Key result
Deferring DVT or PE assessment using clinical probability and D-dimer yields a 1.2% 3-month thromboembolic rate.
Why the study?
Treatment of patients with suspected DVT or PE is problematic if diagnostic imaging is not immediately available, and the safety of deferring objective assessment up to 72 hours needed evaluation.
Does a strategy using pretest clinical probability and D-dimer assessment to guide empirical LMWH therapy allow safe deferral of objective diagnostic testing for suspected DVT and PE for up to 72 hours?
Cohort (n=533)
Does a strategy using pretest clinical probability and D-dimer assessment to guide empirical LMWH therapy allow safe deferral of objective diagnostic testing for suspected DVT and PE for up to 72 hours?
Using pretest clinical probability and D-dimer to guide empirical LMWH therapy allows safe deferral of objective diagnostic imaging for suspected DVT and PE for up to 72 hours without increasing thromboembolic or bleeding risks.
BACKGROUND: Treatment of patients with suspected deep vein thrombosis (DVT) or pulmonary embolism (PE) is problematic if diagnostic imaging is not immediately available. Pretest clinical probability (PCP) and D-dimer assessment can be used to identify patients for whom empirical protective anticoagulation is indicated. To evaluate whether PCP and D-dimer assessment, together with the use of low-molecular-weight heparins (LMWHs), allow objective appraisal of DVT and PE to be deferred for up to 72 hours, patients with suspected DVT and PE were prospectively examined. METHODS: Patients identified with a high PCP or a moderate PCP with positive D-dimer test results received a protective full-dose treatment of LMWH; the remaining patients were discharged without anticoagulant administration. However, all patients were scheduled to undergo objective tests for DVT or PE within 72 hours. Standard antithrombotic therapy was administered when deferred diagnostic tests confirmed venous thromboembolism. RESULTS: In total, 409 consecutive patients with suspected DVT and 124 with suspected PE were included in this study. A total of 23.8% (95% confidence interval [CI], 20.3%-27.3%) of patients had confirmed venous thromboembolism. At the short-term follow-up (72 hours), only a single thromboembolic event (0.2%; upper 95% CI, 0.6%) had occurred, whereas at the 3-month follow-up, 5 events (1.2%; 95% CI, 0.2%-2.1%) had occurred in patients in whom diagnosis of DVT or PE had previously been ruled out. None of the patients had major bleeding events. Ninety percent of patients were treated as outpatients. CONCLUSION: Our study demonstrates that this approach allows the safe deferral of diagnostic procedures for DVT and PE for up to 72 hours.
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Siragusa et al. (2004) conducted a cohort in Suspected deep vein thrombosis (DVT) or pulmonary embolism (PE) (n=533). Pretest clinical probability and D-dimer assessment to defer objective testing was evaluated on Thromboembolic events at 3-month follow-up in patients in whom DVT or PE had been ruled out (95% CI 0.2-2.1). Deferring objective assessment for suspected DVT or PE for up to 72 hours using pretest clinical probability and D-dimer resulted in a 1.2% (95% CI 0.2-2.1%) thromboembolic event rate at 3 months.
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