Combined use of rapid D-Dimer testing and estimation of clinical probability in the diagnosis of deep vein thrombosis: systematic review. BMJ

Division of General Medicine, University of California at Davis, Patient Support Services Building, Suite 2400, Sacramento, California 95817, USA.
BMJ (online) (Impact Factor: 17.45). 11/2004; 329(7470):821. DOI: 10.1136/bmj.38226.719803.EB
Source: PubMed


To summarise the evidence supporting the use of rapid d-dimer testing combined with estimation of clinical probability to exclude the diagnosis of deep venous thrombosis among outpatients.
Medline (June 1993 to December 2003), the Database of Abstracts and Reviews (DARE), and reference lists of studies in English.
We selected 12 studies from among 84 reviewed. The selected studies included more than 5000 patients and used a rapid D-dimer assay and explicit criteria to classify cases as having low, intermediate, or high clinical probability of deep vein thrombosis of the lower extremity among consecutive outpatients.
Diagnosis required objective confirmation, and untreated patients had to have at least three months of follow up. The outcome was objectively documented venous thromboembolism. Two authors independently abstracted data by using a data collection form.
When the less sensitive SimpliRED D-dimer assay was used the three month incidence of venous thromboembolism was 0.5% (95% confidence interval 0.07% to 1.1%) among patients with a low clinical probability of deep vein thrombosis and normal D-dimer concentrations. When a highly sensitive D-dimer assay was used, the three month incidence of venous thromboembolism was 0.4% (0.04% to 1.1%) among outpatients with low or moderate clinical probability of deep vein thrombosis and a normal D-dimer concentration.
The combination of low clinical probability for deep vein thrombosis and a normal result from the SimpliRED D-dimer test safely excludes a diagnosis of acute venous thrombosis A normal result from a highly sensitive D-dimer test effectively rules out deep vein thrombosis among patients classified as having either low or moderate clinical probability of deep vein thrombosis.

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Available from: Richard L Kravitz, Aug 18, 2014
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    • "It has been suggested that the D-dimer test may be useful in early detection of DVT. Many studies of non-traumatized patients reported that the plasma D-dimer assay is indicative of DVT [19-21]. However, the value of D-dimer in DVT after TKA remains controversial. "
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    ABSTRACT: Background Deep venous thrombosis (DVT), which is often associated with pulmonary embolism (PE), is a serious complication after total knee arthroplasty (TKA). In the present study, we examined the overall thrombotic and thrombolytic status using Global Thrombosis Test (GTT) in non-anticoagulated blood of patients undergoing TKA to develop the predictable marker for the incidence of DVT. Methods DVT was diagnosed using doppler ultrasonography a day after the surgery in 31 patients with osteoarthritis (n = 24), rheumatoid arthritis (n = 6) and ankylosing spondylitis (n = 1) by the well-trained operator. We measured overall thrombotic and thrombolytic status using GTT and other biomarkers, which is associated with blood coagulation and fibrinolysis, before and immediately after the surgery. Results Newly-generated DVT during the operation was detected in 11 of 31 patients (35.4%) 1 day after TKA. There were no differences in markers of coagulation (PT and APTT), platelet activity (platelet aggregation-induced by ADP and collagen) and fibrinolysis (FDP and D-dimer) between non-DVT and DVT group both before and after the surgery. Both Pre- and Post-operative GTT-occlusion times (OT), an index of platelet reactivity, were tended to be shorter, but not significant, in DVT group compared with non-DVT group. Pre-operative GTT-lysis time (LT), an index of thrombolytic activity, was significantly shorter in DVT group compared with non-DVT group, while there were no differences in post-operative value of this index between DVT group and non-DVT group, suggesting overall thrombolytic activity was enhanced in DVT group before surgery. Conclusions Our data suggest that enhancement of pre-operative thrombolytic activity assessed by GTT may be a predictable marker for the incidence of DVT after TKA.
    Thrombosis Journal 05/2014; 12(1):11. DOI:10.1186/1477-9560-12-11 · 1.31 Impact Factor
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    • "A combination of pretest probability with a D-dimer test has been proved to be effective [16, 17]. The clinical probability score using patients' clinical signs and symptoms as described by Wells et al. is the most widely used. "
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    ABSTRACT: Aims. Colour doppler ultrasonography (CDUS) is widely used in the diagnosis of deep venous thrombosis (DVT); however, the number of scans positive for above knee DVT is low. The present study evaluates the reliability of the D-dimer test combined with a clinical probability score (Wells score) in ruling out an above knee DVT and identifying patients who do not need a CDUS. Materials and Method. This study is a retrospective audit and reaudit of a total of 816 outpatients presenting with suspected lower limb DVT from March 2009 to March 2010 and from September 2011 to February 2012. Following the initial audit, a revised clinical diagnostic pathway was implemented. Results. In our initial audit, seven patients (4.9%) with a negative D-dimer and a low Wells score had a DVT. On review, all seven had a risk factor identified that was not included in the Wells score. No patient with negative D-dimer and low Wells score with no extra clinical risk factor had a DVT on CDUS (negative predictive value 100%). A reaudit confirmed adherence to our revised clinical diagnostic pathway. Conclusions. A negative D-dimer together with a low Wells score and no risk factors effectively excludes a lower limb DVT and an ultrasound is unnecessary in these patients.
    03/2014; 2014(1):519875. DOI:10.1155/2014/519875
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    • "anisms of vascular injury , underlying hereditary disorders , and proposed risk factors adds a body of new information for consideration . This knowledge may direct both the clinical reasoning process and future research into pre - treatment cervical risk assessment . This may direct research toward the model used in suspected thrombo - embolism ( Fancher et al . , 2004 ) , a condition which mirrors VA and ICA dissection in its complex patho - genesis and level of difficulty to diagnose or predict accurately ."
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    ABSTRACT: An abundance of literature has attempted to provide insight into the association between cervical spine manual therapy and cervical artery dysfunction leading to cerebral ischaemic events. Additionally, specific guidelines have been developed to assist manual therapists in clinical decision-making. Despite this, there remains a lack of agreement within the profession on many issues. This paper presents a critical, re-examination of relevant literature with the aim of providing a contemporary, evidence-informed review of key areas regarding the neurovascular risks of cervical spine manual therapy. From a consideration of case reviews and surveys, haemodynamic principles, and blood flow studies, the authors suggest that: (1) it is currently impossible to meaningfully estimate the size of the risk of post-treatment complications; (2) existing testing procedures have limited clinical utility; and (3) a consideration of the association between pre-existing vascular risk factors, combined with a system based approach to cervical arterial haemodynamics (inclusive of the carotid system), may assist manual therapists in identifying at-risk patients.
    Manual therapy 09/2008; 13(4):278-88. DOI:10.1016/j.math.2007.10.006 · 1.71 Impact Factor
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