Research ArticleSystematic ReviewsA

Review of the Evidence on Diagnosis of Deep Venous Thrombosis and Pulmonary Embolism

Jodi B. Segal, John Eng, Leonardo J. Tamariz and Eric B. Bass
The Annals of Family Medicine January 2007, 5 (1) 63-73; DOI: https://doi.org/10.1370/afm.648

Article Figures & Data

Tables

  • Table 1.

    Wells Prediction Rule for Deep Venous Thrombosis: Clinical Evaluation Table for Predicting Pretest Probability of Deep Vein Thrombosis

    Clinical CharacteristicScore
    Note: A score of 3 or higher indicates a high probability of deep vein thrombosis; 1 or 2, a moderate probability; and 0 or lower, a low probability. In patients with symptoms in both legs, the more symptomatic leg is used.
    Reprinted from The Lancet, Vol 350, Wells PS, Anderson DR, Bormanis J, et al. Value of assessment of pretest probability of deep-vein thrombosis in clinical management, pp 1795–1798, Copyright 2002, with permission from Elsevier.
    Active cancer (treatment ongoing, within previous 6 months or palliative)1
    Paralysis, paresis, or recent plaster immobilization of the lower extremities1
    Recently bedridden >3 days or major surgery within 12 weeks requiring general or regional anesthesia1
    Localized tenderness along the distribution of the deep venous system Entire leg swollen1
    Calf swelling 3 cm larger than asymptomatic side (measured 10 cm below tibial tuberosity)1
    Pitting edema confined to the symptomatic leg1
    Collateral superficial veins (nonvaricose)1
    Alternative diagnosis at least as likely as deep venous thrombosis−2
  • Table 2.

    Geneva and Wells Prediction Rules for Pulmonary Embolism

    Geneva ScorePointsWells ScorePoints
    PaCO2 = partial pressure of carbon dioxide, arterial; PaO2 = partial pressure of oxygen, arterial.
    Adapted from Am J Med, Vol 113, Chagnon I, Bounameaux H, Aujesky D, et al, Comparison of two clinical prediction rules and implicit assessment among patients with suspected pulmonary embolism, pp 269–275, Copyright 2002, with permission from Elsevier.
    Previous pulmonary embolism or deep vein thrombosis+2Previous pulmonary embolism or deep vein thrombosis+1.5
    Heart rate >100 beats per minute+1Heart rate >100 beats per minute+1.5
    Recent surgery+3Recent surgery or immobilization+1.5
    Age, yearsClinical signs of deep vein thrombosis+3
        60–79+1Alternative diagnosis less likely than+3
        ≥80+2Pulmonary embolism+1
    PaCO2+2Hemoptysis+1
        <4.8 kPA (36 mm Hg)+1Cancer
        4.9–5.19 kPa (37–38.9 Hg)+4
    PaO2+3
        <6.5 kPa (48.7 mm Hg)+2
        6.5–7.99 kPa (48.7–55.0 mm Hg)+1
        8–9.49 kPa (60–71.2 mm Hg)+1
        9.5–10.99 kPa (71.4–82.4 mm Hg)+1
    Atelectasis0–4
    Elevated hemidiaphragm5–8
    Clinical probability≥9Clinical probability0–1
        Low    Low2–6
        Intermediate    Intermediate≥7
        High    High
  • Table 3.

    Summary of Systematic Reviews Evaluating the Accuracy of Ultrasound for the Diagnosis Of Deep Venous Thrombosis

    Author, YearClinical PresentationAnatomic RegionNo. of PatientsPrevalence of DVT %Combined Sensitivity % [95% CI] or (range)Combined Specificity % [95% CI] or (range)
    DVT = deep venous thrombosis; CI = confidence interval; NR = not reported.
    * Diagnostic odds ratio.
    White et al,50 1989SymptomaticThigh2664693 [88–97]98 [96–100]
    Becker et al,51 1989SymptomaticThigh and calf1,5785096 (92–100)99 (96–100)
    Cogo et al,52 1995SymptomaticThigh989439698
    Wells et al,53 1995AsymptomaticThigh1,61696297
    Kearon et al,54 1998SymptomaticThigh2,7634089 [85–92]94 [90–98]
    AsymptomaticThigh2,0351647 [37–57]94 [91–98]
    Gottlieb et al,55 1999SymptomaticCalf2122593 [82–98]99 [96–99]
    Mustafa et al,56 2002SymptomaticUpper extremity17073(56–100)(77–100)
    Kassai et al,57 2004AsymptomaticThigh4,182NR645* [170–2,450]
    Calf2,324NR35* [12–105]
  • Table 4.

    Summary of Systematic Reviews of the Accuracy of Computed Tomography for the Diagnosis of Pulmonary Embolism

    Author, YearMain Inclusion CriteriaNo. of PatientsPrevalence of Pulmonary Embolism %Pooled Sensitivity % (Range)or [95% CI]Pooled Specificity % (Range)or [95% CI]
    CI = confidence interval; PA = pulmonary arteriography; CT = computed tomography; PE = pulmonary embolism; NR = not reported; V/Q = ventilation-perfusion.
    * Results include only patients in whom pulmonary angiography was used as reference standard.
    † Positive likelihood ratio.
    ‡ Negative likelihood ratio.
    Harvey et al,60 2000Prospective and retrospective studies with PA as reference standard in most cases8133479 (47–100)89 (75–100)
    Mullins et al,61 2000Diagnosis established by PA or a clinical reference standard*3673593 (50–100)97 (92–100)
    Rathbun et al,62 2000Prospective studies evaluating use of CT for diagnosis of PE using any reference Standard1,330NR(53–100)(81–100)
    Cueto et al,63 2001Prospective studies with positive and negative CT results; PA reference standard268NR80 [73–86]94 [91–98]
    van Beek et al, 64 2001Prospective studies reporting sensitivity and specificity of CT relative to PA or V/Q scan1,1713988 [83–91]92 [89–94]
    Safriel & Zinn,65 2002Diagnosis established by PA or high- probability V/Q scan1,250NR74 [57–100]90 [68–100]
    Roy et al,66 2005Prospective studies;431NR24 (12–47)†
    consecutive patients; diagnosis established by PA for confirmation strategies, and PA or clinical follow-up for exclusion strategies1,197NR0.11 (0.06–0.19)‡
    Hayashino et al,67 2005Studies of helical CT compared to PA obtained within 48 hr520NR86 (80–92)94 (91–96)
    Hogg et al,68 2006Prospective studies with 85% follow-up, with adequate reference standard, or clinical follow-up after negative CT74919–7989 (82–95)95 (91–98)
  • Table 5.

    Summary of Primary Studies of the Accuracy of Computed Tomography for the Diagnosis of Pulmonary Embolism

    Author, YearMain Inclusion CriteriaNo. of CT DetectorsNo. of PatientsMost Distal Arterial Level InterpretedPE Prevalence %Sensitivity % (95% CI)Specificity % (95% CI)
    CT = computed tomography; PE = pulmonary embolism; CI = confidence interval; V/Q = ventilation-perfusion ICU = intensive care unit.
    Remy-Jardin et al,70 1992Clinically suspected PE or unexplained chest radiograph abnormality142Segmental43100 [81–100]96 [79–100]
    Blum et al,71 1994Clinical suspicion of massive PE110Segmental70100 [59–100]100 [29–100]
    Goodman et al,72 1995Nondiagnostic V/Q scan120Subsegmental5564 [31–89]89 [52–100]
    Remy-Jardin et al,73 1996Referral for pulmonary arteriography175Segmental5791 [78–97]78 [60–91]
    Christiansen, 199774High clinical suspicion of PE170Segmental2789 [67–99]96 [87–100]
    Drucker et al,75 1998Referral for pulmonary arteriography147Segmental3260 [32–84]81 [64–93]
    Qanadli et al,76 2000Referral to the radiology department2157Subsegmental3990 [80–96]94 [87–98]
    Velmahos et al,77 2001Surgical ICU patients with explicitly defined clinical 3 ndings associated with PE122Subsegmental5045 [17–77]82 [48–98]
    Winer-Muram et al,69 2004 (multidetector CT)Emergency department and inpatients referred for pulmonary arteriography493Subsegmental19100 [81–100]89 [80–95]

Additional Files

  • Supplemental Appendixes

    Supplemental Appendixes 1-4

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  • The Article in Brief

    Review of the Evidence on Diagnosis of Deep Venous Thrombosis and Pulmonary Embolism

    Jodi Segal , and colleagues

    Background Venous thromboembolism refers to two related conditions: deep venous thrombosis (a blood clot that can form, most often in the deep veins in the legs, thighs, or pelvis) and pulmonary embolism (which occurs if part or all of the blood clot in a deep vein breaks off and blocks an artery in the lung). Practical methods of diagnosing venous thromboembolism are important so that the condition can be treated early. This systematic review summarizes the evidence about the effectiveness of techniques for diagnosing deep venous thrombosis and pulmonary embolism.

  • Annals Journal Club Selection:

    Jan/Feb 2007

    The Annals Journal Club is designed to encourage a learning community of those seeking to improve health care and health through enhanced primary care. Additional information is available on the Journal Club home page.

    The Annals of Family Medicine encourages readers to develop the learning community of those seeking to improve health care and health through enhanced primary care. You can participate by conducting a RADICAL journal club, and sharing the results of your discussions in the Annals online discussion for the featured articles. RADICAL is an acronym for: Read, Ask, Discuss, Inquire, Collaborate, Act, and Learn. The word radical also indicates the need to engage diverse participants in thinking critically about important issues affecting primary care, and then acting on those discussions.1

    Articles for Discussion

    • Segal JB, Eng J, Tamariz LJ, Bass EB. Review of the evidence on diagnosis of deep venous thrombosis and pulmonary embolism. Ann Fam Med. 2007;5(1):63-73.
    • Qaseem A, Snow V, Barry P, et al. Current diagnosis of venous thromboembolism in primary care: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians. Ann Fam Med. 2007;5(1):57-62.

    Discussion Tips

    These articles portray a clinical policy guideline developed by two collaborating professional organizations and the evidence review that was used to develop the guideline. We recommend beginning with the clinical practice guideline for an overview of the scientific evidence, and then reading and discussing the evidence review with an emphasis on how often narrowly configured evidence is framed, retrieved, evaluated, synthesized, and translated into recommendations for practice.2,3 (You also may wish to look at the companion management guideline published in this issue, and the accompanying evidence review published in the Annals of Internal Medicine.)

    Discussion Questions

    • What are the recommendations?
    • How strong is the evidence for each recommendation?
    • What questions were used to frame the evidence review and the guideline development? How well do these questions reflect your questions when faced with a patient in whom you suspect a venous thrombus or a thromboembolism?
    • How well does the study selection approach capture all relevant data?
    • Were all relevant outcomes considered?
    • How were different outcomes and trade-offs considered in making overall recommendations?
    • How do you interpret the variability in some of the studies that went into the evidence review? What effect does this variability have on your application of the findings?
    • What biases are apparent in how the evidence was evaluated and synthesized?
    • How well did the organizations specify their process for developing the guideline from the scientific evidence?
    • How practical are the recommendations for use in practice? How applicable are they to your patients and setting?
    • What needs for primary care�relevant information does this evidence review and recommendation identify?

    References

    1. Stange KC, Miller WL, McLellan LA, et al. Annals journal club: It�s time to get RADICAL. Ann Fam Med. 2006;4:196-197. Available at: http://annfammed.org/cgi/content/full/4/3/196.
    2. Hayward RSA, Wilson MC, Tunis SR, Bass EB, Guyatt GH. Users� guides to the medical literature. VIII. How to use clinical practice guidelines. A. Are the recommendations valid? JAMA. 1995;274(7):570-574.
    3. Wilson MC, Hayward RS, Tunis SR, Bass EB, Guyatt G. Users� guides to the medical literature. VIII. How to use clinical practice guidelines. B. What are the recommendations, and will they help you in caring for your patients? JAMA. 1995;274(20):1630-1632.
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