Diagnosis of

Deep Vein
Thrombosis, A
New Gold
Standard
Tori McCormick
Department of Nursing, Youngstown State University
NURS 6901: Theoretical Foundations
Dr. Valerie O’Dell
August 18, 2020
Introduction
+ How does ultrasound as compared to a d-dimer
affect the accuracy of ruling out deep vein
thrombosis?
+ Proposal
+ Identify and promote new evidence-based practice that
identifies ultrasounds as the gold standard for the diagnosis
of deep vein thrombosis.
+ Formulate an improved diagnostic framework tool based
on the Wells Criteria
+ Cost and time effective
+ Least invasive
+ Least possible risk factors
 Background
+ Venus thromboembolism is a life-threatening
condition
+ Accurate diagnosis and correct therapy are
imperative
+ Venus duplex ultrasound is the new gold standard due to
d-dimer’s lack of specificity
+ Low specificity influences physiological and pathological
factors that could increase the result leading to false positives
• Examples include; increased age,
pregnancy, trauma, cancer and
inflammation
+ Ultrasound is a straightforward diagnostic tool not influenced
by the same factors of the d-dimer
 Background cont.
+ Timely diagnosis and treatment decreases
the risk of pulmonary embolism and
hemodynamic complications.
+ D-dimers increase wait time due to false positives
calling for unnecessary testing
+ Evidence based practice elicits ultrasound as the
standard for deep vein thrombosis because of timely
diagnosis and relatively no possible complications
+ With standards changing what can we do to improve
the deep vein thrombosis diagnostic process?
Objective
+ Assess the reliability of d-dimer assays
and ultrasounds in the diagnosis of
deep vein thrombosis.
+ Reliability is based upon specificity and
sensitivity of both diagnostic tools
+ Improve the Well’s scoring criteria by:
+ Updating and adding categories that take into
account more physiological and pathological
risk factors that influence d-dimer manipulation
+ This implementation may pave the way
for safer more cost-effective practices
Method

Articles from the 1990s-2000s

Through Ebscohost academic libraries
implemented the d-dimer as the best
are available along with research
diagnostic tool for the diagnosis of deep
databases
vein thrombosis
• Healthsource • Trail and error with research phrases
• Nursing Academic Edition such as, inaccuracy of d-dimer,
• Medcom ultrasound accuracy of DVT, and
• Medline Complete venous thromboembolism generated the
most updated results
• CINALH Plus
Method cont.
+ Categorizing studies based on core concepts
+ Literature review table
+ Purpose, sample size, study design, treatment, results, and
limitations

+ With the multiple techniques, approaches, and

validating data, the studies concluded that the
ultrasound is the superior diagnostic tool in
diagnosis of DVT
+ The data synthesized included:
+ Inaccuracy regarding age factors
+ Types of d-dimer assays used
+ Comorbidities
+ Flaws in the diagnostic framework tool
+ Misdiagnosis
Synthesis of Literature

Numerous quantitative studies on this topic are easily accessible

Further evaluation and summary of the 6 studies chosen will follow; allowing for
increased awareness of each study’s methods and results
Synthesis of Literature cont.
+ Abbasi et al. conducted a study comparing the
accuracy of bedside compression ultrasonography to
venous duplex ultrasonography (2013).
+ Identification of a more time-effective diagnostic tool in
determining whether a patient has a deep vein thrombosis
+ The bedside compression exam has an acceptable sensitivity and
accuracy which is valuable in the quick diagnosis of DVT.
Synthesis of Literature cont.
+ D-dimer is a diagnostic tool negatively affected by many physiological
and pathological factors
+ Increased age
+ 88% of patients over 70 years of age and only 14% of those patients were positive for deep vein
thrombosis (Der Sahakian et al., 2010).
+ Type of d-dimer assay utilized
+ 43% probability o a false positive depending on the type of d-dimer assay used (Larsen et al.,
2002).
+ Immobility
+ Malignancy
+ Pregnancy
+ Body mass index

+ Improving the prediction model to include these factors may improve

the diagnostic framework tool accuracy
Synthesis of Literature cont.
+ The final article presented in this case study concludes that d-dimer
testing also generates that 5% of patients were falsely cleared due to
a false negative of the d-dimer (Rahiminejad et al., 2014).
+ The Wells scoring criteria also evaluated in this analysis which
proved some errors in the placement of patients into high and low
risk pre-testing categories.
+ Specifically, 5% with a negative d-dimer and low Wells score had a DVT
+ On a review of those patients had a risk factors identified that was not included in the
Wells score requiring an ultrasound diagnosis.
+ Research studies have already started on how to improve the Well’s scoring criteria.

+ Identifying flaws in the standard of medicine and creating solutions

based on research is the basis of what keeps the nursing practice
progressing.
Results
+ Bedside compression ultrasonography has an
acceptable sensitivity and accuracy level
+ Bedside compression ultrasound yields 86% accuracy
and can be applied to low-risk patients for quick
diagnosis (Abbasi et al., 2012)
+ Increased wait times that comes with other methods of
diagnosis, and possible hemolysis requiring redraws
from d-dimers has the potential to cause:
+ Progression of pulmonary embolism
+ Decreased patient satisfaction
+ Increased crowding in the emergency department
+ Causing exposure to diseases such as Covid-19, influenza A and B, along
with others
Results cont.
+ D-dimers are less accurate as the patient foregoes
the ageing process
+ Due to decreased accuracy this diagnostic tool should be used
with caution in elderly patients
+ Venous duplex ultrasounds do not produce as
many false positives as d-dimers
+ D-dimer has a 57.4% specificity
+ 88% of patients 70 and older had an elevated d-dimer when
only 14% were positive for deep vein thrombosis (Der
Sahakian et al., 2010).
Results cont.
+ Clinically if a d-dimer comes back positive a
CTA is required to rule out pulmonary
embolism.
+ Patient is jeopardized by the exposure to radiation,
increased length of stay and risk of reaction to contrast dye
+ 7,940 patients in this study, 44% had an
elevated d-dimer and diagnosed patients with
pulmonary embolism yields 13% (Kabrhel et
al., 2010)
Results cont.
+ Deep vein thrombosis was
established in 49 patients. D-
dimer assays showed a sensitivity
o 88% and a specificity of ~42%
(Larsen et al., 2010)
+ 43% negative probability
 Results cont.
+ Out of 517 emergency department patients, 157
patients were excluded due to the Wells scoring
criteria.
+ 20% of remaining population had falsely elevated d-dimers
(Mousa et al., 2015)
+ The ultrasound is an excellent alternative
method for diagnosis of DVT
+ High accuracy rates
+ No false positives per this case study
 Results cont.
+ False negative d-dimer also affect
patient outcomes
+ Audit of 816 patients presenting with
lower limb DVT
+ 5% of patients had a negative d-dimer and low
Wells score but were positive for deep vein
thrombosis (Rahiminejad et al., 2014)
 Proposal
+ Improved Well’s scoring criteria including the following factors
+ +1 paralysis / recent plaster cast
+ +1 bed rest >3 days or surgery <4 weeks
+ +1 pain on palpation of deep veins
+ +1 swelling of entire leg
+ +1 diameter difference on affected calf >3cm
+ +1 pitting edema (affected side only)
+ +1 dilated superficial veins (affected side)
+ +1.5 previous PE or DVT
+ +1 hemoptysis
+ +1 cancer
+ +1 age >65
+ +1 elevated BMI
+ +1 thrombophilia
+ +1 inflammation disorders including (arthritis, sickle cell disease, and asthma)
+ Low risk is 4-6 points, moderate to high is greater than 6 points.
 References
+ Abbasi S, Bolverdi E, Zare MA, Hafezimoghadam P, Fathi M, Farsi D, Moghimi M. (2012). Comparison of diagnostic value
of conventional ultrasonography by emergency physicians with doppler ultrasonography by radiology physicians for diagnosis
of deep vein thrombosis. J Pak Med Assoc., 62(5):461-5. PMID: 22755310.
+ Der Sahakian, G., Claessens, Y. E., Allo, J. C., Kansao, J., Kierzek, G., & Pourriat, J. L. (2010). Accuracy of D-dimers to rule
out venous thromboembolism events across age categories. Emergency Medicine International, 2010, 1–4.
https://doi.org/10.1155/2010/185453 
+ Kabrhel, C., Mark Courtney, D., Camargo, C. A., Plewa, M. C., Nordenholz, K. E., Moore, C. L., Richman, P. B., Smithline, H.
A., Beam, D. M., & Kline, J. A. (2010). Factors associated with positive D-dimer results in patients evaluated for pulmonary
embolism. Academic Emergency Medicine, 17(6), 589–597. https://doi.org/10.1111/j.1553-2712.2010.00765.x  
+ Larsen, T. B., Stoffersen, E., Christensen, C. S., & Laursen, B. (2002). Validity of D-dimer tests in the diagnosis of deep vein
thrombosis: A prospective comparative study of three quantitative assays. Journal of Internal Medicine, 252(1), 36–40.
https://doi.org/10.1046/j.1365-2796.2002.00998.x  
+ Mousa, A. Y., Broce, M., Gill, G., Kali, M., Yacoub, M., & AbuRahma, A. F. (2015). Appropriate use of D-dimer testing can
minimize over-utilization of venous duplex ultrasound in a contemporary high-volume hospital. Annals of Vascular
Surgery, 29(2), 311–317. https://doi.org/10.1016/j.avsg.2014.07.032 
+ Rahiminejad, M., Rastogi, A., Prabhudesai, S., Mcclinton, D., MacCallum, P., Platton, S., & Friedman, E. (2014). Evaluating
the use of a negative D-Dimer and modified low Wells score in excluding above knee deep venous thrombosis in an outpatient
population, assessing need for diagnostic ultrasound. ISRN Radiology, 2014, 1–5. https://doi.org/10.1155/2014/519875