ADJUST-DVT – Age-Adjusted Dimer for DVT

Written by Caitlin Nicholson

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Using Wells-based pretest probability with an age-adjusted D-dimer safely ruled out lower-extremity DVT in ED outpatients with zero 3-month VTE events among patients between the conventional and age-adjusted cutoffs.

With age comes wisdom… and a higher D-dimer cutoff.
This multinational prospective management study (ADJUST-DVT) enrolled 3,205 ED outpatients with suspected lower-extremity DVT across 27 centers in four countries. Pretest probability was determined using the Wells score, after which patients with non-high/unlikely probability underwent highly sensitive D-dimer testing, while high/likely patients proceeded directly to compression ultrasonography. DVT was ruled out without imaging if D-dimer was <500 μg/L in patients <50 years  old or below an age-adjusted cutoff (age × 10 μg/L) in those ≥50, followed by 3-month clinical follow-up. The primary outcome was symptomatic venous thromboembolism (VTE) among patients with D-dimer values between 500 μg/L and their age-adjusted cutoff. Among 2,169 patients with non-high/unlikely probability, the age-adjusted strategy increased negative D-dimer results by 7.4% overall and substantially improved rule-out in patients ≥75 years (8.7% to 26.1%). Importantly, no VTE events occurred in the primary outcome group (0/161), supporting the safety of this approach while reducing imaging utilization.

Limitations include use of multiple D-dimer assays and both 2- and 3-level Wells scores, though failure rates were similar across strategies. The study was not randomized against the conventional 500 μg/L cutoff and relied on 3-month VTE rates as the safety benchmark. Clinicians occasionally overrode the algorithm with ultrasound despite negative D-dimer results, identifying a few distal DVTs. This applies only to outpatient lower-extremity DVT. Overall, this trial provides prospective validation that age-adjusted D-dimer safely increases diagnostic efficiency—particularly in older adults—without increasing missed clinically significant VTE.

How will this change my practice?
This gives me more confidence using Wells plus age-adjusted D-dimer to work up suspected DVT, especially in older patients, and zero events in patients with D-dimers between 500 and their age-adjusted cutoff is reassuring. Yet, it reinforces the importance of clinical gestalt—Wells is only as good as the bedside assessment behind it, and there will always be patients who “don’t fit the algorithm.” Overall, this brings DVT evaluation in line with our approach to PE, improves efficiency, and is safe.

Editor’s note: FINALLY! ~ Nick Zelt

Source
ADJUST-DVT Investigators. Age-Adjusted D-Dimer Cutoff Levels to Rule Out Deep Vein Thrombosis. JAMA. 2026 Feb 3;335(5):416-424. doi: 10.1001/jama.2025.21561. PMID: 41490105; PMCID: PMC12771389.