Pre-diagnostic management of patients suspicious of deep vein thrombosis

Background: We analysed the feasibility of the 9th ACCP-guidelines recommendation of starting therapeutic anti- coagulation in patients with a high suspicion of deep vein thrombosis (DVT) and tried to answer the question as to whether it generates a relevant over- or under-use of anti-coagulants in the period prior to the definitive diagnosis. Patients and methods: From March to May 2013 we included 98 consecutive out-patients (mean age 63 ± 17 years, 39 males) suspected of DVT, classifying them according to the 9th ACCP-guidelines recommendations into two groups with high and low clinical suspicion. Those with a high suspicion (Wells Score ≥ 2 and elevated DDimer concentration) initially received Rivaroxaban 15 mg orally. Results: Out of the 80 patients with a high clinical suspicion, 15 (19%) received therapeutic anti-coagulation without any medical necessity because DVT was finally excluded. Out of the 10 patients with a low clinical suspicion, 2 (20%) with a finally proven DVT might have benefited from initial therapeutic anti-coagulation. Females were at a slightly higher risk of receiving therapeutic anti-coagulation unnecessarily. Out of the 45 females with a high clinical suspicion, who received therapeutic anti-coagulation, DVT was excluded in 9 (20%). In males it was 6 (17%) out of 35 patients. The costs for those 80 patients accepting initial anti-coagulation by taking Rivaroxaban 15 mg were €312. By using Certoparin 8000 I.E. the cost would have been €792, which is 150% higher compared to Rivaroxaban within in the same period. Conclusion: Defining patients to have a high suspicion for DVT by Wells score and DDimer is associated with an over-use of therapeutic anticoagulation in almost every fifth patients.