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1、DiagnosisofDeepVenousThrombosis(DVT)oftheLowerExtremityfromtheACCP/ChestGuidelines,9thEd.TheACCPrecommendationsfordiagnosisofDVTofthelegarebasedontheseprinciplesofsafety:•Reducingoverallfalse-negativesto2%orless(asdefinedbysymptomaticDVTorPEwithin3-6monthsafte
2、ranegativetest);•ReducingtheriskoffatalPEaftertestingto<0.1%(1in1,000);•Reducingtheriskoffatalhemorrhageduetoanticoagulationto<0.1%(1in1,000).TheACCPrecommendationsareinessencethe^outputs”oftheauthors5ownBayesianriskmodel,intowhichtheypluggedinassumptionsfortr
3、ueDVTprevalence,bleedingrisk,riskfordeathfromrecurrentPE,etc.,allobtained(whereverpossible)fromtheratesoftheseeventsobservedinpreviousclinicaltrials.Authorscouldnotalwaysassurethemselvesofmeetingtheabovesafety/suretystandards,inwhichcasetheydowngradedtherecomm
4、endations'strength.TheseACCPrecommendationsarefornonpregnantpatientswithasuspectedfirstDVTofthelowerextremity;theChestguidelinesfordiagnosisofafirstlegDVTinpregnantwomenandthediagnosisofrecurrentDVTwillbereviewedsoon.ACCPRecommendation:Risk-StratifyPatientsfor
5、LikelihoodofDVTRatherthanpursuingastandardapproachforallpatientswithsuspectedDVT,risk-stratifypatientsaslow,intermediate,orhighpretestprobabilityforDVT,authorsadvise(Grade2B,suggestionbasedonmoderate-strengthevidence).Whileacknowledgingitslimitations,theycauti
6、ouslyendorseusingtheWellsscoreforthis,whichprovidesriskassessmentasfollows:WellsScoreProb,ofDVTLow5%Moderate17%High53%TestingForPatientswithaLOWPretestProbabilityforDVT(figure)ACCPrecommendationsfortestingofpatientswithalowpretestprobabilityforafirstDVTofthele
7、gadvisecheckingeither:•ModeratelysensitiveD・dimer(whole-bloodorulatexsemi-quantitative,nsensitivity~85%);•HighlysensitiveD-dimer(ELISA-basedor^quantitativelatexorimmunoturbidimetric,Msensitivity-95%);•Compressionultrasoundoftheproximallegveins(ratherthanwhole-
8、legultrasound).TheysuggestusingD-dimerpreferentiallyovercompressionultrasoundoftheproximalveinsastheinitialtest(Grade2B/2C)・IfD-dimerisnegativeinapatientwithalowpretestprobabilityf
