Q&A

Elevated D-dimer level predicts recurrent VTE

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  • BACKGROUND: Management of patients with VTE after completion of anticoagulation remains controversial. This prospective trial evaluates the prognostic value of D-dimer level in predicting VTE recurrence.
  • POPULATION STUDIED: A total of 610 patients were enrolled—Austrian adults diagnosed with VTE by venography, sonography, ventilation/perfusion (V/Q) scan, or spiral computed tomography and treated for at least 3 months with anticoagulants. Exclusion criteria included more than 1 previous VTE, surgery, trauma or pregnancy within the last 3 months, deficiency of natural anticoagulants or the presence of cancer, lupus anti-coagulant, or long-term antithrombotic therapy.
  • STUDY DESIGN AND VALIDITY: Subjects were enrolled at completion of anticoagulation and observed every 3 months during the first year and every 6 months thereafter. Three weeks after discontinuation of oral anti-coagulation, antithrombin, proteins C and S, factor V Leiden, factor II G20210A, and D-dimer levels using the enzyme-linked immunosorbent assay (ELISA) method were obtained.
  • OUTCOMES MEASURED: The major outcome measured was recurrent VTE. Outcomes such as cost, impact of labeling, and clinician/patient satisfaction were not addressed.
  • RESULTS: The average duration of observation was 38 months; overall frequency of recurrent VTE was 13%. There was a graded increase in risk of recurrence with increasing D-dimer levels. Compared with patients with D-dimer levels ≥250 ng/mL those with levels <250 ng/mL had significantly lower risk of recurrent VTE (relative risk=0.3; 95% confidence interval, 0.1–0.6); controlling for age, sex, factor V Leiden, factor II, G20210, and factor VIII did not change this finding.


 

PRACTICE RECOMMENDATION

Patients with venous thromboembolism (VTE) and no obvious underlying cause or major clotting protein abnormalities whose D-dimer levels are <250 ng/mL have a significantly reduced long-term risk of recurrent VTE. Physicians should consider obtaining this test and providing this information to patients.

Given the burgeoning numbers of tests being developed to assess thrombophilia risk, the attraction of the D-dimer is that it may represent a global measure of risk of recurrent disease. Physicians should understand, however, that clinical research is still preliminary and look for further evidence of the prognostic performance of D-dimer across populations with different ethnicity and the outcomes of long-term treatment on patients at higher risk of VTE as measured by D-dimer.

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