Screening for Deep Vein Thrombosis and Pulmonary Embolism in Outpatients with Suspected DVT or PE by the Sequential Use of Clinical Score: A Sensitive Quantitative D-Dimer Test and Noninvasive Diagnostic Tools

Jan Jacques Michiels; Alain Gadisseur; Marc van der Planken; Wilfried Schroyens; Marianne De Maeseneer; Jan T. Hermsen; Paul H. Trienekens; Henk Hoogsteden; Peter M. T. Pattynama

doi:10.1055/s-2005-922480

Seminars in Vascular Medicine, Table of Contents

Semin Vasc Med 2005; 05(4): 351-364
DOI: 10.1055/s-2005-922480

Screening for Deep Vein Thrombosis and Pulmonary Embolism in Outpatients with Suspected DVT or PE by the Sequential Use of Clinical Score: A Sensitive Quantitative D-Dimer Test and Noninvasive Diagnostic Tools

Jan Jacques Michiels¹ ^, ⁵ , Alain Gadisseur¹ , Marc van der Planken² , Wilfried Schroyens¹ , Marianne De Maeseneer³ , Jan T. Hermsen⁴ , Paul H. Trienekens⁴ , Henk Hoogsteden⁶ , Peter M.T Pattynama⁷

¹Hemostasis and Thrombosis Research, Department of Hematology, University Hospital Antwerp, Antwerp, Belgium
²Hemostasis Laboratory Department of Clinical Biology, University Hospital Antwerp, Antwerp, Belgium
³Vascular Laboratory, Department of Vascular Surgery, University Hospital Antwerp, Antwerp, Belgium
⁴Medical Diagnostic Center Rijnmond, Rotterdam, The Netherlands
⁵Goodheart Institute, Hematology, Hemostasis & Thrombosis Science Center, Rotterdam, The Netherlands
⁶Department of Pulmonary Diseases, Erasmus Medical Center, Rotterdam, The Netherlands
⁷Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands

Abstract

ABSTRACT

The requirement for a safe diagnostic strategy should be based on an overall posttest incidence of venous thromboembolism (VTE) of less than 1% during 3-month follow-up. The negative predictive value (NPV) during 3 months of follow-up is 98.1 to 99% after a normal venogram, 97 to 98% after a normal compression ultrasonography (CUS), and > 99% after serial CUS testing. Serial CUS testing is safe but 100 CUS must be repeated to find one or two CUS positive for deep vein thrombosis (DVT), which is not cost-effective and indicates the need to improve the diagnostic workup of DVT by the use of clinical score assessment and D-dimer testing. The NPV varies from 97.6 to 99.4% for low clinical score followed by a negative SimpiRED test, indicating the need for a first CUS. The NPV is 98.4 to 99.3% for a normal rapid enzyme-linked immunosorbent assay (ELISA) VIDAS D-dimer test result (< 500 ng/mL) irrespective of clinical score. The NPV is more than 99% for a negative CUS followed by either a negative SimpiRED test or an ELISA VIDAS test result of < 1000 ng/mL without the need to repeat a second CUS within 1 week. The sequential use of a sensitive, rapid ELISA D-dimer and clinical score assessment will safely reduce the need for CUS testing by 40 to 60%. Large prospective outcome studies demonstrate that with one negative examination with complete duplex color ultrasonography (CCUS) of the proximal and distal veins of the affected leg with suspected DVT, it is safe to withhold anticoagulant treatment, with a negative predictive value of 99.5%. This may indicates that CCUS is equal to serial CUS or the combined use of clinical score, D-dimer testing, and CUS. Pulmonary angiography is the gold standard for segmental pulmonary embolism (PE) but not for subsegmental PE. A normal perfusion lung scan and a normal rapid ELISA VIDAS D-dimer test safely excludes PE. Helical spiral computed tomography (CT) detects all clinically relevant PE and a large number of alternative diagnoses in symptomatic patients with suspected PE and can replace both the ventilation perfusion scan and pulmonary angiography to safely rule in PE and to rule out PE with an NPV of > 99%. The combination of clinical assessment, a rapid ELISA VIDAS D-dimer, followed by CUS will reduce the need for helical spiral CT by 40 to 50%.

KEYWORDS

Deep vein thrombosis - D-dimer assay - compression ultrasonography - clinical score - pulmonary embolism - venous thromboembolism - ventilation perfusion scan - spiral CT

Full Text

References

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Jan Jacques MichielsM.D. Ph.D.

Goodheart Institute & Foundation, Hematology Hemostasis Thrombosis Science Center

Erasmus Tower, Veenmos 13, 3069 AT Rotterdam, The Netherlands