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Electronic letters published:
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Diagnosing a first venous thrombosis or a recurrent event: discrepancies in the role of D-dimer. Sho
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José R Paño-Pardo, MD Internal Medicine Department. Hospital Universtario La Paz, María del Carmen Fernández-Capitán, Marta Mora-Rillo
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joserrapa{at}ya.com José R Paño-Pardo, et al.
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Diagnosing recurrent deep vein thrombosis (DVT) is challenging for the clinician due to the absence of accurate tests. Rathbun et al1 (December 7th issue) propose a sole negative D-dimer (DD) test as a safe tool to rule out diagnosis of recurrent DVT. This conclusion apparently opposes the principles used to diagnose a suspected first episode of DVT. In this case, it is widely believed that a negative DD test may safely exclude the diagnosis just when the clinical pretest probability of DVT, as assessed by validated clinical models, is low2,3. Over 5% of patients with clinically estimated moderate probability and a negative DD test have DVT2. In this case a sole negative DD testing is not sufficient to rule out the diagnosis. On the other hand, in the cohort of patients described by Rathbun, in which the prevalence of DVT in patients with a negative DD test is probably up to 6%, DD testing is recommended as an isolated tool to exclude the diagnosis when negative. Two different attitudes when facing the same disease with the same diagnostic tool (same false negative ratio). Is there any reason for these discordant messages? The absence of adequate tools for diagnosis of acute thrombosis when there is prior history of DVT may be an important factor to be considered. Nevertheless we believe that, considering the potential outcome of non diagnosed acute DVT, a more thorough diagnostic approach with compression ultrasonography is needed routinely in these patients. The issue is probably to improve its performance. Perphaps routine compression ultrasonography several months after a first episode of DVT would contribute to solve this problem, at least in patients in which rethrombosis is suspected not immediately after the initial episode. 1. Rathbun SW, Whitsett TL, Raskob GE. Negative D-dimer result to exclude recurrent deep venous thrombosis: a management trial. Ann Intern Med. 2004;141(11):839-45. 2. Kearon C, Ginsberg JS, Douketis J, et al. Management of suspected deep venous thrombosis in outpatients by using clinical assessment and D- dimer testing. Ann Intern Med 2001;135:108-11. 3. Wells PS, Anderson DR, Rodger M, et al. Evaluation of-Dimer in the Diagnosis of Suspected Deep-Vein Thrombosis. N Engl J Med 2003;349:1227- 35. Conflict of Interest:None declared |
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