Impact of gender on the clinical presentation and diagnosis of deep-vein thrombosis

Rupert M. Bauersachs; Hanno Riess; Viola Hach-Wunderle; Horst Gerlach; Heike Carnarius; Sonja Eberle; Eberhard Rabe; Sebastian M. Schellong

doi:10.1160/TH09-10-0705

Thrombosis and Haemostasis, Table of Contents

Thromb Haemost 2010; 103(04): 710-717
DOI: 10.1160/TH09-10-0705

Blood Coagulation, Fibrinolysis and Cellular Haemostasis

Schattauer GmbH

Impact of gender on the clinical presentation and diagnosis of deep-vein thrombosis

Rupert M. Bauersachs

¹Department of Vascular Medicine, Darmstadt Municipal Hospital, Darmstadt, Germany

,

Hanno Riess

²Hematology and Oncology Department, Charité University Hospital, Berlin, Germany

,

Viola Hach-Wunderle

³Angiology Department, Northwest Hospital, Frankfurt am Main, Germany

,

Horst Gerlach

⁴Phlebology Unit, General Medical Centre, Mannheim, Germany

,

Heike Carnarius

⁵GlaxoSmithKline GmbH & Co KG, Hamburg, Germany

,

Sonja Eberle

⁶GlaxoSmithKline GmbH & Co KG, Munich, Germany

,

Eberhard Rabe

⁷Dermatology Department, Bonn University Hospital, Bonn, Germany

,

Sebastian M. Schellong

⁸Medical Department II, Dresden Friedrichstadt Hospital, Dresden, Germany; Under the auspices of the Deutsche Gesellschaft für Angiologie, Deutsche Gesellschaft für Phlebologie, Gesellschaft für Thrombose- und Hämostaseforschung

› Author Affiliations

Abstract

Summary

It is uncertain whether gender influences the clinical presentation of deep-vein thrombosis (DVT) and the discriminative value of the Wells diagnostic pretest probability score. The aim of the study was to determine whether gender impacts the clinical presentation and diagnosis of DVT. The study analysed a cohort of 4,976 outpatients with clinically suspected DVT of the leg prospectively recruited by 326 vascular medicine physicians in the German ambulatory care sector between October and December 2005. The diagnosis of DVT was based on compression ultrasonography in 96% of patients. Among 4,777 patients who had a diagnostic work-up for DVT there were more women (n=2,998) than men (n=1,779). However, the prevalence of confirmed DVT was 37.0% (658/1779) in men vs. 24.3% (730/2,998) in women (p<0.001). Among patients with confirmed DVT, proximal DVT was more common in men (59.6% vs. 44.5% in women, p<0.001). Swelling of the leg, pitting oedema and dilated superficial veins were more frequently reported by men (p<0.001). The percentage of patients with a high probability Wells clinical pretest score was higher in men than in women (67.0% vs. 57.0%, p<0.001). However, overall, the score equally discriminated risk groups for DVT in both sexes. In conclusion, women were more frequently referred for a diagnostic work-up for DVT than men, but the prevalence of DVT was higher in men and their thrombotic events were more severe. Nevertheless, the Wells clinical pretest probability score correctly identified low- and high-risk groups in both genders.

Keywords

Clinical presentation - deep-vein thrombosis - diagnosis - gender - Wells score

Full Text

References

References
1 Nordstrom M, Lindblad B, Bergqvist D. et al. A prospective study of the incidence of deep-vein thrombosis within a defined urban population. J Intern Med 1992; 232: 155-160.
2 White RH, Dager WE, Zhou H. et al. Racial and gender differences in the incidence of recurrent venous thromboembolism. Thromb Haemost 2006; 96: 267-273.
3 Anderson Jr. FA, Wheeler HB, Goldberg RJ. et al. A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism. The Worcester DVT Study. Arch Intern Med 1991; 151: 933-938.
4 Cogo A, Bernardi E, Prandoni P. et al. Acquired risk factors for deep-vein thrombosis in symptomatic outpatients. Arch Intern Med 1994; 154: 164-168.
5 Silverstein MD, Heit JA, Mohr DN. et al. Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based study. Arch Intern Med 1998; 158: 585-593.
6 White RH, Gettner S, Newman JM. et al. Predictors of rehospitalization for symptomatic venous thromboembolism after total hip arthroplasty. N Engl J Med 2000; 343: 1758-1764.
7 Oger E. Incidence of venous thromboembolism: a community-based study in Western France. EPI-GETBP Study Group. Groupe d‘Etude de la Thrombose de Bretagne Occidentale. Thromb Haemost 2000; 83: 657-660.
8 Tormene D, Barbar S, Perlati M. et al. Sex-related type of venous thromboembolism in patients with and without thrombophilia. Thromb Haemost 2009; 102: 177-178.
9 Tsai AW, Cushman M, Rosamond WD. et al. Cardiovascular risk factors and venous thromboembolism incidence: the longitudinal investigation of thromboembolism etiology. Arch Intern Med 2002; 162: 1182-1189.
10 Fowkes FJ, Price JF, Fowkes FG. Incidence of diagnosed deep vein thrombosis in the general population: systematic review. Eur J Vasc Endovasc Surg 2003; 25: 1-5.
11 Andreou ER, Koru-Sengul T, Linkins L. et al. Differences in clinical presentation of deep vein thrombosis in men and women. J Thromb Haemost 2008; 06: 1713-1719.
12 Schellong S, Gerlach H, Hach-Wunderle V. et al. Diagnosis of deep-vein thrombosis: Adherence to guidelines and outcomes in real world health care. Thromb Haemost 2009; 102: 1234-1240.
13 Wells PS, Hirsh J, Anderson DR. et al. Accuracy of clinical assessment of deep-vein thrombosis. Lancet 1995; 345: 1326-1330.
14 Wells PS, Anderson DR, Rodger M. et al. Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. N Engl J Med 2003; 349: 1227-1235.
15 Kahn SR, Joseph L, Abenhaim L. et al. Clinical prediction of deep vein thrombosis in patients with leg symptoms. Thromb Haemost 1999; 81: 353-357.
16 Tick LW, Ton E, van Voorthuizen T. et al. Practical diagnostic management of patients with clinically suspected deep vein thrombosis by clinical probability test, compression ultrasonography, and D-dimer test. Am J Med 2002; 113: 630-635.
17 Anderson DR, Kovacs MJ, Kovacs G. et al. Combined use of clinical assessment and d-dimer to improve the management of patients presenting to the emergency department with suspected deep vein thrombosis (the EDITED Study). J Thromb Haemost 2003; 01: 645-651.
18 Oudega R, Hoes AW, Moons KG. The Wells rule does not adequately rule out deep venous thrombosis in primary care patients. Ann Intern Med 2005; 143: 100-107.
19 Oudega R, Moons KG, Hoes AW. Ruling out deep venous thrombosis in primary care. A simple diagnostic algorithm including D-dimer testing. Thromb Haemost 2005; 94: 200-205.
20 Wells PS, Anderson DR, Bormanis J. et al. Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet 1997; 350: 1795-1798.
21 Beebe HG, Scissons RP, Salles-Cunha SX. et al. Gender bias in use of venous ultra-sonography for diagnosis of deep venous thrombosis. J Vasc Surg 1995; 22: 538-542.
22 Oudega R, Moons KG, Hoes AW. Limited value of patient history and physical examination in diagnosing deep vein thrombosis in primary care. Fam Pract 2005; 22: 86-91.
23 Galanaud JP, Sevestre-Pietri MA, Bosson JL. et al. Comparative study on risk factors and early outcome of symptomatic distal versus proximal deep vein thrombosis: results from the OPTIMEV study. Thromb Haemost 2009; 102: 493-500.
24 McRae S, Tran H, Schulman S. et al. Effect of patient’s sex on risk of recurrent venous thromboembolism: a meta-analysis. Lancet 2006; 368: 371-378.
25 Wille-Jorgensen P, Jorgensen T, Andersen M. et al. Postphlebitic syndrome and general surgery: an epidemiologic investigation. Angiology 1991; 42: 397-403.
26 Rabe E, Pannier-Fischer F, Bromen K. et al. Bonner Venenstudie der Deutschen Gesellschaft für Phlebologie. Phlebologie 2003; 32: 1-14.
27 Federal Statistical Office.. The Information System of the Federal Health Monitoring: Subjective state of health and complaints. Verlag Metzler-Poeschel; Stuttgart: 1998
28 Wells PS, Owen C, Doucette S. et al. Does this patient have deep vein thrombosis?. J Am Med Assoc 2006; 295: 199-207.
29 Sevestre MA, Labarere J, Casez P. et al. Accuracy of complete compression ultra-sound in ruling out suspected deep venous thrombosis in the ambulatory setting. A prospective cohort study. Thromb Haemost 2009; 102: 166-172.
30 Qaseem A, Snow V, Barry P. et al. Current diagnosis of venous thromboembolism in primary care: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians. Ann Intern Med 2007; 146: 454-458.
31 Goodacre S, Sampson F, Stevenson M. et al. Measurement of the clinical and cost-effectiveness of non-invasive diagnostic testing strategies for deep vein thrombosis. Health Technol Assess 2006; 10: 1-168 iii-iv.