BMJ 1998;317:1037-1040 ( 17 October )

Papers

D-dimer testing as an adjunct to ultrasonography in patients with clinically suspected deep vein thrombosis: prospective cohort study

Enrico Bernardi, research fellow, a Paolo Prandoni, senior researcher, a Anthonie W A Lensing, senior researcher, i Giancarlo Agnelli, senior researcher, c Giuliana Guazzaloca, senior researcher, d Gianluigi Scannapieco, senior researcher, e Franco Piovella, senior researcher, f Fabio Verlato, senior researcher, b Cristina Tomasi, senior researcher, g Marco Moia, senior researcher, h Luigi Scarano, research fellow, a Antonio Girolami, senior researcher, a on behalf of the Multicentre Italian D-dimer Ultrasound Study Investigators Group.

a Istituto di Semeiotica Medica, University of Padua, 35128 Padua, Italy, b Azienda Ospedaliera di Padova Servizio di Angiologia, University of Padua, c Istituto di Medicina Interna e Vascolare, Azienda Ospedaliera di Perugia, Policlinico Monteluce, 06122 Perugia, Italy, d Divisione di Angiologia, Azienda Ospedaliera S Orsola Malpighi, 40138 Bologna, Italy, e I Divisione Medica, Ospedale Civile di Venezia, Venice 30100, Italy, f Medicina Interna e Oncologia Medica, Policlinico San Matteo, Pavia Policlinico, Piazzale Golgi 2, 27100 Pavia, Italy, g I Medicina, Ospedale di Bolzano, 39100 Bolzano, Italy, h Ospedale Maggiore e Università di Milano, 20122 Milan, Italy, i Centre for Vascular Medicine, Academic Medical Centre, H-2, 1105 AZ Amsterdam, Netherlands

Correspondence to: Dr Lensing a.w.lensing{at}amc.uva.nl

Objective To investigate the efficacy of using a rapid plasma D-dimer test as an adjunct to compression ultrasound for diagnosing clinically suspected deep vein thrombosis.
Design D-dimer concentrations were determined in all patients with a normal ultrasonogram at presentation. Repeat ultrasonography was performed 1 week later only in patients with abnormal D-dimer test results.
Main outcome measure Patients with normal ultrasonograms were not treated with anticoagulants and were followed for 3 months for thromboembolic complications.
Setting University research and affiliated centres.
Subjects 946 patients with clinically suspected deep vein thrombosis.
Results Ultrasonograms were abnormal at presentation in 260 (27.5%) patients. Of the remaining 686 patients tested for D-dimer, 88 (12.8%) had abnormal concentrations. During follow up venous thromboembolic complications occurred in one of the 598 patients who were not treated with anticoagulants and who had an initial normal ultrasonogram and D-dimer concentration, whereas thromboembolic complications occurred in two of the 83 untreated patients who had abnormal D-dimer concentrations but a normal repeat ultrasonogram. The cumulative incidence of venous thromboembolic complications during follow up was 0.4% (95% confidence interval 0% to 0.9%). The rapid plasma D-dimer test used as an adjunct to compression ultrasonography resulted in a reduction in the mean number of repeat ultrasound examinations and additional hospital visits from 0.7 to 0.1 per patient.
Conclusions Testing for D-dimer as an adjunct to a normal baseline ultrasound examination decreased the number of subsequent ultrasound examinations considerably without any increased risk of venous thromboembolic complications in patients not receiving anticoagulants. The use of ultrasound and testing for D-dimer enabled treatment decisions to be made at the time of presentation in most patients.

Key messages

  • Patients with clinically suspected deep vein thrombosis who have a normal baseline ultrasonogram have a small but clinically important risk of subsequent venous thromboembolic complications

  • Repeat ultrasonography is not indicated in patients who have both a normal initial ultrasonogram and D-dimer test result, but should be performed at 1 week in those who have a normal initial ultrasonogram but an abnormal D-dimer test result

  • D-dimer testing as an adjunct to a normal baseline ultrasonogram reduced the number of repeat ultrasound examinations considerably without an increased risk of venous thromboembolic complications in patients not receiving anticoagulants

  • The ultrasonography and D-dimer testing strategy allowed treatment decisions to be made at the time of presentation in most patients



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Rapid Responses:

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When to test for D Dimers
Kakil Ibrahim Rasul
bmj.com, 19 Oct 1998 [Full text]
Outpatient testing for deep vein thrombosis
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