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Does this patient have deep vein thrombosis?

Philip S Wells1, Carolyn Owen, Steve Doucette

  • 1Department of Medicine, University of Ottawa, Ontario. pwells@ohri.ca

JAMA
|January 13, 2006
PubMed
Summary

Clinical prediction rules improve deep vein thrombosis (DVT) diagnosis. For low-probability patients, a negative D-dimer test can exclude DVT, avoiding further imaging.

Area of Science:

  • Medical Diagnostics
  • Clinical Epidemiology
  • Thrombosis Research

Background:

  • Outpatients with suspected deep vein thrombosis (DVT) present with nonspecific symptoms, increasing the risk of missed diagnoses and fatal pulmonary embolism.
  • A selective and efficient diagnostic process is crucial given the potential prevalence of DVT in this population.

Purpose of the Study:

  • To systematically review studies evaluating the prevalence of DVT using clinical prediction rules, with or without D-dimer testing.
  • To assess the diagnostic accuracy of D-dimer testing across different clinical probability strata for DVT.

Main Methods:

  • Systematic review of English and French studies from 1990-2004, including prospective enrollment of outpatients with suspected DVT.
  • Application of clinical prediction rules prior to D-dimer testing or imaging, with a minimum 3-month patient follow-up.

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  • Data abstraction and pooling for DVT prevalence, sensitivity, specificity, and likelihood ratios (LRs) of D-dimer, analyzed by clinical probability (low, moderate, high).

    • Main Results:

    • Fourteen studies (over 8000 patients) utilized clinical prediction rules; 11 incorporated D-dimer testing.
    • DVT prevalence was 5.0% (low), 17% (moderate), and 53% (high) probability groups; overall prevalence was 19%.
    • D-dimer testing showed varying sensitivity and specificity across probability groups, with negative LRs generally low, particularly in low-probability patients (0.18%).

    Conclusions:

    • Estimating clinical probability before diagnostic tests enhances DVT diagnostic accuracy.
    • In low-probability patients (DVT prevalence <5%), a negative D-dimer result can reliably exclude DVT, potentially obviating ultrasound.
    • For patients with high clinical suspicion, D-dimer results should not solely guide clinical decisions due to lower specificity.