This Article  • Full text  • PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Citing articles on ISI (25)  • Contact me when this article is cited  Related Content  • Related articles  • Similar articles in JAMA  Topic Collections  • Venous Thromboembolism  • Cardiovascular System  • Alert me on articles by topic  Social Bookmarking   What's this?

Philip S. Wells, MD, MSc; Carolyn Owen, MD; Steve Doucette, MSc; Dean Fergusson, PhD; Huyen Tran, MD

JAMA. 2006;295:199-207.

Context  Outpatients with suspected deep vein thrombosis (DVT) have nonspecific signs and symptoms. Missed DVT diagnosis may result in fatal pulmonary embolism. Since many patients may have DVT, a selective and efficient diagnostic process is needed.

Objective  To systematically review trials that determined the prevalence of DVT using clinical prediction rules either with or without D-dimer, for the diagnosis of DVT.

Data Sources  English- and French-language studies were identified from MEDLINE from 1990 to July 2004 and supplemented by a review of all relevant bibliographies.

Study Selection  We included studies that prospectively enrolled consecutive, unselected outpatients with suspected DVT and applied clinical prediction rules before D-dimer testing or diagnostic imaging. All studies included sufficient information to allow the calculation of the prevalence of DVT for at least 1 of the 3 clinical probability estimates (low, moderate, or high). We required that patients be followed up for a minimum 3-month period. Unless the clinical model incorporated prior DVT, studies were excluded if patients with a history of prior DVT were enrolled.

Data Extraction  Two reviewers independently reviewed and abstracted data for estimating the prevalence of DVT, sensitivity, specificity, and likelihood ratios (LRs) of D-dimer in each of the 3 clinical probability estimates. Data for the D-dimer in all studies were pooled and analyzed as high-sensitivity/low-specificity test or a moderate-sensitivity/moderate-specificity test.

Data Synthesis  Fourteen studies involving more than 8000 patients used 1 clinical prediction rule for diagnosing DVT, of which 11 incorporated D-dimer testing in the diagnostic algorithm. The prevalence of DVT in the low, moderate, and high clinical probability groups was 5.0% (95% CI, 4.0%-8.0%), 17% (95% CI, 13%-23%), and 53% (95% CI, 44%-61%), respectively. The overall prevalence of DVT was 19% (95% CI, 16%-23%). Pooling all studies, the sensitivity, specificity, and negative LRs of D-dimer testing in the low probability group were 88% (95% CI, 81%-92%), 72% (95% CI, 65%-78%), and 0.18% (95% CI, 0.12-0.18); in the moderate probability group: 90% (95% CI, 80%-95%), 58% (95% CI, 49%-67%), and 0.19% (95% CI, 0.11-0.32); and in the high probability group: 92% (95% CI, 85%-96%), 45% (95% CI, 37%-52%), and 0.16% (95% CI, 0.09-0.30). The LRs for a normal result on a high or moderately sensitive D-dimer assay among patients with: (1) low clinical suspicion were 0.10 (95% CI, 0.03-0.37) and 0.20 (95% CI, 0.12-0.31); (2) moderate clinical suspicion were 0.05 (95% CI, 0.01-0.21) and 0.23 (95% CI, 0.13-0.39); and (3) high clinical suspicion were 0.07 (95% CI, 0.03-0.18) and 0.15 (95% CI, 0.10-0.38).

Conclusions  Diagnostic accuracy for DVT improves when clinical probability is estimated before diagnostic tests. Patients with low clinical probability on the predictive rule have prevalence of DVT of less than 5%. In low-probability patients with negative D-dimer results, diagnosis of DVT can be excluded without ultrasound; in patients with high clinical suspicion for DVT, results should not affect clinical decisions.

Author Affiliations: Department of Medicine, University of Ottawa; Division of Hematology, Ottawa Hospital, Ontario (Dr Wells); Department of Epidemiology and Community Medicine, University of Ottawa, Ontario (Drs Wells and Fergusson); Ottawa Health Research Institute, Ottawa, Ontario (Drs Wells, Fergusson, and Mr Doucette); Department of Medicine, University of British Columbia, Vancouver (Dr Owen); and Department of Medicine, McMaster University, Hamilton, Ontario (Dr Tran).

CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati     What's this?

RELATED ARTICLES

Effectiveness of Managing Suspected Pulmonary Embolism Using an Algorithm Combining Clinical Probability, D-Dimer Testing, and Computed Tomography
Writing Group for the Christopher Study Investigators
JAMA. 2006;295(2):172-179.
ABSTRACT | FULL TEXT  

Diagnosing Pulmonary Embolism With Improved Certainty and Simplicity
Russell D. Hull
JAMA. 2006;295(2):213-215.
EXTRACT | FULL TEXT  

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Safely Ruling Out Deep Venous Thrombosis in Primary Care
Buller et al.
ANN INTERN MED 2009;150:229-235.
ABSTRACT | FULL TEXT  

Noninvasive Diagnosis of Deep Vein Thrombosis
Landefeld
JAMA 2008;300:1696-1697.
FULL TEXT  

When Is Diagnostic Testing Inappropriate or Irrational? Acceptable Regret Approach
Hozo and Djulbegovic
Med Decis Making 2008;28:540-553.
ABSTRACT  

Elevation of plasma D-dimer is closely associated with venous thrombosis produced by double-lumen catheter in pre-dialysis patients
Kanno et al.
Nephrol Dial Transplant 2007;22:1224-1227.
ABSTRACT | FULL TEXT  

Diagnosis and treatment of deep-vein thrombosis.
Scarvelis and Wells
CMAJ 2006;175:1087-1092.
ABSTRACT | FULL TEXT  

Review: the Wells clinical prediction guide and D-dimer testing predict deep vein thrombosis
Perrier
Evid. Based Med. 2006;11:119-119.
FULL TEXT  

Diagnosing Pulmonary Embolism With Improved Certainty and Simplicity
Hull
JAMA 2006;295:213-215.
FULL TEXT