Avaliação do manejo diagnóstico de trombose venosa profunda no departamento de emergência de um hospital terciário em Santa Catarina: um estudo transversal
Evaluation of the diagnostic management of deep vein thrombosis in the emergency department of a tertiary hospital in Santa Catarina, Brazil: a cross-sectional study
Background: Venous thromboembolism is an entity that encompasses both deep vein thrombosis and pulmonary thromboembolism. Although protocols for the diagnosis of these diseases are well defined, there is evidence of inappropriate use of diagnostic resources. Objectives: To define the epidemiological profiles of patients admitted to the emergency department with suspected deep vein thrombosis, to determine rates of inappropriate ordering of D-dimer assays and color venous Doppler echocardiography of the lower limbs, and to identify whether these requests followed the recommendations contained in the 2015 Brazilian Society of Angiology and Vascular Surgery guidelines. Methods: We conducted a cross-sectional observational study that retrospectively evaluated 168 patients with suspected deep vein thrombosis for whom D-dimer assays were requested. The most common risk factors were measured and the pretest probability was calculated with the Wells score. The epidemiological profile of these patients and the rates of inappropriate D-dimer testing were assessed using descriptive statistics. Results: The D-dimer requests were inadequate in 55 (32.7%) patients. Venous color Doppler ultrasound was used to examine the lower limbs of 14 (8.3%) of the patients with a low probability according to the Wells score and a negative D-dimer result. No additional diagnostic methods were used in 19 (11.3%) of those with a low probability according to the Wells score and a high D-dimer result. There was unnecessary use of CDUS in 35 (20.8%) cases. The overall rate of inappropriate workup was 53.5%. Conclusions: Differences were found between clinical practice and the recommendations for diagnostic evaluation of patients with suspected deep vein thrombosis, with inappropriate use of diagnostic tests.
1 Tritschler T, Kraaijpoel N, Le Gal G, Wells PS. Venous thromboembolism: Advances in Diagnosis and Treatment. JAMA. 2018;320(15):1583-94.
2 Anderson FA Jr, Wheeler HB, Goldberg RJ, et al. A population-based perspective of the hospital incidence and case fatality rates of deep vein thrombosis and pulmonary embolism: the Worcester DVT study. Arch Intern Med. 1991;151(5):933-8.
3 White RH. The epidemiology of venous thromboembolism. Circulation. 2003;107(23, Suppl 1):I4-8. PMid:12814979.
4 Barros MVL, Pereira VSR, Pinto DM. Controvérsias no diagnóstico e tratamento da trombose venosa profunda pela ecografia vascular. J Vasc Bras. 2012;11(2):137-43.
5 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.
6 Wells PS, Anderson DR, Bormanis J, et al. Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet. 1997;350(9094):1795-8.
7 Bounameaux H, Cirafici P, De Moerloose P, et al. Measurement of D-dimer in plasma as diagnostic aid in suspected pulmonary embolism. Lancet. 1991;337(8735):196-200.
8 Huisman MV, Klok FA. Diagnostic management of acute deep vein thrombosis and pulmonary embolism. J Thromb Haemost. 2013;11(3):412-22.
9 Wells PS, Owen C, Doucette S, Fergusson D, Tran H. Does this patient have deep vein thrombosis? JAMA. 2006;295(2):199-207.
10 Gaitini D. Current approaches and controversial issues in the diagnosis of deep vein thrombosis via duplex doppler ultrasound. J Clin Ultrasound. 2006;34(6):289-97.
11 Choosing Wisely Initiative. ABIM foundation [atualizado 2020 ago 03; citado 2020 ago 05].
12 Fortes VB, Rollo HA, Fortes AT Jr, et al. Avaliação do modelo de predição clínica de Wells et al. no diagnóstico da trombose venosa profunda dos membros inferiores. J Vasc Bras. 2007;6(1):7-16.
13 Rollo HA, Fortes VB, Fortes AT Jr, et al. Abordagem diagnóstica dos pacientes com suspeita de trombose venosa profunda dos membros inferiores. J Vasc Bras. 2005;4(1):79-92.
14 Thachil J, Fitzmaurice DA, Toh CH. Appropriate use of d-dimer in hospital patients. Am J Med. 2010;123(1):17-9.
15 Pânico MDB, Matielo MF, Porto CLL, Marques MA, Yoshida RDA. Projeto Diretrizes SBACV. Trombose venosa profunda diagnóstico e tratamento. São Paulo: SBACV; 2015
16 Dean AG, Sullivan KM, Soe MM. OpenEpi: Open Source Epidemiologic Statistics for Public Health. Versão 3.01 [atualizado 2013 maio 06; citado 2022 abr 17]. http: www.openepi.com
17 Teismann NA, Cheung PT, Frazee B. Is the ordering of imaging for suspected venous thromboembolism consistent with D- dimer result? Ann Emerg Med. 2009;54(3):442-6.
18 Wells PS, Anderson DR, Rodger M, et al. Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. N Engl J Med. 2003;349(13):1227-35.
19 Stein PD, Hull RD, Patel KC, et al. D-Dimer for the exclusion of acute venous thrombosis and pulmonary embolism. A systematic review. Ann Intern Med. 2004;140(8):589-602.
20 Righini M, Van Es J, Den Exter PL, et al. Age-adjusted d-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study. JAMA. 2014;311(11):1117-24.
21 Arnason T, Wells PS, Forster AJ. Appropriateness of diagnostic strategies for evaluating suspected venous thromboembolism. Thromb Haemost. 2007;97(2):195-201.
22 Courtney DM, Kline JA, Kabrhel C, et al. Clinical features from the history and physical examination that predict the presence or absence of pulmonary embolism in symptomatic emergency department patients: Results of a prospective, multicenter study. Ann Emerg Med. 2010;55(4):307-315.e1.
23 Heit JA, Spencer FA, White RH. The epidemiology of venous thromboembolism. J Thromb Thrombolysis. 2016;41(1):3-14.
24 Bulger CM, Jacobs C, Patel NH. Epidemiology of acute deep vein thrombosis. Tech Vasc Interv Radiol. 2004;7(2):50-4.
25 Kniffin WD Jr, Baron JA, Barrett J, Birkmeyer JD, Anderson FA Jr. The epidemiology of diagnosed pulmonary embolism and deep venous thrombosis in the Eldery. Arch Intern Med. 1994;154(8):861-6.
26 Shields GP, Turnipseed S, Panacek EA, Melnikoff N, Gosselin R, White RH. Validation of the Canadian clinical probability model for acute venous thrombosis. Acad Emerg Med. 2002;9(6):561-6.
27 Kearon C, Ginsberg GS, Douketis JD, et al. Management of suspect deep venous thrombosis in outpatients by using clinical assessment and D-dimer testing. Ann Intern Med. 2001;135(2):108-11.
28 Kamolratanapiboon K, Tantanate C. Inappropriate use of D-dimer and impact on the test characteristics for deep vein thrombosis exclusion. Scand J Clin Lab Invest. 2019;79(6):431-6.
29 Kristoffersen AH, Ajzner E, Rogic D, et al. Is d-dimer used according to clinical algorithms in the diagnostic work-up patients with suspicion of venous thromboembolism? A study in six European countries. Thromb Res. 2016;142:1-7.
30 Wells PS, Anderson DR. Diagnosis of deep-vein thrombosis in the year 2000. Curr Opin Pulm Med. 2000;6(4):309-13.
31 Mousa AY, Broce M, Gill G, Kali M, Yacoub M, AbuRahma AF. Appropriate use of D-dimer testing can minimize over-utilization of venous duplex ultrasound in a contemporary high-volume hospital. Ann Vasc Surg. 2015;29(2):311-7.
32 Wells PS, Anderson DR, Rodger M, et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer. Ann Intern Med. 2001;135(2):98-107.
33 Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999;282(15):1458-65.