0

The full content of Annals is available to subscribers

Subscribe/Learn More  >
Articles |

A Randomized Trial of Diagnostic Strategies after Normal Proximal Vein Ultrasonography for Suspected Deep Venous Thrombosis: d-Dimer Testing Compared with Repeated Ultrasonography

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; and Michael Gent, DSc
[+] Article and Author Information

From McMaster University and the Henderson Research Centre, Hamilton, Ontario, Canada.


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.


Ann Intern Med. 2005;142(7):490-496. doi:10.7326/0003-4819-142-7-200504050-00007
Text Size: A A A

Over a 3-year period, 1209 patients met inclusion criteria. Of these, 269 patients were early exclusions (Figure 1). Of the remaining 940 patients, 70 had deep venous thrombosis on initial ultrasonography. Of 870 eligible patients, 810 gave informed consent and were randomly assigned to the d-dimer group (408 patients) or the repeated ultrasonography group (402 patients) (Table 1 and Figures 1 and 2).

First Page Preview

View Large
First page PDF preview

Figures

Grahic Jump Location
Figure 2.
Diagnostic algorithm and patient outcomes for all randomly assigned patients.

Shaded boxes indicate outcome assessments. *Includes 1 patient with deep venous thrombosis (DVT) that was diagnosed by unscheduled venography on the day of presentation. †One patient was treated with an inferior venacaval filter, without anticoagulant therapy, and had a subsequent fatal pulmonary embolism. VTE = venous thromboembolism.

Grahic Jump Location

Tables

References

Letters

NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Comments

Submit a Comment
Single complete ultrasound as an option to refute suspected symptomatic DVT
Posted on May 10, 2005
Scott M Stevens
LDS Hospital
Conflict of Interest: None Declared

We appreciate the contribution of Dr. Kearon and colleagues of a new diagnostic approach to suspected deep vein thrombosis [1]. The "one stop" diagnostic strategy [2] 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.

Conflict of Interest:

None declared

Submit a Comment

Summary for Patients

Diagnosing Deep Venous Thrombosis

The summary below is from the full report titled “A Randomized Trial of Diagnostic Strategies after Normal Proximal Vein Ultrasonography for Suspected Deep Venous Thrombosis: d-Dimer Testing Compared with Repeated Ultrasonography.” It is in the 5 April 2005 issue of Annals of Internal Medicine (volume 142, pages 490-496). The authors are C. Kearon, J.S. Ginsberg, J. Douketis, M.A. Crowther, A.G. Turpie, S.M. Bates, A. Lee, P. Brill-Edwards, T. Finch, and M. Gent.

Read More...

Clinical Slide Sets

Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.

Toolkit

Buy Now

to gain full access to the content and tools.

Want to Subscribe?

Learn more about subscription options

Advertisement
Related Articles
Related Point of Care
Topic Collections
PubMed Articles
Forgot your password?
Enter your username and email address. We'll send you a reminder to the email address on record.
(Required)
(Required)