10 µg/L FEU); and the clinical probability-adjusted strategy which uses a D-dimer threshold of 1000 µg/L FEU in patients with low clinical probability and 500 µg/L FEU in patients with moderate clinical probability. A total of 1649 outpatients with low or moderate clinical probability for a first suspected deep vein thrombosis or pulmonary embolism were included. The NPV of both the clinical probability-adjusted strategy (99.7%) and the age-adjusted strategy (99.6%) were similar. However, the proportion of patients with a negative result was greater with the clinical probability-adjusted strategy (56.1% vs, 50.9%; difference 5.2%; 95% CI 3.5% to 6.8%). These findings suggest that clinical probability-adjusted D-dimer interpretation is a better way of interpreting D-dimer results compared to age-adjusted interpretation.

scholarly journals Factors affecting the recurrence in patients with venous thromboembolism: A retrospective cohort study

2021 ◽  
Vol 29 (3) ◽  
pp. 384-390
Author(s):  
Yasemin Ateş ◽  
Züleyha Bingöl ◽  
Gülfer Okumuş ◽  
Orhan Arseven
Keyword(s):  
Risk Factors ◽  
Deep Vein Thrombosis ◽  
Venous Thromboembolism ◽  
Pulmonary Thromboembolism ◽  
First Year ◽  
Factors Affecting ◽  
Vein Thrombosis ◽  
Hereditary Risk ◽  
Deep Vein ◽  
D Dimer

Background: The aim of the study was to evaluate the frequency of recurrence and the risk factors for recurrence in patients who were diagnosed with venous thromboembolism. Methods: Between January 2005 and January 2015, a total of 412 venous thromboembolism patients (164 males, 248 females; mean age: 53.5±16.6 years; range: 19 to 95 years) were retrospectively analyzed. The demographics, underlying risk factors, comorbidities, imaging findings, and treatment data of the patients were recorded. Results: At least one transient/permanent risk factor was found in 341 (82.7%) of the index events, and the other 71 (17.2%) were idiopathic. Recurrence developed in 76 (18.4%) of the patients. The duration of the treatment in the first event was significantly longer in recurrent cases (p=0.007). The recurrence rate in patients diagnosed with only deep vein thrombosis or patients diagnosed with pulmonary thromboembolism + deep vein thrombosis was significantly higher than the patients diagnosed with only pulmonary thromboembolism (24% vs. 14.2%, respectively; p=0.007). The rate of idiopathic venous thromboembolism was higher in recurrent cases than in non-recurrent cases (26.3% vs. 15.2%, respectively; p=0.028). At the end of the first year, the mean D-dimer levels were higher in recurrent cases (p=0.034). Hereditary risk factors were also higher in recurrent cases (39.5% vs. 19.3%, respectively; p=0.031). There was no significant correlation between recurrence and mortality. Conclusion: The presence of deep vein thrombosis, idiopathic events, high D-dimer levels at the end of the first year and hereditary risk factors seem to be associated with recurrence.

Sign in / Sign up

Export Citation Format

Share Document