Management of Suspected Deep Venous Thrombosis in Outpatients by Using Clinical Assessment and d-dimer Testing

  1. Clive Kearon, MB, PhD;
  2. Jeffrey S. Ginsberg, MD;
  3. James Douketis, MD;
  4. Mark Crowther, MD;
  5. Patrick Brill-Edwards, MD;
  6. Jeffrey I. Weitz, MD; and
  7. Jack Hirsh, MD
  1. From Hamilton Civic Hospitals Research Centre and McMaster University, Hamilton, Ontario, Canada.

    Abstract

    Background: When deep venous thrombosis is suspected, objective testing is required to confirm or refute the diagnosis.

    Objective: To determine whether the combination of a low clinical suspicion and a normal d-dimer result rules out deep venous thrombosis.

    Design: Prospective cohort study.

    Setting: Three tertiary care hospitals in Canada.

    Patients: 445 outpatients with a suspected first episode of deep venous thrombosis.

    Interventions: Patients were categorized as having low, moderate, or high pretest probability of thrombosis and underwent whole-blood d-dimer testing. Patients with a low pretest probability and a negative result on the d-dimer test had no further diagnostic testing and received no anticoagulant therapy. Additional diagnostic testing was done in all other patients.

    Measurements: Venous thromboembolic events during 3-month follow-up.

    Results: 177 (40%) patients had both a low pretest probability and a negative d-dimer result. One of these patients had deep venous thrombosis during follow-up (negative predictive value, 99.4% [95% CI, 96.9% to 100%]).

    Conclusion: The combination of a low pretest probability of deep venous thrombosis and a negative result on a whole-blood d-dimer test rules out deep venous thrombosis in a large proportion of symptomatic outpatients.

    Article and Author Information

    • Acknowledgments: The authors thank J. Bennett, D. Ridgewell, and P. Stevens for providing technological and nursing assistance and collating the data. They also thank P. Massicotte, M. Andrew, P. Powers, M. Sternbach, and A. Patel for contributing patients.

    • Grant Support: Drs. Kearon and Douketis are Research Scholars of the Heart and Stroke Foundation of Canada, and Dr. Crowther is a Research Scholar of the Medical Research Council of Canada. Drs. Ginsberg and Weitz are Career Investigators of the Heart and Stroke Foundation of Ontario, and Dr. Weitz also holds the J. Fraser Mustard endowed chair in cardiovascular research at the Heart and Stroke Foundation of Canada. The d-dimer kits were donated by AGEN Biomedical, Ltd. (Brisbane, Australia).

    • Corresponding Author: Clive Kearon, MB, PhD, McMaster University Clinic, Room 401, Henderson General Hospital, 711 Concession Street, Hamilton, Ontario L8V 1C3, Canada.

    • Current Author Addresses: Dr. Kearon: McMaster University Clinic, Room 401, Henderson General Hospital, 711 Concession Street; Hamilton, Ontario L8V 1C3, Canada.

    • Drs. Ginsberg and Brill-Edwards: McMaster University Medical Centre, Room 3W15, 1200 Main Street West, Hamilton, Ontario L87 3Z5, Canada.

    • Drs. Crowther and Douketis: St. Joseph's Hospital, Room L 208-4, 50 Charlton Avenue East, Hamilton, Ontario L8N 4A6, Canada.

    • Drs. Weitz and Hirsh: Hamilton Civic Hospitals Research Centre, 711 Concession Street, Hamilton, Ontario L8V 1C3, Canada.

    • Author Contributions: Conception and design: C. Kearon, J.S. Ginsberg, J. Douketis, M. Crowther, P. Brill-Edwards, J.I. Weitz, J. Hirsh.

    • Analysis and interpretation of the data: C. Kearon.

    • Drafting of the article: C. Kearon, J.S. Ginsberg, J. Douketis, M. Crowther, P. Brill-Edwards, J.I. Weitz, J. Hirsh.

    • Critical revision of the article for important intellectual content: C. Kearon, J.S. Ginsberg.

    • Final approval of the article: C. Kearon, J.S. Ginsberg, J. Douketis, M. Crowther, P. Brill-Edwards, J.I. Weitz, J. Hirsh.

    • Provision of study materials or patients: C. Kearon, J.S. Ginsberg, J. Douketis, M. Crowther, P. Brill-Edwards, J.I. Weitz, J. Hirsh.

    • Statistical expertise: C. Kearon.

    • Obtaining of funding: C. Kearon, J.S. Ginsberg.

    • Administrative, technical, or logistic support: C. Kearon, J.S. Ginsberg.

    • Collection and assembly of data: C. Kearon, J.S. Ginsberg, J. Douketis, M. Crowther, P. Brill-Edwards, J.I. Weitz, J. Hirsh.

    Summary for Patients

    • Summaries for Patients:A New and Improved System for Excluding the Diagnosis of Deep Venous Thrombosis Ann Intern Med July 17, 2001 135:S24
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    1. Ann Intern Med July 17, 2001 vol. 135 no. 2 108-111
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