Clinical Prediction of Lower Limb Deep Vein Thrombosis in Symptomatic Hospitalized Patients

Summary

We evaluated two clinical scores for the prediction of deep venous thrombosis (DVT) in hospitalized patients (Wells’ and Kahn’s). We included 273 patients referred to the vascular exploration unit for the suspicion of DVT. A clinical questionnaire was filled in by the practitioner and the scores were calculated from this form. 66 of the 273 patients had a DVT. When Wells’ score was 3, a DVT was found by duplex echography in 51% patients ; when the score was 0, a DVT was found in 9%. Kahn’s score was not adapted to this population. We then developed a new simple score (cancer, palsy or plaster immobilization, warmth, superficial venous dilation, unilateral pitting edema, other diagnosis). A DVT was found in 76% patients with a score of 3 and in 11% in those with a score of 0. We therefore propose a 6-item score whose main advantages are simplicity and usefulness in routine practice.

Keywords

Deep venous thrombosis - clinical prediction - venous thromboembolic disease

• References

• 1 Anderson Jr FA, 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: 933-8.
• 2 Alpert JS, Dalen JE. Epidemiology and natural history of venous thromboembolism. Prog Cardiovasc Dis 1994; 36: 417-22.
• 3 Diebold J, Lohrs U. Venous thrombosis and pulmonary embolism. A study of 5039 autopsies. Pathol Res Pract 1991; 187: 260-6.
• 4 Saeger W, Genzkow M. Venous thromboses and pulmonary embolisms in post-mortem series: probable causes by correlations of clinical data and basic diseases. Path Res Pract 1994; 190: 394-9.
• 5 Lindblad B, Sternby NH, Berqvist D. Incidence of venous thromboembolism verified by necropsy over 30 years. B M J 1991; 302: 709-11.
• 6 McLachlin J, Richards T, Paterson JC. An evaluation of clinical signs in the diagnosis of venous thrombosis. Arch Surg 1962; 85: 738-44.
• 7 Hager K. Problems of acute deep venous thrombosis. I. The interpretation of signs and symptoms. Angiology 1969; 20: 219-23.
• 8 Cranley JJ, Canos AJ, Sull WJ. The diagnosis of deep venous thrombosis. Fallibility of clinical symptoms and signs. Arch Surg 1976; 111: 34-6.
• 9 Sandler DA, Martin JF, Duncan JS. et al. Diagnosis of deep vein thrombosis: comparison of clinical evaluation, ultrasound, plethysmography and venogram with X-ray venogram. Lancet 1984; 2: 716-9.
• 10 Wells PS, Hirsh J, Anderson DR. et al. Accuracy of clinical assessment of deep-vein thrombosis. Lancet 1995; 345: 1326-30.
• 11 Kearon C, Julian JA, Newman TE. et al. Non-invasive diagnosis of deep venous thrombosis. Ann Intern Med 1998; 128: 663-77.
• 12 Becker DM, Philbrick JT, Abbitt PL. Real time ultrasonography for the diagnosis of lower extremity deep venous thrombosis. Arch Intern Med 1989; 149: 1731-4.
• 13 Elias A, Le Corff G, Bouvier JL, Benichou M, Serradmigni A. Value of real time B-mode ultrasound imaging in the diagnosis of deep venous thrombosis of the lower limbs. Int Angiol 1987; 6: 157-82.
• 14 Rose SC, Zwiebel WJ, Nelson BD, Priest DL. et al. Symptomatic lower extremity deep venous thrombosis: accuracy, limitations and role of color duplex flow imaging in diagnosis. Radiology 1990; 175: 639-44.
• 15 Prandoni P, Lensing AWA, Buller HR. et al. Failure of computerized impedance plethysmography in the diagnosis management of patients with clinically suspected deep vein thrombosis. Thromb Haemost 1991; 65: 233-36.
• 16 Kearon C, Julian JA, Newman TE, Ginsberg JS. Non-invasive diagnosis of deep venous thrombosis. Ann Intern Med 1998; 128: 663-77.
• 17 Landefield CS, McGuire E, Cohen AM. Clinical findings associated with acute proximal deep vein thrombosis: a basis for quantifying clinical judgment. Am J Med 1990; 88: 382-8.
• 18 Wells PS, Anderson DR, Bormanis J. et al. Application of a diagnostic clinical model for the management of hospitalized patients with suspected deep-vein thrombosis. Thromb Haemost 1999; 81: 493-7.
• 19 Kahn SR, Joseph, Abenhaim L, Leclerc JR. Clinical prediction of deep vein thrombosis in patients with leg symptoms. Thromb Haemost 1999; 81: 353-7.
• 20 Dauzat M, Laroche JP, Charras C. et al. Real-time B mode ultrasonography for better specificity in the non-invasive diagnosis of deep venous thrombosis. J Ultrasound Med 1986; 5: 625-31.
• 21 Persson AV, Jones C, Zide R, Jewell ER. Use of the triplex scanner in diagnosis of deep venous thrombosis. Arch Surg 1989; 124: 593-7.
• 22 Colton T. Statistics in Medicine. Boston, Massachusetts: Little, Brown and company; 1974
• 23 Hosmer DW, Lemeshow S. Applied Logistic Regression. New York: John Wiley and sons; 1989
• 24 Hanley JA, McNeil BJ. The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology 1982; 143: 29-36.
• 25 Hull R, Hirsh J, Sackett DL, Stoddart G. Cost effectiveness of clinical diagnosis, venography, and noninvasive testing in patients with symptomatic deep-vein thrombosis. N Eng J Med 1981; 304: 1561-7.
• 26 Heijboer H, Buller HR, Lensing AWA, Turpie AGG, Colly LP, Ten Cate JW. A comparison of real-time compression ultrasonography with impedance plethysmography for the diagnosis of deep-vein thrombosis in symptomatic outpatients. N Eng J Med 1993; 329: 1365-9.
• 27 Ginsberg JS, Wells PS, Hirsh J. et al. Re-evaluation of the sensitivity of impedance plethysmography for the detection of proximal deep vein thrombosis. Arch Intern Med 1994; 154: 1930-3.
• 28 Coon WW, Willis PW, Keeler JB. Venous thromboembolism and other venous diseases in the Tecumseh Community Health study. Circulation 1973; 48: 839-46.
• 29 Briscoe ME. Why do people go to the doctor? Sex differences in the correlates of GP consultation. Soc Sci and Med 1987; 25: 507-13.
• 30 Nicolaides AN, Irving D. Clinical factors and the risk of deep vein thrombosis. in: Thromboembolism. Nicolaides AN. Ed. Baltimore: University Park Press; 1975: 193-204.
• 31 Janssen HF, Schachner J, Hubbard J, Hartman JT. The risk of deep venous thrombosis: a computerized epidemiologic approach. Surgery 1987; 101: 205-12.
• 32 Wasson JH, Sox HC, Neff RK, Goldman L. Clinical prediction rules. Applications and methodological standards. N Eng J Med 1985; 313: 793-9.
• 33 Laupacis A, Sekar N, Stiell IG. Clinical prediction rules. A review and suggested modifications of methodological standards. JAMA 1997; 277: 488-94.