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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, MD;
Raffaela Anastasio, MD;
Camillo Porta, MD;
Francesco Falaschi, MD;
Stefano Pirrelli, MD;
Piernicola Palmieri, MD;
Gabriella Gamba, MD;
Katerina Granzow, MD;
Alessandra Malato, MD;
Viviana Minardi, MD;
Paola Tatoni, MD;
Maria Antonietta Bressan, MD;
Guglielmo Mariani, MD
Arch Intern Med. 2004;164:2477-2482.
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 Affiliations: Thrombosis and Hemostasis Unit, Division of Haematology, University of Palermo, Palermo (Drs Siragusa, Anastasio, Malato, and Minardi); Servizio Pronto Soccorso Accettazione (Drs Porta, Falaschi, Granzow, Tatoni, and Bressan), Divisione di Chirurgia Vascolare (Drs Pirrelli and Palmieri), Medicina Interna ed Oncologia Medica (Dr Gamba), IRCCS Policlinico San Matteo, Pavia; and Cattedra di Ematologia, Dipartimento di Medicina Interna e Sanità Pubblica, Università de L’Aquila, L’Aquila (Dr Mariani), Italy.
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
Objective Assessment of Pulmonary Embolism Can Be Deferred without Increased Risk.
Siragusa et al.
ASH ANNUAL MEETING ABSTRACTS 2005;106:1628-1628.
ABSTRACT
ED Management of DVT and PE
JWatch Emergency Med. 2005;2005:1-1.
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