Special Articles
9 January 2018

Diagnosis of Venous Thromboembolism: 20 Years of Progress

Publication: Annals of Internal Medicine
Volume 168, Number 2

Abstract

Many guidelines suggest incorporating clinical assessment, imaging, and D-dimer testing into diagnostic algorithms in patients with suspected deep venous thrombosis (DVT) and pulmonary embolism (PE). This special article reviews the evidence supporting the use of algorithms and their individual components for diagnosis of upper- and lower-extremity DVT and PE in adults, including pregnant women. The authors identified evidence through several electronic database searches to April 2017, evaluated the robustness of selected evidence, assessed whether diagnostic approaches that do not use algorithms are acceptable, and identified knowledge gaps that require further research.

Get full access to this article

View all available purchase options and get full access to this article.

References

1.
Stein PDMatta F. Epidemiology and incidence: the scope of the problem and risk factors for development of venous thromboembolism. Clin Chest Med. 2010;31:611-28. [PMID: 21047571]  doi: 10.1016/j.ccm.2010.07.001
2.
Heit JAMohr DNSilverstein MDPetterson TMO'Fallon WMMelton LJ 3rd. Predictors of recurrence after deep vein thrombosis and pulmonary embolism: a population-based cohort study. Arch Intern Med. 2000;160:761-8. [PMID: 10737275]
3.
Bauld DLKovacs MJ. Dalteparin in emergency patients to prevent admission prior to investigation for venous thromboembolism. Am J Emerg Med. 1999;17:11-5. [PMID: 9928688]
4.
Wiener RSSchwartz LMWoloshin S. Time trends in pulmonary embolism in the United States: evidence of overdiagnosis. Arch Intern Med. 2011;171:831-7. [PMID: 21555660]  doi: 10.1001/archinternmed.2011.178
5.
Henry JWRelyea BStein PD. Continuing risk of thromboemboli among patients with normal pulmonary angiograms. Chest. 1995;107:1375-8. [PMID: 7750334]
6.
Hull RHirsh JSackett DLTaylor DWCarter CTurpie AGet al. Replacement of venography in suspected venous thrombosis by impedance plethysmography and 125I-fibrinogen leg scanning: a less invasive approach. Ann Intern Med. 1981;94:12-5. [PMID: 7447204]
7.
Shea BJGrimshaw JMWells GABoers MAndersson NHamel Cet al. Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol. 2007;7:10. [PMID: 17302989]
8.
Scottish Intercollegiate Guidelines Network. Clinical Guidelines: Criteria for Appraisal for National Use. Edinburgh, Scotland: Scottish Intercollegiate Guidelines Network; 1995.
9.
Ceriani ECombescure CLe Gal GNendaz MPerneger TBounameaux Het al. Clinical prediction rules for pulmonary embolism: a systematic review and meta-analysis. J Thromb Haemost. 2010;8:957-70. [PMID: 20149072]  doi: 10.1111/j.1538-7836.2010.03801.x
10.
Goodacre SSutton AJSampson FC. Meta-analysis: the value of clinical assessment in the diagnosis of deep venous thrombosis. Ann Intern Med. 2005;143:129-39. [PMID: 16027455]
11.
Wells PSOwen CDoucette SFergusson DTran H. Does this patient have deep vein thrombosis? JAMA. 2006;295:199-207. [PMID: 16403932]
12.
PIOPED Investigators. Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). JAMA. 1990;263:2753-9. [PMID: 2332918]
13.
Bayes T. An essay towards solving a problem in the doctrine of chances. 1763. MD Comput. 1991;8:157-71. [PMID: 1857193]
14.
Wells PSHirsh JAnderson DRLensing AWFoster GKearon Cet al. Accuracy of clinical assessment of deep-vein thrombosis. Lancet. 1995;345:1326-30. [PMID: 7752753]
15.
Wells PSAnderson DRBormanis JGuy FMitchell MGray Let al. Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet. 1997;350:1795-8. [PMID: 9428249]
16.
Lucassen WGeersing GJErkens PMReitsma JBMoons KGBüller Het al. Clinical decision rules for excluding pulmonary embolism: a meta-analysis. Ann Intern Med. 2011;155:448-60. [PMID: 21969343].  doi: 10.7326/0003-4819-155-7-201110040-00007
17.
Penaloza AMelot CMotte S. Comparison of the Wells score with the simplified revised Geneva score for assessing pretest probability of pulmonary embolism. Thromb Res. 2011;127:81-4. [PMID: 21094985]  doi: 10.1016/j.thromres.2010.10.026
18.
Kline JAMitchell AMKabrhel CRichman PBCourtney DM. Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. J Thromb Haemost. 2004;2:1247-55. [PMID: 15304025]
19.
Rodger MAMaser EStiell IHowley HEWells PS. The interobserver reliability of pretest probability assessment in patients with suspected pulmonary embolism. Thromb Res. 2005;116:101-7. [PMID: 15907523]
20.
Wolf SJMcCubbin TRFeldhaus KMFaragher JPAdcock DM. Prospective validation of Wells criteria in the evaluation of patients with suspected pulmonary embolism. Ann Emerg Med. 2004;44:503-10. [PMID: 15520710]
21.
Penaloza AMélot CDochy EBlocklet DGevenois PAWautrecht JCet al. Assessment of pretest probability of pulmonary embolism in the emergency department by physicians in training using the Wells model. Thromb Res. 2007;120:173-9. [PMID: 17055556]
22.
Singh BMommer SKErwin PJMascarenhas SSParsaik AK. Pulmonary embolism rule-out criteria (PERC) in pulmonary embolism—revisited: a systematic review and meta-analysis. Emerg Med J. 2013;30:701-6. [PMID: 23038695]  doi: 10.1136/emermed-2012-201730
23.
Chunilal SDEikelboom JWAttia JMiniati MPanju AASimel DLet al. Does this patient have pulmonary embolism? JAMA. 2003;290:2849-58. [PMID: 14657070]
24.
Runyon MSWebb WBJones AEKline JA. Comparison of the unstructured clinician estimate of pretest probability for pulmonary embolism to the Canadian score and the Charlotte rule: a prospective observational study. Acad Emerg Med. 2005;12:587-93. [PMID: 15995088]
25.
Gibson NSSohne MKruip MJTick LWGerdes VEBossuyt PMet alChristopher study investigators. Further validation and simplification of the Wells clinical decision rule in pulmonary embolism. Thromb Haemost. 2008;99:229-34. [PMID: 18217159]  doi: 10.1160/TH07-05-0321
26.
Siccama RNJanssen KJVerheijden NAOudega RBax Lvan Delden JJet al. Systematic review: diagnostic accuracy of clinical decision rules for venous thromboembolism in elderly. Ageing Res Rev. 2011;10:304-13. [PMID: 21130902]  doi: 10.1016/j.arr.2010.10.005
27.
Ambid-Lacombe CCambou JPBataille VBaudoin DVassal-Hebrard BBoccalon Het al. [Excellent performances of Wells' score and of the modified Wells' score for the diagnosis of proximal or distal deep venous thrombosis in outpatients or inpatients at Toulouse University Hospital: TVP-PREDICT study]. J Mal Vasc. 2009;34:211-7. [PMID: 19359112]  doi: 10.1016/j.jmv.2009.02.004
28.
Silveira PCIp IKGoldhaber SZPiazza GBenson CBKhorasani R. Performance of Wells score for deep vein thrombosis in the inpatient setting. JAMA Intern Med. 2015;175:1112-7. [PMID: 25985219]  doi: 10.1001/jamainternmed.2015.1687
29.
Di Marca SCilia CCampagna AD'Arrigo GAbd ElHafeez STripepi Get al. Comparison of Wells and revised Geneva rule to assess pretest probability of pulmonary embolism in high-risk hospitalized elderly adults. J Am Geriatr Soc. 2015;63:1091-7. [PMID: 26032745]  doi: 10.1111/jgs.13459
30.
Douma RAKessels JBBuller HRGerdes VE. Knowledge of the D-dimer test result influences clinical probability assessment of pulmonary embolism. Thromb Res. 2010;126:e271-5. [PMID: 20810151]  doi: 10.1016/j.thromres.2010.07.008
31.
Di Nisio MSquizzato ARutjes AWBüller HRZwinderman AHBossuyt PM. Diagnostic accuracy of D-dimer test for exclusion of venous thromboembolism: a systematic review. J Thromb Haemost. 2007;5:296-304. [PMID: 17155963]
32.
Geersing GJJanssen KJOudega RBax LHoes AWReitsma JBet al. Excluding venous thromboembolism using point of care D-dimer tests in outpatients: a diagnostic meta-analysis. BMJ. 2009;339:b2990. [PMID: 19684102]  doi: 10.1136/bmj.b2990
33.
Luxembourg BSchwonberg JHecking CSchindewolf MZgouras DLehmeyer Set al. Performance of five D-dimer assays for the exclusion of symptomatic distal leg vein thrombosis. Thromb Haemost. 2012;107:369-78. [PMID: 22234425]  doi: 10.1160/TH11-07-0511
34.
Goodacre SSampson FThomas Svan Beek ESutton A. Systematic review and meta-analysis of the diagnostic accuracy of ultrasonography for deep vein thrombosis. BMC Med Imaging. 2005;5:6. [PMID: 16202135]
35.
Johnson SAStevens SMWoller SCLake EDonadini MCheng Jet al. Risk of deep vein thrombosis following a single negative whole-leg compression ultrasound: a systematic review and meta-analysis. JAMA. 2010;303:438-45. [PMID: 20124539]  doi: 10.1001/jama.2010.43
36.
Thomas SMGoodacre SWSampson FCvan Beek EJ. Diagnostic value of CT for deep vein thrombosis: results of a systematic review and meta-analysis. Clin Radiol. 2008;63:299-304. [PMID: 18275870]  doi: 10.1016/j.crad.2007.09.010
37.
Abdalla GFawzi Matuk RVenugopal VVerde FMagnuson THSchweitzer MAet al. The diagnostic accuracy of magnetic resonance venography in the detection of deep venous thrombosis: a systematic review and meta-analysis. Clin Radiol. 2015;70:858-71. [PMID: 26091753]  doi: 10.1016/j.crad.2015.04.007
38.
Pomero FDentali FBorretta VBonzini MMelchio RDouketis JDet al. Accuracy of emergency physician-performed ultrasonography in the diagnosis of deep-vein thrombosis: a systematic review and meta-analysis. Thromb Haemost. 2013;109:137-45. [PMID: 23138420]  doi: 10.1160/TH12-07-0473
39.
Karande GYHedgire SSSanchez YBaliyan VMishra VGanguli Set al. Advanced imaging in acute and chronic deep vein thrombosis. Cardiovasc Diagn Ther. 2016;6:493-507. [PMID: 28123971]  doi: 10.21037/cdt.2016.12.06
40.
Hamadah AAlwasaidi TLEGal GCarrier MWells PSScarvelis Det al. Baseline imaging after therapy for unprovoked venous thromboembolism: a randomized controlled comparison of baseline imaging for diagnosis of suspected recurrence. J Thromb Haemost. 2011;9:2406-10. [PMID: 21985174]  doi: 10.1111/j.1538-7836.2011.04533.x
41.
Ageno WSquizzato AWells PSBüller HRJohnson G. The diagnosis of symptomatic recurrent pulmonary embolism and deep vein thrombosis: guidance from the SSC of the ISTH. J Thromb Haemost. 2013;11:1597-602. [PMID: 23682905]  doi: 10.1111/jth.12301
42.
Anderson DRKahn SRRodger MAKovacs MJMorris THirsch Aet al. Computed tomographic pulmonary angiography vs ventilation-perfusion lung scanning in patients with suspected pulmonary embolism: a randomized controlled trial. JAMA. 2007;298:2743-53. [PMID: 18165667]  doi: 10.1001/jama.298.23.2743
43.
Hayashino YGoto MNoguchi YFukui T. Ventilation-perfusion scanning and helical CT in suspected pulmonary embolism: meta-analysis of diagnostic performance. Radiology. 2005;234:740-8. [PMID: 15734930]
44.
Mos ICKlok FAKroft LJDE Roos ADekkers OMHuisman MV. Safety of ruling out acute pulmonary embolism by normal computed tomography pulmonary angiography in patients with an indication for computed tomography: systematic review and meta-analysis. J Thromb Haemost. 2009;7:1491-8. [PMID: 19552684]  doi: 10.1111/j.1538-7836.2009.03518.x
45.
Phillips JJStraiton JStaff RT. Planar and SPECT ventilation/perfusion imaging and computed tomography for the diagnosis of pulmonary embolism: a systematic review and meta-analysis of the literature, and cost and dose comparison. Eur J Radiol. 2015;84:1392-400. [PMID: 25868674]  doi: 10.1016/j.ejrad.2015.03.013
46.
Le Roux PYAbgral RJaffrelot MDelluc AGut-Gobert CQuerellou Set al. Diagnosis of pulmonary embolism: planar images generated from V/Q SPECT are not a reliable substitute for traditional planar V/Q scan. Nucl Med Commun. 2012;33:695-700. [PMID: 22441133]  doi: 10.1097/MNM.0b013e328352c7d2
47.
Righini MLe Gal GAujesky DRoy PMSanchez OVerschuren Fet al. Diagnosis of pulmonary embolism by multidetector CT alone or combined with venous ultrasonography of the leg: a randomised non-inferiority trial. Lancet. 2008;371:1343-52. [PMID: 18424324]  doi: 10.1016/S0140-6736(08)60594-2
48.
Da Costa Rodrigues JAlzuphar SCombescure CLe Gal GPerrier A. Diagnostic characteristics of lower limb venous compression ultrasonography in suspected pulmonary embolism: a meta-analysis. J Thromb Haemost. 2016;14:1765-72. [PMID: 27377039]  doi: 10.1111/jth.13407
49.
Squizzato APomero FAllione APriotto RRiva NHuisman MVet al. Diagnostic accuracy of magnetic resonance imaging in patients with suspected pulmonary embolism: a bivariate meta-analysis. Thromb Res. 2017;154:64-72. [PMID: 28427005]  doi: 10.1016/j.thromres.2017.03.027
50.
Jiang LMa YZhao CShen WFeng XXu Yet al. Role of transthoracic lung ultrasonography in the diagnosis of pulmonary embolism: a systematic review and meta-analysis. PLoS One. 2015;10:e0129909. [PMID: 26076021]  doi: 10.1371/journal.pone.0129909
51.
Carrier MRighini MWells PSPerrier AAnderson DRRodger MAet al. Subsegmental pulmonary embolism diagnosed by computed tomography: incidence and clinical implications. A systematic review and meta-analysis of the management outcome studies. J Thromb Haemost. 2010;8:1716-22. [PMID: 20546118]  doi: 10.1111/j.1538-7836.2010.03938.x
52.
Pena EKimpton MDennie CPeterson RLE Gal GCarrier M. Difference in interpretation of computed tomography pulmonary angiography diagnosis of subsegmental thrombosis in patients with suspected pulmonary embolism [Letter]. J Thromb Haemost. 2012;10:496-8. [PMID: 22212300]  doi: 10.1111/j.1538-7836.2011.04612.x
53.
Szucs-Farkas ZChriste AMegyeri BRohacek MVock PNagy EVet al. Diagnostic accuracy of computed tomography pulmonary angiography with reduced radiation and contrast material dose: a prospective randomized clinical trial. Invest Radiol. 2014;49:201-8. [PMID: 24473367]  doi: 10.1097/RLI.0000000000000016
54.
Sostman HDStein PDGottschalk AMatta FHull RGoodman L. Acute pulmonary embolism: sensitivity and specificity of ventilation-perfusion scintigraphy in PIOPED II study. Radiology. 2008;246:941-6. [PMID: 18195380]  doi: 10.1148/radiol.2463070270
55.
Wells PSAnderson DRRodger MStiell IDreyer JFBarnes Det al. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and D-dimer. Ann Intern Med. 2001;135:98-107. [PMID: 11453709]
56.
Bernardi EPrandoni PLensing AWAgnelli GGuazzaloca GScannapieco Get al. D-dimer testing as an adjunct to ultrasonography in patients with clinically suspected deep vein thrombosis: prospective cohort study. The Multicentre Italian D-dimer Ultrasound Study Investigators Group. BMJ. 1998;317:1037-40. [PMID: 9774286]
57.
Bernardi ECamporese GBüller HRSiragusa SImberti DBerchio Aet alErasmus Study Group. Serial 2-point ultrasonography plus D-dimer vs whole-leg color-coded Doppler ultrasonography for diagnosing suspected symptomatic deep vein thrombosis: a randomized controlled trial. JAMA. 2008;300:1653-9. [PMID: 18840838]  doi: 10.1001/jama.300.14.1653
58.
Gibson NSSchellong SMKheir DYBeyer-Westendorf JGallus ASMcRae Set al. Safety and sensitivity of two ultrasound strategies in patients with clinically suspected deep venous thrombosis: a prospective management study. J Thromb Haemost. 2009;7:2035-41. [PMID: 19817986]  doi: 10.1111/j.1538-7836.2009.03635.x
59.
Bates SMJaeschke RStevens SMGoodacre SWells PSStevenson MDet al. Diagnosis of DVT: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141:e351S-418S. [PMID: 22315267]  doi: 10.1378/chest.11-2299
60.
Wells PSAnderson DRRodger MForgie MKearon CDreyer Jet al. Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. N Engl J Med. 2003;349:1227-35. [PMID: 14507948]
61.
Linkins LABates SMLang EKahn SRDouketis JDJulian Jet al. Selective D-dimer testing for diagnosis of a first suspected episode of deep venous thrombosis: a randomized trial. Ann Intern Med. 2013;158:93-100. [PMID: 23318311].  doi: 10.7326/0003-4819-158-2-201301150-00003
62.
Oudega RMoons KGHoes AW. Ruling out deep venous thrombosis in primary care. A simple diagnostic algorithm including D-dimer testing. Thromb Haemost. 2005;94:200-5. [PMID: 16113804]
63.
Büller HRTen Cate-Hoek AJHoes AWJoore MAMoons KGOudega RAMUSE (Amsterdam Maastricht Utrecht Study on thromboEmbolism) Investigators. Safely ruling out deep venous thrombosis in primary care. Ann Intern Med. 2009;150:229-35. [PMID: 19221374]
64.
Schouten HJGeersing GJKoek HLZuithoff NPJanssen KJDouma RAet al. Diagnostic accuracy of conventional or age adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism: systematic review and meta-analysis. BMJ. 2013;346:f2492. [PMID: 23645857]  doi: 10.1136/bmj.f2492
65.
Stein PDFowler SEGoodman LRGottschalk AHales CAHull RDet alPIOPED II Investigators. Multidetector computed tomography for acute pulmonary embolism. N Engl J Med. 2006;354:2317-27. [PMID: 16738268]
66.
Fabiá Valls MJvan der Hulle Tden Exter PLMos ICHuisman MVKlok FA. Performance of a diagnostic algorithm based on a prediction rule, D-dimer and CT-scan for pulmonary embolism in patients with previous venous thromboembolism. A systematic review and meta-analysis. Thromb Haemost. 2015;113:406-13. [PMID: 25373512]  doi: 10.1160/TH14-06-0488
67.
Pasha SMKlok FASnoep JDMos ICGoekoop RJRodger MAet al. Safety of excluding acute pulmonary embolism based on an unlikely clinical probability by the Wells rule and normal D-dimer concentration: a meta-analysis. Thromb Res. 2010;125:e123-7. [PMID: 19942258]  doi: 10.1016/j.thromres.2009.11.009
68.
Righini MVan Es JDen Exter PLRoy PMVerschuren FGhuysen Aet al. Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study. JAMA. 2014;311:1117-24. [PMID: 24643601]  doi: 10.1001/jama.2014.2135
69.
van Es NKraaijpoel NKlok FAHuisman MVDen Exter PLMos ICet al. The original and simplified Wells rules and age-adjusted D-dimer testing to rule out pulmonary embolism: an individual patient data meta-analysis. J Thromb Haemost. 2017;15:678-84. [PMID: 28106338]  doi: 10.1111/jth.13630
70.
Raymakers AJMayo JMarra CAFitzGerald M. Diagnostic strategies incorporating computed tomography angiography for pulmonary embolism: a systematic review of cost-effectiveness analyses. J Thorac Imaging. 2014;29:209-16. [PMID: 23846107]  doi: 10.1097/RTI.0b013e3182999e41
71.
Roy PMMeyer GVielle BLe Gall CVerschuren FCarpentier Fet alEMDEPU Study Group. Appropriateness of diagnostic management and outcomes of suspected pulmonary embolism. Ann Intern Med. 2006;144:157-64. [PMID: 16461959]
72.
Simpson ELLawrenson RANightingale ALFarmer RD. Venous thromboembolism in pregnancy and the puerperium: incidence and additional risk factors from a London perinatal database. BJOG. 2001;108:56-60. [PMID: 11213005]
73.
Ray JGChan WS. Deep vein thrombosis during pregnancy and the puerperium: a meta-analysis of the period of risk and the leg of presentation. Obstet Gynecol Surv. 1999;54:265-71. [PMID: 10198931]
74.
Nijkeuter MGinsberg JSHuisman MV. Diagnosis of deep vein thrombosis and pulmonary embolism in pregnancy: a systematic review. J Thromb Haemost. 2006;4:496-500. [PMID: 16405518]
75.
Tan MHuisman MV. The diagnostic management of acute venous thromboembolism during pregnancy: recent advancements and unresolved issues. Thromb Res. 2011;127 Suppl 3:S13-6. [PMID: 21262431]  doi: 10.1016/S0049-3848(11)70005-6
76.
Kucher N. Clinical practice. Deep-vein thrombosis of the upper extremities. N Engl J Med. 2011;364:861-9. [PMID: 21366477]  doi: 10.1056/NEJMcp1008740
77.
Prandoni PPolistena PBernardi ECogo ACasara DVerlato Fet al. Upper-extremity deep vein thrombosis. Risk factors, diagnosis, and complications. Arch Intern Med. 1997;157:57-62. [PMID: 8996041]
78.
Kleinjan ADi Nisio MBeyer-Westendorf JCamporese GCosmi BGhirarduzzi Aet al. Safety and feasibility of a diagnostic algorithm combining clinical probability, D-dimer testing, and ultrasonography for suspected upper extremity deep venous thrombosis: a prospective management study. Ann Intern Med. 2014;160:451-7. [PMID: 24687068].  doi: 10.7326/M13-2056

Information & Authors

Information

Published In

cover image Annals of Internal Medicine
Annals of Internal Medicine
Volume 168Number 216 January 2018
Pages: 131 - 140

History

Published online: 9 January 2018
Published in issue: 16 January 2018

Keywords

Authors

Affiliations

Philip S. Wells, MD, MSc
University of Ottawa, Ottawa Hospital Research Institute, and Ottawa Hospital, Ottawa, Ontario, Canada (P.S.W., M.A.F.)
Ryma Ihaddadene, BHSc, MSc
University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (R.I., A.R.)
Aoife Reilly, BSc
University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (R.I., A.R.)
Melissa Anne Forgie, MD, MSc
University of Ottawa, Ottawa Hospital Research Institute, and Ottawa Hospital, Ottawa, Ontario, Canada (P.S.W., M.A.F.)
Disclosures: Dr. Wells reports speaker fees from Bayer HealthCare and Daiichi Sankyo, personal fees from Itreas and Janssen, and grant support from Pfizer/Bristol-Myers Squibb and Bayer HealthCare outside the submitted work. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M17-0291.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Corresponding Author: Philip S. Wells, MD, MSc, Department of Medicine, Ottawa Hospital General Campus, 501 Smyth Road, Box 206, Ottawa, Ontario K1H 8L6, Canada; e-mail, [email protected].
Current Author Addresses: Drs. Wells and Forgie, Ms. Ihaddadene, and Ms. Reilly: Department of Medicine, Ottawa Hospital General Campus, 501 Smyth Road, Box 206, Ottawa, Ontario K1H 8L6, Canada.
Author Contributions: Conception and design: P.S. Wells, R. Ihaddadene, M.A. Forgie.
Analysis and interpretation of the data: P.S. Wells, R. Ihaddadene, A. Reilly, M.A. Forgie.
Drafting of the article: P.S. Wells, R. Ihaddadene, M.A. Forgie.
Critical revision of the article for important intellectual content: P.S. Wells, R. Ihaddadene, M.A. Forgie.
Final approval of the article: P.S. Wells, R. Ihaddadene, A. Reilly, M.A. Forgie.
Provision of study materials or patients: P.S. Wells, M.A. Forgie.
Statistical expertise: P.S. Wells, M.A. Forgie.
Obtaining of funding: P.S. Wells, M.A. Forgie.
Administrative, technical, or logistic support: P.S. Wells, M.A. Forgie.
Collection and assembly of data: P.S. Wells, R. Ihaddadene, A. Reilly, M.A. Forgie.
This article was published at Annals.org on 9 January 2018.

Metrics & Citations

Metrics

Citations

If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. For an editable text file, please select Medlars format which will download as a .txt file. Simply select your manager software from the list below and click Download.

For more information or tips please see 'Downloading to a citation manager' in the Help menu.

Format





Download article citation data for:
Philip S. Wells, Ryma Ihaddadene, Aoife Reilly, et al. Diagnosis of Venous Thromboembolism: 20 Years of Progress. Ann Intern Med.2018;168:131-140. [Epub 9 January 2018]. doi:10.7326/M17-0291

View More

Get Access

Login Options:
Purchase

You will be redirected to acponline.org to sign-in to Annals to complete your purchase.

Create your Free Account

You will be redirected to acponline.org to create an account that will provide access to Annals.

View options

PDF/ePub

View PDF/ePub

Related in ACP Journals

Full Text

View Full Text

Media

Figures

Other

Tables

Share

Share

Copy the content Link

Share on social media