Clive Kearon, MB, PhD; Jeffrey S. Ginsberg, MD; James Douketis, MD; Mark A. Crowther, MD; Alexander G. Turpie, MB; Shannon M. Bates, MD; Agnes Lee, MD; Patrick Brill-Edwards, MD; Terri Finch; Michael Gent, DSc
Grant Support: By the National Health Research Development Program of Health Canada (grant 6606-5620-400). AGEN Biomedical Ltd. donated the d-dimer kits. Drs. Kearon and Douketis are supported by the Heart and Stroke Foundation of Canada. Drs. Ginsberg is supported by the Heart and Stroke Foundation of Ontario. Drs. Crowther and Ginsberg are supported by the Canadian Institutes of Health Research. Dr. Bates is supported by the Canadian Institutes of Health Research, University–Industry Program. Dr. Lee is supported by the Canadian Institutes of Health Research, Drug Research and Development Program.
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Clive Kearon, MB, PhD, Hamilton Health Sciences, Henderson Division, 711 Concession Street, Hamilton, Ontario, L8V 1C3.
Current Author Addresses: Drs. Kearon and Lee: Henderson General Hospital, Hamilton Health Sciences Hospital, 711 Concession Street, Hamilton, Ontario L8V 1C3, Canada.
Drs. Ginsberg, Bates, 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.
Dr. Turpie: Hamilton General Hospital, Hamilton Health Sciences Hospital, 237 Barton Street East, Hamilton, Ontario L8L 2X2, Canada.
Ms. Finch and Professor Gent: Clinical Trials and Methodology Group, Henderson Research Centre, 711 Concession Street, Hamilton, Ontario L8V 1C3, Canada.
Author Contributions: Conception and design: C. Kearon, J.S. Ginsberg.
Analysis and interpretation of the data: C. Kearon, J.S. Ginsberg, M. Gent.
Drafting of the article: C. Kearon, J.S. Ginsberg.
Critical revision of the article for important intellectual content: C. Kearon, J.S. Ginsberg, J. Douketis, M.A. Crowther, A.G. Turpie, S.M. Bates, A. Lee, P. Brill-Edwards, T. Finch, M. Gent.
Final approval of the article: C. Kearon, J.S. Ginsberg, J. Douketis, M.A. Crowther, A.G. Turpie, S.M. Bates, A. Lee, P. Brill-Edwards, T. Finch, M. Gent.
Provision of study materials or patients: C. Kearon, J.S. Ginsberg, J. Douketis, M.A. Crowther, A.G. Turpie, S.M. Bates, A. Lee, P. Brill-Edwards.
Statistical expertise: C. Kearon, M. Gent.
Obtaining of funding: C. Kearon, J.S. Ginsberg.
Administrative, technical, or logistic support: T. Finch, M. Gent.
Collection and assembly of data: T. Finch.
Kearon C., Ginsberg J., Douketis J., Crowther M., Turpie A., Bates S., Lee A., Brill-Edwards P., Finch T., Gent M.; A Randomized Trial of Diagnostic Strategies after Normal Proximal Vein Ultrasonography for Suspected Deep Venous Thrombosis: d-Dimer Testing Compared with Repeated Ultrasonography. Ann Intern Med. 2005;142:490-496. doi: 10.7326/0003-4819-142-7-200504050-00007
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Published: Ann Intern Med. 2005;142(7):490-496.
Physicians use several strategies to diagnose deep venous thrombosis (DVT).
This trial randomly assigned 810 outpatients with suspected DVT and negative results on proximal vein ultrasonography to repeated ultrasonography at 1 week or d-dimer testing followed by no further tests if results were negative and venography if results were positive. Repeated ultrasonography diagnosed fewer DVTs than the d-dimer strategy (0.7% vs. 4.7%). In both groups followed for 6 months, only 1% to 2% of patients without DVT on initial testing developed symptomatic thromboembolism.
In patients with suspected DVT and negative results on proximal vein ultrasonography, a d-dimer–based strategy that minimizes additional assessments had similar safety to repeated ultrasonography.
Scott M Stevens
May 10, 2005
Single complete ultrasound as an option to refute suspected symptomatic DVT
We appreciate the contribution of Dr. Kearon and colleagues of a new diagnostic approach to suspected deep vein thrombosis . The "one stop" diagnostic strategy  of the combination of negative proximal ultrasound followed by d-dimer (and venography if abnormal) is a very useful strategy, especially in those patients whose ability to follow-up for a second proximal ultrasound is uncertain. We would also point out that single complete ultrasound has three prospective trials demonstrating similar diagnostic efficacy [3-5], and believe this strategy should be added to the menu of "one stop" diagnostic options in centers where a complete ultrasound technique is available. This strategy does result in detection of isolated calf vein thrombosis, an entity whose management includes several potential strategies: (1) anticoagulation (2) repeat compression ultrasonography to detect extension to the proximal segments or (3) venography before giving anticoagulants.
1. Kearon C, Ginsberg JS, Douketis J, Crowther MA, Turpie AG, Bates SM, et al. A randomized trial of diagnostic strategies after normal proximal vein ultrasonography for suspected deep venous thrombosis: D- dimer testing compared with repeated ultrasonography. Ann Intern Med. 2005;142:490-6.
2. Hull R.. Revisiting the Past Strengthens the Present: An Evidence -Based Medicine Approach for the Diagnosis of Deep Vein Thrombosis. Ann Intern Med. 2005;142:583-5.
3. Stevens SM, Elliott 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 -91.
4. Schellong SM, Schwarz T, Halbritter K, Beyer J, Siegert G, Oettler W, et al. Complete compression ultrasonography of the leg veins as a single test for the diagnosis of deep vein thrombosis. Thromb Haemost. 2003;89:228-34.
5. Elias A, Mallard L, Elias M, Alquier C, Guidolin F, Gauthier B, 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;89:221-7.
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