DVT_clot_illustration  

Diagnosis of DVT: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. 

[Link to free full-text Guideline Summary at National Guideline Clearinghouse]

Bates SM, Jaeschke R, Stevens SM, Goodacre S, Wells PS, Stevenson MD, Kearon C, Schunemann HJ, Crowther M, Pauker SG, Makdissi R, Guyatt GH. Diagnosis of DVT: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2012 Feb;141(2 Suppl):e351S-418S. [Free full-text Chest article PDF | PubMed® abstract]

[EXCERPTS]

Major Recommendations

Diagnosis of Suspected First Lower Extremity Deep Vein Thrombosis (DVT)

In patients with a suspected first lower extremity DVT, the expert panel suggests that the choice of diagnostic tests process should be guided by the clinical assessment of pretest probability rather than by performing the same diagnostic tests in all patients (Grade 2B).

Testing Using Risk Stratification

In patients with a low pretest probability of first lower extremity DVT (see Fig. 1 in the original guideline document), the expert panel recommends one of the following initial tests: (i) a moderately sensitive D-dimer, (ii) a highly sensitive D-dimer, or (iii) compression ultrasonography (CUS) of the proximal veins rather than (i) no diagnostic testing (Grade 1B for all comparisons), (ii) venography (Grade 1B for all comparisons), or (iii) whole-leg ultrasound (US) (Grade 2B for all comparisons). The expert panel suggests initial use of a moderately sensitive (Grade 2C) or highly sensitive (Grade 2B) D-dimer rather than proximal CUS.

If the D-dimer is negative (see Fig. 1 in the original guideline document), the expert panel recommends no further testing over further investigation with (i) proximal CUS, (ii) whole-leg US, or (iii) venography (Grade 1B for all comparisons). If the proximal CUS is negative, the expert panel recommends no further testing compared with (i) repeat proximal CUS after 1 week, (ii) whole-leg US, or (iii) venography (Grade 1B for all comparisons).

If the D-dimer is positive (see Fig. 1 in the original guideline document), the expert panel suggests further testing with CUS of the proximal veins rather than (i) whole-leg ultrasonography (US) (Grade 2C) or (ii) venography (Grade 1B). If CUS of the proximal veins is positive, the expert panel suggests treating for DVT and performing no further testing over performing confirmatory venography (Grade 2C).

In patients with a moderate pretest probability of first lower extremity DVT (see Fig. 2 in the original guideline document), the expert panel recommends one of the following initial tests: (i) a highly sensitive D-dimer or (ii) proximal CUS, or (iii) whole-leg US rather than (i) no testing (Grade 1B for all comparisons) or (ii) venography (Grade 1B for all comparisons). The expert panel suggests initial use of a highly sensitive D-dimer rather than US (Grade 2C).

If the highly sensitive D-dimer is negative (see Fig. 2 in the original guideline document), the expert panel recommends no further testing over further investigation with (i) proximal CUS, (ii) whole-leg US, or (iii) venography (Grade 1B for all comparisons).

If the highly sensitive D-dimer is positive, the expert panel recommends proximal CUS or whole-leg US rather than no testing (Grade 1B for all comparisons) or venography (Grade 1B for all comparisons).

If proximal CUS is chosen as the initial test and is negative (see Fig. 2 in the original guideline document), the expert panel recommends (i) repeat proximal CUS in 1 week or (ii) testing with a moderate or highly sensitive D-dimer assay over no further testing (Grade 1C) or venography (Grade 2B). In patients with a negative proximal CUS but a positive D-dimer, the expert panel recommends repeat proximal CUS in 1 week over no further testing (Grade 1B) or venography (Grade 2B).

In patients with (i) negative serial proximal CUS or (ii) a negative single proximal CUS and negative moderate or highly sensitive D-dimer, the expert panel recommends no further testing rather than further testing with (i) whole-leg US or (ii) venography (Grade 1B for all comparisons).

If whole-leg US is negative (see Fig. 2 in the original guideline document), the expert panel recommends no further testing over (i) repeat US in one week, (ii) D-dimer testing, or (iii) venography (Grade 1B for all comparisons). If proximal CUS is positive, the expert panel recommends treating for DVT rather than confirmatory venography (Grade 1B). If isolated distal DVT is detected on whole-leg US, the expert panel suggests serial testing to rule out proximal extension over treatment (Grade 2C).

In patients with a high pretest probability of first lower extremity DVT (see Fig. 3 in the original guideline document), the expert panel recommends either (i) proximal CUS or (ii) whole-leg US over no testing (Grade 1B for all comparisons) or venography (Grade 1B for all comparisons).

If proximal CUS or whole-leg US is positive for DVT (see Fig. 3 in the original guideline document), the expert panel recommends treatment rather than confirmatory venography (Grade 1B).

In patients with a negative proximal CUS (see Fig. 3 in the original guideline document), the expert panel recommends additional testing with a highly sensitive D-dimer or whole-leg US or repeat proximal CUS in 1 week over no further testing (Grade 1B for all comparisons) or venography (Grade 2B for all comparisons). The expert panel recommends that patients with a single negative proximal CUS and positive D-dimer undergo whole-leg US or repeat proximal CUS in 1 week over no further testing (Grade 1B) or venography (Grade 2B). In patients with negative serial proximal CUS, a negative single proximal CUS and negative highly sensitive D-dimer, or a negative whole-leg US, the expert panel recommends no further testing over venography or additional US (Grade 1B for negative serial proximal CUS and for negative single proximal CUS and highly sensitive D-dimer; Grade 2B for negative whole-leg US).

The expert panel recommends that in patients with high pretest probability (see Fig. 3 in the original guideline document), moderately or highly sensitive D-dimer assays should not be used as stand-alone tests to rule out DVT (Grade 1B).

Definitions:

Strength of the Recommendations Grading System [available online]

[Link to free full-text Guideline Summary at National Guideline Clearinghouse] 

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