下肢深静脉血栓形成(DVT)诊断.docVIP

Diagnosis of Deep Venous Thrombosis (DVT) of the Lower Extremity from the?ACCP / Chest Guidelines, 9th Ed. The ACCP recommendations for diagnosis of DVT of the leg are based on these principles of safety: Reducing overall?false-negatives?to?2%?or less (as defined by symptomatic DVT or PE within 3-6 months after a negative test); Reducing the risk of?fatal PE?after testing to?0.1%?(1 in 1,000); Reducing the risk of?fatal hemorrhage?due to anticoagulation to?0.1%?(1 in 1,000). The ACCP recommendations are in essence the “outputs” of the authors’ own Bayesian risk model, into which they plugged in assumptions for true DVT prevalence, bleeding risk, risk for death from recurrent PE, etc., all obtained (wherever possible) from the rates of these events observed in previous clinical trials. Authors could not always assure themselves of meeting the above safety / surety standards, in which case they downgraded the recommendations’ strength. These ACCP recommendations are for?nonpregnant?patients with a suspected?first DVT of the lower extremity; the Chest guidelines for diagnosis of a?first leg DVT in pregnant women?and the diagnosis of?recurrent DVT?will be reviewed soon. ACCP Recommendation: Risk-Stratify Patients for Likelihood of DVT Rather than pursuing a standard approach for all patients with suspected DVT, risk-stratify patients as low, intermediate, or high pretest probability for DVT, authors advise (Grade 2B, suggestion based on moderate-strength evidence). While acknowledging its limitations, they cautiously endorse using the?Wells score?for this, which provides risk assessment as follows: Wells Score Prob. of DVT Low 5% Moderate 17% High 53% Testing For Patients with a LOW Pretest Probability for DVT (figure) ACCP recommendations for testing of patients with a?low pretest probability for a first DVT of the leg?advise checking either: Moderately sensitive D-dimer?(whole-blood or “latex semi-quantitative,” sensitivity ~85%); Highly sensitive D-dimer?(ELISA-b