在基层医疗中安全排除深静脉血栓形成

Safely ruling out deep venous thrombosis in primary care.

作者信息

Büller Harry R, Ten Cate-Hoek Arina J, Hoes Arno W, Joore Manuela A, Moons Karel G M, Oudega Ruud, Prins Martin H, Stoffers Henri E J H, Toll Diane B, van der Velde Eit F, van Weert Henk C P M

机构信息

Academic Medical Center, Department of Vascular Medicine, University of Amsterdam, Amsterdam, the Netherlands.

出版信息

Ann Intern Med. 2009 Feb 17;150(4):229-35.

PMID:19221374

Abstract

BACKGROUND

Up to 90% of patients referred for ultrasonography with suspected deep venous thrombosis (DVT) of the leg do not have the disease.

OBJECTIVE

To evaluate the safety and efficiency of using a clinical decision rule that includes a point-of-care d-dimer assay at initial presentation in primary care to exclude DVT.

DESIGN

A prospective management study.

SETTING

Approximately 300 primary care practices in 3 regions of the Netherlands (Amsterdam, Maastricht, and Utrecht).

PATIENTS

1028 consecutive patients with clinically suspected DVT.

INTERVENTION

Patients were managed on the basis of the result of the clinical decision rule, which included a d-dimer result. Patients with a score of 3 or less were not referred for ultrasonography and received no anticoagulant treatment; patients with a score of 4 or more were referred for ultrasonography.

MEASUREMENTS

The primary outcome was symptomatic, objectively confirmed, venous thromboembolism during 3-month follow-up.

RESULTS

The mean age of the 1028 study patients was 58 years, and 37% of patients were men. A valid score was obtained in 1002 patients (98%). In 500 patients (49%), with a score of 3 or less, 7 developed venous thromboembolism within 3 months (incidence, 1.4% [95% CI, 0.6% to 2.9%]). A total of 502 patients (49%) had a score of 4 or more; 3 did not have ultrasonography. Ultrasonography showed DVT in 125 patients (25%), for an overall prevalence in evaluable patients of 13% (125 of 1002). Of the 374 patients who had normal ultrasonography results, 4 developed venous thromboembolism within 3 months (1.1% [CI, 0.3% to 2.7%]).

LIMITATION

The study lacked a randomized design and relied on clinical follow-up to detect missed thrombotic disease.

CONCLUSION

A diagnostic management strategy in primary care by using a simple clinical decision rule and a point-of-care d-dimer assay reduces the need for referral to secondary care of patients with clinically suspected DVT by almost 50% and is associated with a low risk for subsequent venous thromboembolic events.

FUNDING

The Netherlands Organization for Scientific Research.

摘要

背景

转诊进行腿部深静脉血栓形成（DVT）疑似超声检查的患者中，高达90%并无此病。

目的

评估在初级保健机构初次就诊时使用包含即时检测D-二聚体检测的临床决策规则来排除DVT的安全性和有效性。

设计

一项前瞻性管理研究。

地点

荷兰3个地区（阿姆斯特丹、马斯特里赫特和乌得勒支）约300家初级保健机构。

患者

1028例临床疑似DVT的连续患者。

干预

根据临床决策规则的结果对患者进行管理，该规则包括D-二聚体检测结果。得分3分及以下的患者不转诊进行超声检查，也不接受抗凝治疗；得分4分及以上的患者转诊进行超声检查。

测量指标

主要结局为3个月随访期间有症状的、经客观证实的静脉血栓栓塞。

结果

1028例研究患者的平均年龄为58岁，37%为男性。1002例患者（98%）获得了有效评分。500例患者（49%）得分3分及以下，其中7例在3个月内发生静脉血栓栓塞（发生率为1.4%[95%CI，0.6%至2.9%]）。共有502例患者（49%）得分4分及以上；3例未进行超声检查。超声检查显示125例患者（25%）有DVT，在可评估患者中的总体患病率为13%（1002例中的125例）。在超声检查结果正常的374例患者中，4例在3个月内发生静脉血栓栓塞（1.1%[CI，0.3%至2.7%]）。