Does d-dimer really improve DVT prediction in stroke?


Good question, and even though thromboprofylaxis is already given according to guidelines in some countries, I can see the added value of a good discriminating prediction rule. Especially finding those patients with low DVT risk might be useful. But using d-dimer is a whole other question. To answer this, a thorough prediction model needs to be set up both with and without the information of d-dimer and only a direct comparison of these two models will provide the information we need.

In our view, that is not what the paper by Balogun et al did. And after critical appraisal of the tables and text, we found some inconsistencies that prohibits the reader from understanding what exactly was done and which results were obtained. In the end, we decided to write a letter to the editor, especially to prevent that other readers to mistakenly take over the conclusion of the authors. This conclusion, being that “D-dimer concentration with in 48 h of acute stroke is independently associated with development of DVT.This observation would require confirmation in a large study.” Our opinion is that the data from this study needs to be analysed properly to justify such an conclusion. One of the key elements in our letter is that the authors never compare the AUC of the model with and without d-dimer. This is needed as that would provide the bulk of the answer whether or not d-dimer should be measured. The only clue we have are the ORs of d-dimer, which range between 3-4, which is not really impressive when it comes to diagnosis and prediction. For more information on this, please check this paper on the misuse of the OR as a measure of interest for diagnosis/prediction by Pepe et al.

A final thing I want to mention is that our letter was the result of a mini-internship of one of the students at the Master programme of the CSB and was drafted in collaboration with our Virchow scholar HGdH from the Netherlands. Great team work!

The letter can be found on the website of Thrombosis Research as well as on my Mendeley profile.