Evaluation of the usefulness of a D dimer test in combination with clinical pretest probability score in the prediction and exclusion of Venous Thromboembolism by medical residents

Thrombosis Journal

Khalid Maghrabi⁷  Mohannad Hawari²  Ahmed Nasmi²  Mahmoud Moawad²  Naser ElKum³  Adher AlSayed⁴  Hazzaa AlZahrani⁴  Fawaz Skaff⁶  Mohamed Zeitouni²  Bandar ALAmro²  Dania AlKhafaji²  Saad AlGhamdi²  Nahlah AlGhasham¹  Tarek Owaidah⁵ 

[1] Department of Pathology, College of medicine, Qassim University, Buraidah, Saudi Arabia;Department of Medicine, King Faisal Specialist Hospital and Research Center, Alfaisal university, Riyadh, Saudi Arabia;Department of Biostatistics, Sidra Medical and Research Center, Doha, Qatar;King Faisal Cancer Centre, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia;Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia;Department of Radiology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia;Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia

关键词: Pulmonary embolism;    Deep vein thrombosis;    Clinical probability;    d-dimer;   

Others  :  1135346
DOI  :  10.1186/s12959-014-0028-7

 received in 2014-07-22, accepted in 2014-11-03,  发布年份 2014

【 摘 要 】

Introduction

Venous thromboembolism (VTE) requires urgent diagnosis and treatment to avoid related complications. Clinical presentations of VTE are nonspecific and require definitive confirmation by imaging techniques. A clinical pretest probability (PTP) score system helps predict VTE and reduces the need for costly imaging studies. D-dimer (DD) assay has been used to screen patients for VTE and has shown to be specific for VTE. The combined use of PTP and DD assay may improve exclusion of VTE and safely avoid imaging studies.

Materials and methods

We prospectively used the Wells PTP score and a DD test to evaluate 230 consecutive patients who presented with VTE symptoms. The receiver operating characteristic curve was used to identify a new DD cutoff value, which was applied to VTE diagnosis and compared with the upper limit of locally established reference range for prediction of thrombosis alone and in combination with the clinical PTP score.

Results

We evaluated 118 patients with VTE symptoms fulfilling the inclusion criteria, 64 (54.2%) with clinically suspected deep vein thrombosis (DVT) and 54 (45.8%) with symptoms of pulmonary embolism (PE). The PTP was low in 28 (43.8%) and moderate/high in 36 (56.25%) of the suspected DVT patients, and low in 29 (53.7%) and moderate/high in 25 (46.3%) of the suspected PE patients. Eighteen cases were confirmed by imaging studies: 9 DVT and 9 PE. The agreement between confirmed cases and PTP was significant with PE but not DVT. The negative predictive value for both DVT and PE with current DD cutoff value of <250 μg/L DDU was 100%, whereas with the calculated cutoff the NPV was 88%.

Conclusions

We confirm that PTP score is valuable tool for medical residents to improve the detection accuracy of VTE, especially for PE. The DD cutoff value of 250 μg/L FEU is ideal for excluding most cases of low PTP; however, the calculated cutoff was less specific for the exclusion of VTE.

【 授权许可】

   
2014 Owaidah et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

【 参考文献 】

• [1]Wells PS, Anderson DR, Rodger M, Forgie M, Kearon C, Dreyer J, Kovacs G, Mitchell M, Lewandowski B, Kovacs MJ: Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. N Engl J Med 2003, 349:1227-1235.
• [2]Wells PS: Integrated strategies for the diagnosis of venous thromboembolism. J Thromb Haemost 2007, 5(Suppl 1):41-50.
• [3]Wells PS, Anderson DR, Bormanis J, Guy F, Mitchell M, Gray L, Clement C, Robinson KS, Lewandowski B: Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet 1997, 350:1795-1798.
• [4]Keeling DM, Mackie IJ, Moody A, Watson HG: Haemostasis and thrombosis task force of the British committee for standards in haematology. The diagnosis of deep vein thrombosis in symptomatic outpatients and the potential for clinical assessment and D-dimer assays to reduce the need for diagnostic imaging. Br J Haematol 2004, 124:15-25.
• [5]Gardiner C, Pennaneac’h C, Walford C, Machin SJ, Mackie IJ: An evaluation of rapid D-dimer assays for the exclusion of deep vein thrombosis. Br J Haematol 2005, 128:842-848.
• [6]Wells PS, Anderson DR, Rodger M, Stiell I, Dreyer JF, Barnes D, Forgie M, Kovacs G, Ward J, Kovacs MJ: Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and D-dimer. Ann Intern Med 2001, 135:98-107.
• [7]Kelly J, Rudd A, Lewis RR, Hunt BJ: Plasma D-dimers in the diagnosis of venous thromboembolism. Arch Intern Med 2002, 162:747-756.
• [8]Stein PD, Hull RD, Patel KC, Olson RE, Ghali WA, Brant R, Biel RK, Bharadia V, Kalra NK: D-dimer for the exclusion of acute venous thrombosis and pulmonary embolism: a systematic review. Ann Intern Med 2004, 140:589-602.
• [9]Wells PS, Brill-Edwards P, Stevens P, Panju A, Patel A, Douketis J, Massicotte MP, Hirsh J, Weitz JI, Kearon C: A novel and rapid whole-blood assay for D-dimer in patients with clinically suspected deep vein thrombosis. Circulation 1995, 91:2184-2187.
• [10]Freyburger G, Trillaud H, Labrouche S, Gauthier P, Javorschi S, Bernard P, Grenier N: D-dimer strategy in thrombosis exclusion—a gold standard study in 100 patients suspected of deep venous thrombosis or pulmonary embolism: 8 DD methods compared. Thromb Haemost 1998, 79:32-37.
• [11]Brill-Edwards P, Lee A: D-dimer testing in the diagnosis of acute venous thromboembolism. Thromb Haemost 1999, 82:688-694.
• [12]Adam SS, Key NS, Greenberg CS: D-dimer antigen: current concepts and future prospects. Blood 2009, 113:2878-2887. doi:10.1182/blood-2008-06-165845. Epub 2008 Nov 13. Review
• [13]Perveen S, Unwin D, Shetty AL: Point of care D-dimer testing in the emergency department: a bioequivalence study. Ann Lab Med 2013, 33:34-38. doi:10.3343/alm.2013.33.1.34. Epub 2012 Dec 17
• [14]Peter FF, Victor FT: The evaluation of suspected pulmonary embolism. N Engl J Med 2003, 349:1247-1256.
• [15]Wells PS, Anderson DR, Rodger M, Ginsberg JS, Kearon C, Gent M, Turpie AG, Bormanis J, Weitz J, Chamberlain M, Bowie D, Barnes D, Hirsh J: Derivation of a simple clinical model to categorize patients, probability of pulmonary embolism: increasing the models, utility with the SimpliRED D-dimer. Thromb Haemost 2000, 83:416-420.
• [16]Kelly L, Hunt BJ: The utility of pretest probability in patient with clinically suspected thromboembolism. J Thromb Haemost 2003, 1:1888-1896.
• [17]van der Velde EF, Toll DB, Ten Cate-Hoek AJ, Oudega R, Stoffers HE, Bossuyt PM, Büller HR, Prins MH, Hoes AW, Moons KG, van Weert HC: Comparing the diagnostic performance of 2 clinical decision rules to rule out deep vein thrombosis in primary care patients. Ann Fam Med 2011, 9:31-36.
• [18]van Es J, Mos I, Douma R, Erkens P, Durian M, Nizet T, van Houten A, Hofstee H, ten Cate H, Ullmann E, Büller H, Huisman M, Kamphuisen PW: The combination of four different clinical decision rules and an age-adjusted D-dimer cut-off increase the number of patients in whom acute pulmonary embolism can safely be excluded. Thromb Haemost 2012, 107:167-171.
• [19]Musset D, Parent F, Meyer G, Maître S, Girard P, Leroyer C, Revel MP, Carette MF, Laurent M, Charbonnier B, Laurent F, Mal H, Nonent M, Lancar R, Grenier P, Simonneau G: Diagnostic strategy for patients with suspected pulmonary embolism: a prospective multicenter outcome study. Lancet 2002, 360(9349):1914-1920.
• [20]Perrier A, Miron MJ, Desmarais S, de Moerloose P, Slosman D, Didier D, Unger PF, Junod A, Patenaude JV, Bounameaux H: Using clinical evaluation and lung scan to rule out suspected pulmonary embolism: is it a valid option in patients with normal results of lower-limb venous compression ultrasonography? Arch Intern Med 2000, 160:512-516.
• [21]Sanson BJ, Lijmer JG, Mac Gillavry MR, Turkstra F, Prins MH, Büller HR: Comparison of a clinical probability estimate and two clinical models in patients with suspected pulmonary embolism. ANTELOPE-Study Group. Thromb Haemost 2000, 83(2):199-203.
• [22]Kelly J, Hunt BJ: The utility of pretest probability assessment in patients with clinically suspected venous thromboembolism. J Thromb Haemost 2003, 1:1888-1896.
• [23]Kline JA, Courtney DM, Than MP, Hogg K, Miller CD, Johnson CL, Smithline HA: Accuracy of very low pretest probability estimates for pulmonary embolism using the method of attribute matching compared with the Wells score. Acad Emerg Med 2010, 18(2):133-141.
• [24]Biss TT, Brandão LR, Kahr WH, Chan AK, Williams S: Clinical probability score and D-dimer estimation lack utility in the diagnosis of childhood pulmonary embolism. J Thromb Haemost 2009, 7:1633-1638.
• [25]Luxembourg B, Schwonberg J, Hecking C, Schindewolf M, Zgouras D, Lehmeyer S, Lindhoff-Last E: Performance of five D-dimer assays for the exclusion of symptomatic distal leg vein thrombosis. Thromb Haemost 2012, 107:369-378. doi:10.1160/TH11-07-0511. Epub 2012 Jan 11
• [26]Prisco D, Grifoni E: The role of D-dimer testing in patients with suspected venous thromboembolism. Semin Thromb Hemost 2009, 35(1):50-59.
• [27]Dempfle CE, Zips S, Ergül H, Heene DL: Fibrin assay comparative trial study group. The Fibrin Assay Comparison Trial (FACT): evaluation of 23 quantitative D-dimer assays as basis for the development of D-dimer calibrators. FACT study group. Thromb Haemost 2001, 85:671-678.
• [28]Van der Graaf F, van den Borne H, van der Kolk M, de Wild PJ, Janssen GW, van Uum SH: Exclusion of deep venous thrombosis with D-dimer testing - Comparison of 13 D-dimer methods in 99 outpatients suspected of deep venous thrombosis using venography as reference standard. Thromb Haemost 2000, 83:191-198.
• [29]De Moerloose P, Palareti G, Aguilar C, Legnani C, Reber G, Peetz D: A multicenter evaluation of a new quantitative highly sensitive D-dimer assay for exclusion of venous thromboembolism. Thromb Haemost 2008, 100:505-512.
• [30]Yamaki T, Nozaki M, Sakurai H, Kikuchi Y, Soejima K, Kono T, Hamahata A, Kim K: Combined use of pretest clinical probability score and latex agglutination D-dimer testing for excluding acute deep vein thrombosis. J Vasc Surg 2009, 50:1099-1105.
• [31]Penaloza A, Laureys M, Wautrecht JC, Lheureux P, Motte S: Accuracy and safety of pretest probability assessment of deep vein thrombosis by physicians in training using the explicit Wells clinical model. J Thromb Haemost 2006, 4:278-281.
• [32]Kearon C, Ginsberg JS, Douketis J, Crowther M, Brill-Edwards P, Weitz JI, Hirsh J: Management of suspected deep venous thrombosis in outpatients by using clinical assessment and D-dimer testing. Ann Intern Med 2001, 135:108-111.
• [33]Janes S, Ashford N: Use of a simplified clinical scoring system and D-dimer testing can reduce the requirement for radiology in the exclusion of deep vein thrombosis by over 20%. Br J Haematol 2001, 112:1079-1082.