D-dimer Assays for the Exclusion of Venous Thromboembolism: Which Test for which Diagnostic Strategy?

Summary

D-dimer measurement has proven to be very useful to rule out deep vein thrombosis (DVT) and pulmonary embolism (PE) in symptomatic outpatients (1). The problem faced by many physicians is the choice and the position of the D-Dimer tests in the diagnostic work-up of patients suspected of venous thromboembolism (VTE). In the last and present issues of Thrombosis and Haemostasis, two very interesting studies addressing these questions were published.

In the first paper (2), de Groot and colleagues evaluated, in a management study, the clinical utility of incorporating the SimpliRED assay in the diagnostic work-up of patients with suspected PE. Of the 245 study subjects, 59 did not receive anticoagulant therapy on the basis of a nondiagnostic lung scan, a normal D-dimer and a non-high clinical probability of PE. In the follow-up, only one patient experienced a thromboembolic event (which can be compared with the 6% of subsequent rate of VTE in the follow-up of the 54 patients with a normal perfusion lung scan). However, if SimpliRED D-dimer would have been used alone as a first exclusion step, 6 of 61 patients with proven PE had been missed (9.8%, 95% CI 3.7-20.2).

• References

• 1 Bounameaux H, de Moerloose P, Perrier A, Miron M-J. D-dimer testing in suspected venous thromboembolism: an update. Q J Med 1997; 90: 437-42.
• 2 de Groot MR, van Marwijk MKooy, Pouwels JGJ, Engelage AH, Kuipers BF, Büller HR. The use of a rapid D-dimer blood test in the diagnostic work-up for pulmonary embolism. Thromb Haemost 1999; 82: 1588-92.
• 3 van der Graaf F, van der Borne H, van der Kolk M, de Wild PJ, Janssen GWT, van Uum SHM. Exclusion of deep vein 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: 191-8.
• 4 Perrier A, Bounameaux H, Morabia A, de Moerloose P, Slosman D, Didier D, Unger PF, Junod A. Diagnosis of pulmonary embolism by a decision analysis-based strategy including clinical probability, D-dimer levels, and ultrasonography: a management study. Arch Intern Med 1996; 156: 531-6.
• 5 Ginsberg JS, Kearon C, Douketis J. et al The use of D-dimer testing and impedance plethysmographic examination in patients with clinical indications of deep vein thrombosis. Arch Intern Med 1997; 157: 1077-81.
• 6 Bernardi E, Prandoni P, Lensing AWA. et al D-dimer testing as an adjunct to ultrasonography in patients with clinically suspected deep vein thrombosis: prospective cohort study. BMJ 1998; 317: 1037-40.
• 7 Perrier A, Desmarais S, Miron M-J, de Moerloose P, Lepage R, Slosman D, Didier D, Unger PF, Patenaude JV, Bounameaux H. Noninvasive diagnosis of pulmonary venous thromboembolism in outpatient including clinical probability, D-dimer and ultrasonography. Lancet 1999; 353: 190-5.
• 8 Cogo A, Lensing AWA, Koopman MMW. et al Compression ultrasonography for diagnostic management of patients with clinically suspected deep vein thrombosis: prospective cohort study. BMJ 1998; 316: 17-20.
• 9 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: 1795-8.
• 10 Miron M-J, Perrier A, Bounameaux H, de Moerloose P, Slosman D, Didier D, Junod A. Contribution of noninvasive evaluation to the diagnosis of pulmonary embolism in hospitalized patients. Eur Respir J 1999; 13: 1365-70.
• 11 Mauron T, Baumgartner I, Z’Brun A, Desmarmels FBiasiutti, Redondo M, Do DD, Lämmle B, Wuillemin W. SimpliRED D-dimer assay: comparability of capillary and citrated venous whole blood, between-assay variability, and performance of the test for exclusion of deep vein thrombosis in symptomatic outpatients. Thromb Haemost 1998; 79: 1217-9.