Deferment of objective assessment of deep vein thrombosis and pulmonary embolism without increased risk of thrombosis: A practical approach based on the pretest clinical model, D-dimer testing, and the use of low-molecular-weight heparins

Sergio Siragusa, Raffaela Anastasio, Camillo Porta, Francesco Falaschi, Stefano Pirrelli, Piernicola Palmieri, Gabriella Gamba, Katerina Granzow, Alessandra Malato, Viviana Minardi, Paola Tatoni, Maria Antonietta Bressan, Guglielmo Mariani

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Abstract

Background: Treatment of patients with suspected deep vein thrombosis (DVT) or pulmonary embolism (PE) is problematic if diagnostic imaging is not immediately available. Pretest clinical probability (PCP) and D-dimer assessment can be used to identify patients for whom empirical protective anticoagulation is indicated. To evaluate whether PCP and D-dimer assessment, together with the use of low-molecular-weight heparins (LMWHs), allow objective appraisal of DVT and PE to be deferred for up to 72 hours, patients with suspected DVT and PE were prospectively examined. Methods: Patients identified with a high PCP or a moderate PCP with positive D-dimer test results received a protective full-dose treatment of LMWH; the remaining patients were discharged without anticoagulant administration. However, all patients were scheduled to undergo objective tests for DVT or PE within 72 hours. Standard antithrombotic therapy was administered when deferred diagnostic tests confirmed venous thromboembolism. Results: In total, 409 consecutive patients with suspected DVT and 124 with suspected PE were included in this study. A total of 23.8% (95% confidence interval [CI], 20.3%-27.3%) of patients had confirmed venous thromboembolism. At the short-term follow-up (72 hours), only a single thromboembolic event (0.2%; upper 95% CI, 0.6%) had occurred, whereas at the 3-month follow-up, 5 events (1.2%; 95% CI, 0.2%-2.1%) had occurred in patients in whom diagnosis of DVT or PE had previously been ruled out. None of the patients had major bleeding events. Ninety percent of patients were treated as outpatients. Conclusion: Our study demonstrates that this approach allows the safe deferral of diagnostic procedures for DVT and PE for up to 72 hours.

Original languageEnglish
Pages (from-to)2477-2482
Number of pages6
JournalArchives of Internal Medicine
Volume164
Issue number22
DOIs
Publication statusPublished - Dec 13 2004

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Low Molecular Weight Heparin
Pulmonary Embolism
Venous Thrombosis
Thrombosis
Venous Thromboembolism
Confidence Intervals
fibrin fragment D
Diagnostic Imaging
Routine Diagnostic Tests
Anticoagulants
Outpatients
Therapeutics
Hemorrhage

ASJC Scopus subject areas

  • Internal Medicine

Cite this

@article{627a6ad90c8c4773b800a50a65fc3e40,
title = "Deferment of objective assessment of deep vein thrombosis and pulmonary embolism without increased risk of thrombosis: A practical approach based on the pretest clinical model, D-dimer testing, and the use of low-molecular-weight heparins",
abstract = "Background: Treatment of patients with suspected deep vein thrombosis (DVT) or pulmonary embolism (PE) is problematic if diagnostic imaging is not immediately available. Pretest clinical probability (PCP) and D-dimer assessment can be used to identify patients for whom empirical protective anticoagulation is indicated. To evaluate whether PCP and D-dimer assessment, together with the use of low-molecular-weight heparins (LMWHs), allow objective appraisal of DVT and PE to be deferred for up to 72 hours, patients with suspected DVT and PE were prospectively examined. Methods: Patients identified with a high PCP or a moderate PCP with positive D-dimer test results received a protective full-dose treatment of LMWH; the remaining patients were discharged without anticoagulant administration. However, all patients were scheduled to undergo objective tests for DVT or PE within 72 hours. Standard antithrombotic therapy was administered when deferred diagnostic tests confirmed venous thromboembolism. Results: In total, 409 consecutive patients with suspected DVT and 124 with suspected PE were included in this study. A total of 23.8{\%} (95{\%} confidence interval [CI], 20.3{\%}-27.3{\%}) of patients had confirmed venous thromboembolism. At the short-term follow-up (72 hours), only a single thromboembolic event (0.2{\%}; upper 95{\%} CI, 0.6{\%}) had occurred, whereas at the 3-month follow-up, 5 events (1.2{\%}; 95{\%} CI, 0.2{\%}-2.1{\%}) had occurred in patients in whom diagnosis of DVT or PE had previously been ruled out. None of the patients had major bleeding events. Ninety percent of patients were treated as outpatients. Conclusion: Our study demonstrates that this approach allows the safe deferral of diagnostic procedures for DVT and PE for up to 72 hours.",
author = "Sergio Siragusa and Raffaela Anastasio and Camillo Porta and Francesco Falaschi and Stefano Pirrelli and Piernicola Palmieri and Gabriella Gamba and Katerina Granzow and Alessandra Malato and Viviana Minardi and Paola Tatoni and Bressan, {Maria Antonietta} and Guglielmo Mariani",
year = "2004",
month = "12",
day = "13",
doi = "10.1001/archinte.164.22.2477",
language = "English",
volume = "164",
pages = "2477--2482",
journal = "Archives of Internal Medicine",
issn = "0003-9926",
publisher = "American Medical Association",
number = "22",

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TY - JOUR

T1 - Deferment of objective assessment of deep vein thrombosis and pulmonary embolism without increased risk of thrombosis

T2 - A practical approach based on the pretest clinical model, D-dimer testing, and the use of low-molecular-weight heparins

AU - Siragusa, Sergio

AU - Anastasio, Raffaela

AU - Porta, Camillo

AU - Falaschi, Francesco

AU - Pirrelli, Stefano

AU - Palmieri, Piernicola

AU - Gamba, Gabriella

AU - Granzow, Katerina

AU - Malato, Alessandra

AU - Minardi, Viviana

AU - Tatoni, Paola

AU - Bressan, Maria Antonietta

AU - Mariani, Guglielmo

PY - 2004/12/13

Y1 - 2004/12/13

N2 - Background: Treatment of patients with suspected deep vein thrombosis (DVT) or pulmonary embolism (PE) is problematic if diagnostic imaging is not immediately available. Pretest clinical probability (PCP) and D-dimer assessment can be used to identify patients for whom empirical protective anticoagulation is indicated. To evaluate whether PCP and D-dimer assessment, together with the use of low-molecular-weight heparins (LMWHs), allow objective appraisal of DVT and PE to be deferred for up to 72 hours, patients with suspected DVT and PE were prospectively examined. Methods: Patients identified with a high PCP or a moderate PCP with positive D-dimer test results received a protective full-dose treatment of LMWH; the remaining patients were discharged without anticoagulant administration. However, all patients were scheduled to undergo objective tests for DVT or PE within 72 hours. Standard antithrombotic therapy was administered when deferred diagnostic tests confirmed venous thromboembolism. Results: In total, 409 consecutive patients with suspected DVT and 124 with suspected PE were included in this study. A total of 23.8% (95% confidence interval [CI], 20.3%-27.3%) of patients had confirmed venous thromboembolism. At the short-term follow-up (72 hours), only a single thromboembolic event (0.2%; upper 95% CI, 0.6%) had occurred, whereas at the 3-month follow-up, 5 events (1.2%; 95% CI, 0.2%-2.1%) had occurred in patients in whom diagnosis of DVT or PE had previously been ruled out. None of the patients had major bleeding events. Ninety percent of patients were treated as outpatients. Conclusion: Our study demonstrates that this approach allows the safe deferral of diagnostic procedures for DVT and PE for up to 72 hours.

AB - Background: Treatment of patients with suspected deep vein thrombosis (DVT) or pulmonary embolism (PE) is problematic if diagnostic imaging is not immediately available. Pretest clinical probability (PCP) and D-dimer assessment can be used to identify patients for whom empirical protective anticoagulation is indicated. To evaluate whether PCP and D-dimer assessment, together with the use of low-molecular-weight heparins (LMWHs), allow objective appraisal of DVT and PE to be deferred for up to 72 hours, patients with suspected DVT and PE were prospectively examined. Methods: Patients identified with a high PCP or a moderate PCP with positive D-dimer test results received a protective full-dose treatment of LMWH; the remaining patients were discharged without anticoagulant administration. However, all patients were scheduled to undergo objective tests for DVT or PE within 72 hours. Standard antithrombotic therapy was administered when deferred diagnostic tests confirmed venous thromboembolism. Results: In total, 409 consecutive patients with suspected DVT and 124 with suspected PE were included in this study. A total of 23.8% (95% confidence interval [CI], 20.3%-27.3%) of patients had confirmed venous thromboembolism. At the short-term follow-up (72 hours), only a single thromboembolic event (0.2%; upper 95% CI, 0.6%) had occurred, whereas at the 3-month follow-up, 5 events (1.2%; 95% CI, 0.2%-2.1%) had occurred in patients in whom diagnosis of DVT or PE had previously been ruled out. None of the patients had major bleeding events. Ninety percent of patients were treated as outpatients. Conclusion: Our study demonstrates that this approach allows the safe deferral of diagnostic procedures for DVT and PE for up to 72 hours.

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