Abstract
This review summarizes recent information about the diagnosis of deep venous thrombosis (DVT) and pulmonary embolism (PE) using noninvasive imaging tests, clinical assessment, and D-dimer assays, and describes how these tests can be employed in diagnostic testing algorithms for the investigation of patients with suspected DVT and PE. The clinical diagnosis of deep venous thrombosis is unreliable, but clinical prediction rules based on signs and symptoms do facilitate the categorization of patients into high, low, or medium risk categories. High sensitivity D-dimer assays further help in excluding cases but do not help in ruling in venous thromboembolism. D-dimer assays and clinical prediction rules also help in the diagnosis of pulmonary embolism. These assessments, along with objective imaging studies such as compression ultrasonography for DVT or computerized tomographic pulmonary angiograms for PE can be used in a systematic way to reliably rule in or exclude venous thromboembolism.
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References
Horlander KT, Mannino DM, Leeper KV. Pulmonary embolism mortality in the United States, 1979–1998. An analysis using multiple-cause mortality data. Arch Intern Med 2003;163:1711–1717.
Schluger N, Henschke C, King T, et al. Diagnosis of pulmonary embolism at a large teaching hospital. J Thorac Imaging 1994;9:180–184.
Lensing AW, Prandoni P, Brandjes DPM, et al. Detection of deep-vein thrombosis by real-time B-mode ultrasonography. N Engl J Med 1989;320:342–345.
Cogo A, Lensing AWA, Koopman MMW, et al. Compression ultrasonography for diagnostic management of patients with clinically suspected deep vein thrombosis: prospective cohort study. Br Med J 1998;316:17–20.
Heijboer H, Buller HR, Lensing AWA, Turpie AGG, Colly LP, ten Cate JW. A comparison of real-time compression ultrasonography with impedance plethysmography for the diagnosis of deep-vein thrombosis in symptomatic outpatients. N Engl J Med 1993;329:1365–1369.
Anand SS, Wells PS, Hunt D, Brill-Edwards P, Cook D, Ginsberg JS. Does this patient have deep vein thrombosis? JAMA 1998;279:1094–1099.
Kearon C, Julian JA, Newman TE, Ginsberg JS. Noninvasive diagnosis of deep vein thrombosis. Ann Intern Med 1998;128:663–677.
Wells PS, Lensing AWA, Davidson BL, Prins MH, Hirsh J. Accuracy of ultrasound for the diagnosis of deep venous thrombosis in asymptomatic patients after orthopedic surgery. A meta-analysis. Ann Intern Med 1995;122:47–53.
Perone N, Bounameaux H, Perrier A. Comparison of four strategies for diagnosing deep vein thrombosis: A cost-effectiveness analysis. Am J Med 2000;110:33–40.
Hillner BE, Philbrick JT, Becker DM. Optimal management of suspected lower-extremity deep vein thrombosis. An evaluation with cost assessment of 24 management strategies. Arch Intern Med 1992;152:165–175.
Stevens SM, Elliot CG, Chan KJ, Egger MJ, Ahmed KM. Withholding anticoagulation after a negative result on duplex ultrasonography for suspected symptomatic deep venous thrombosis. Ann Intern Med 2004;140:985–991.
Schellong SM, Schwarz T, Halbritter K, et al. Complete compression ultrasonography of the leg veins as a single test for the diagnosis of deep vein thrombosis. Thromb Haemost 2003;89:228–234.
Elias A, Mallard L, Elias M, et al. A single complete ultrasound investigation of the venous network for the diagnostic management of patients with a clinically suspected first episode of deep venous thrombosis of the lower limbs. Thromb Haemost 2003;89:221–227.
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.
Owen CJ, Doucette S, Wells PS. The use of a clinical prediction model and D-dimer (DD) testing in the diagnosis of deep vein thrombosis (DVT): A systematic review. Blood 2004;104:300a.
Bayes T. An essay towards solving a problem in the doctrine of chances. Philos Trans R Soc Lon 1763;53:370–418.
Heller I, Topilsky M, Shapira I, Isakov A. Graphic representation of sequential Bayesian analysis. Methods Inf Med 1999;38:182–186.
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.
Bosson JL, Barro C, Satger B, Carpentier PH, Polack B, Pernod G. Quantitative high D-dimer value is predictive of pulmonary embolism occurrence independently of clinical score in a well-defined low risk factor population. J Thromb Haemost 2005;3:93–99.
Bosson JL, Labarere J, Sevestre MA, et al. Deep vein thrombosis in elderly patients hospitalized in subacute care facilities. A multicenter cross-sectional study of risk factors, prophylaxis and prevalence. Arch Intern Med 2003;163:2613–2618.
Righini M, Goehring C, Bounameaux H, Perrier A. Effects of age on the performance of common diagnostic tests for pulmonary embolism. Am J Med 2000;109:357–361.
Kovacs MJ, MacKinnon KM, Anderson DR, et al. A comparison of three rapid D-dimer methods for the diagnosis of venous thromboembolism. Br J Haematol 2001;115:140–144.
Heim SW, Schectman JM, Siadaty MS, Philbrick JT. D-dimer testing for deep venous thrombosis: a metaanalysis. Clin Chem 2004;50:1136–1147.
Perzanowski C, Dellweg D, Eiger G. Limited use of the SimpliRED assay in confirming pulmonary embolism. Thromb Haemost 2004;91:633–635.
Meyer G, Fischer AM, Collignon MA, et al. Diagnostic value of two rapid and individual D-dimer assays in patients with clinically suspected pulmonary embolism: comparison with microplate enzyme-linked immunosorbent assay. Blood Coagul Fibrinolysis 1998;9:603–608.
de Monye W, Huisman MV, Pattynama PMT. Observer dependency of the Simplired D-Dimer assay in 81 consecutive patients with suspected pulmonary embolism. Thromb Res 1999;96:293–298.
Turkstra F, van Beek EJR, Buller HR. Observer and biological variation of a rapid whole blood d-dimer test. Thromb Haemost 1998;79:1–3.
Philbrick JT, Heim SW. The D-dimer test for deep venous thrombosis: gold standards and bias in negative predictive value. Clin Chem 2003;49:570–574.
Stein PD, Hull RD, Patel KC, et al. D-Dimer for the exclusion of acute venous thrombosis and pulmonary embolism. A systematic review. Ann Intern Med 2004;140:589–602.
Kraaijenhagen RA, Lijmer JG, Bossuyt PMM, Prins MH, Heisterkamp SH, Buller HR. The accuracy of D-dimer in the diagnosis of venous thromboembolism : a meta-analysis. In: Kraaijenhagen RA, ed. The Etiology, diagnosis and treatment of venous thromboembolism. The Netherlands: 2000:159–183.
British Society for Haematology. The diagnosis of deep vein thrombosis in symptomatic outpatients and the potential for clinical assessment and D-dimer assays to reduce the need for diagnostic imaging. Br J Haematol 2004;124:15–25.
Bauld DL, Kovacs MJ. Dalteparin in emergency patients to prevent admission prior to investigation for venous thromboembolism. Am J Emerg Med 1999;17:11–14.
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;1:645–651.
Heijboer H, Jongbloets LMM, Buller HR, Lensing AWA, ten Cate JW. Clinical utility of real-time compression ultrasonography for diagnostic management of patients with recurrent venous thrombosis. Acta Rad 1992;33:297–300.
Rathbun SW, Whitsett TL, Raskob GE. Negative D-dimer result to exclude recurrent deep venous thrombosis: a management trial. Ann Intern Med 2004;141:839–845.
Stein PD, Athanasoulis C, Alavi A, et al. Complications and validity of pulmonary angiography in acute pulmonary embolism. Circulation 1992;85:462–468.
PIOPED Investigators. Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). JAMA 1990;263:2753–2759.
Henry JW, Relyea B, Stein PD. Continuing risk of thromboemboli among patients with normal pulmonary angiograms. Chest 1995;107:1375–1378.
Hull RD, Hirsh J, Carter CJ, et al. Pulmonary angiography, ventilation lung scanning, and venography for clinically suspected pulmonary embolism with abnormal perfusion lung scan. Ann Intern Med 1983;98:891–899.
Remy-Jardin M, Remy J, Artraud D, Fribourg M, Beregi JP. Spiral CT of pulmonary embolism: diagnostic approach, interpretive pitfalls and current indications. Eur Radiol 1998;8:1376–1390.
Rathbun SW, Raskob G, Whitsett TL. Sensitivity and specificity of helical computed tomography in the diagnosis of pulmonary embolism: A systematic review. Ann Intern Med 2000;132:227–232.
Forgie MA, Wells PS, Wells G, Millward S. A systematic review of the accuracy of helical CT in the diagnosis of acute pulmonary embolism. Blood 1997;90:3223.
Mayo JR, Remy-Jardin M, Muller NL, et al. Pulmonary embolism: prospective comparison of spiral CT with ventilation-perfusion scintigraphy. Radiology 1997;205:447–452.
Shah AA, Davis SD, Gamsu G, Intriere L. Parenchymal and pleural findings in patients with and patients without acute pulmonary embolism detected at spiral CT. Radiology 1999;211:147–153.
Wells PS, Ginsberg JS, Anderson DR, et al. Use of a clinical model for safe management of patients with suspected pulmonary embolism. Ann Intern Med 1998;129:997–1005.
Sanson BJ, Lijmer JG, MacGillavry MRM, Turkstra F, Prins MH, Buller HR. Comparison of a clinical probability estimate and two clinical models in patients with suspected pulmonary embolism. Thromb Haemost 2000;83:199–203.
Miniati M, Prediletto R, Formichi B, et al. Accuracy of clinical assessment in the diagnosis of pulmonary embolism. Am J Respir Crit Care Med 1999;159:864–871.
Wicki J, Perneger TV, Junod AF, Bounameaux H, Perrier A. Assessing clinical probability of pulmonary embolism in the emergency ward: a simple score. Arch Intern Med 2001;161:92–97.
Chagnon I, Bounameaux H, Aujesky D, et al. Comparison of two clinical prediction rules and implicit assessment among patients with suspected pulmonary embolism. Am J Med 2002;113:269–275.
Hyers TM. Venous thromboembolism. Am J Respir Crit Care Med 1999;159:1–14.
Wells PS, Anderson DR, Rodger MA, et al. Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: Increasing the models utility with the SimpliRED D-dimer. Thromb Haemost 2000;83:416–420.
Kline JA, Mitchell AM, Kabrhel C, Richman PB, Courtney DM. Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. J Thromb Haemost 2004;2:1247–1255.
Wolf SJ, McCubbin TR, Feldhaus KM, Faragher JP, Adcock DM. Prospective validation of Wells criteria in the evaluation of patients with suspected pulmonary embolism. Ann Emerg Med 2004;44:503–510.
Hull RD, Raskob GE, Coates G, Panju AA. Clinical validity of a normal perfusion lung scan on patients with suspected pulmonary embolism. Chest 1990;97:23–26.
van Beek EJ, Kuyer PMM, Schenk BE, Brandjes DPM, ten Cate JW, Buller HR. A normal perfusion lung scan in patients with clinically suspected pulmonary embolism: Frequency and clinical validity. Chest 1995;108:170–173.
Kipper MS, Moser KM, Kortman KE, Ashburn WL. Long-term follow-up of patients with suspected pulmonary embolism and a normal lung scan. Perfusion scans in embolic suspects. Chest 1982;82:411–415.
Gosselin MV, Rubin GD, Leung AN, Huang J, Rizk NW. Unsuspected pulmonary embolism: prospective detection on routine helical CT scans. Radiology 1998;208:209–215.
Storto ML, Di Credico A, Guido F, Larici AR, Bonomo L. Incidental detection of pulmonary emboli on routine MDCT of the chest. AJR Am J Roentgenol 2005;184:264–267.
Musset D, Parent F, Meyer G, et al. Diagnostic strategy for patients with suspected pulmonary embolism: a prospective multicenter outcome study. Lancet 2002;360:1914–1920.
Moores LK, Jackson WL, Jr., Shorr AF, Jackson JL. Meta-analysis: outcomes in patients with suspected pulmonary embolism managed with computed tomographic pulmonary angiography. Ann Intern Med 2004;141:866–874.
Worsley DF, Alavi A. Comprehensive analysis of the results of the PIOPED Study. Prospective Investigation of Pulmonary Embolism Diagnosis Study. J Nucl Med 1995;36:2380–2387.
Mullins MD, Becker DM, Hagspiel KD, Philbrick JT. The role of spiral volumetric computed tomography in the diagnosis of pulmonary embolism. Arch Intern Med 2000;160:293–298.
Cohen J. Statistical power analysis for the behavioral sciences. 2nded., Hillsdale, NJ, Lawrence Erlbaum Assoc., 1988.
Wells PS, Anderson DR, Rodger MA, et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: Management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and D-dimer. Ann Intern Med 2001;135:98–107.
Perrier A, Roy P-M, Aujesky D, et al. Diagnosing pulmonary embolism in outpatients with clinical assessment, D-Dimer measurement, venous ultrasound, and helical computed tomography: A multicenter management study. Am J Med 2004;116:291–299.
Goldstein NM, Kollef MH, Ward S, Gage BF. The impact of the introduction of a rapid D-dimer assay on the diagnostic evaluation of suspected Pulmonary Embolism. Arch Intern Med 2001;161:567–571.
Oudkerk M, van Beek EJ, Wielopolski P, et al. Comparison of contrast-enhanced magnetic resonance angiography and conventional pulmonary angiography for the diagnosis of pulmonary embolism: a prospective study. Lancet 2002;359:1643–1647.
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Dr. Wells is the recipient of a Canada Research Chair in Thromboembolic Diseases
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Wells, P.S. Advances in the Diagnosis of Venous Thromboembolism. J Thromb Thrombolysis 21, 31–40 (2006). https://doi.org/10.1007/s11239-006-5573-x
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DOI: https://doi.org/10.1007/s11239-006-5573-x