Deep Venous Thrombosis (DVT) Guidelines

Updated: Jun 05, 2019
  • Author: Kaushal (Kevin) Patel, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
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Guidelines

Diagnosis of Venous Thromboembolism

In November 2018, the American Society of Hematology (ASH) released guidelines for the diagnosis of venous thromboembolism (VTE). [166]  The American Academy of Family Physicians endorsed these guidelines in March 2019 and provided the following key recommendations from the guidelines. [167]

D-dimer testing alone should not be used to rule in or diagnose a PE, and a positive D-dimer alone should not be used to diagnose DVT.

Pulmonary Embolism (PE)

Individuals with a low or intermediate pretest probability or prevalence: Clinicians should use a D-dimer strategy to rule out PE, followed by a ventilation-perfusion (VQ) scan or computed tomography pulmonary angiography (CTPA) in patients requiring additional testing. D-dimer testing alone should not be used to rule in a PE.

Individuals with a high pretest probability or prevalence (≥50%): Clinicians should start with CTPA to diagnose PE. If CTPA is not available, a VQ scan should be used with appropriate follow-up testing.

Individuals with a high pretest probability/prevalence: D-dimer testing alone should not be used to diagnose PE and should not be used as a subsequent test after CT scanning.

Individuals with a positive D-dimer or likely pretest probability: CTPA should be performed. D-dimer testing can be used to exclude recurrent PE in individuals with an unlikely pretest probability.

Outpatients older than 50 years: Use of an age-adjusted D-dimer cutoff is safe and improves the diagnostic yield. Age-adjusted cutoff = Age (years) × 10 µg/L (using D-dimer assays with a cutoff of 500 µg/L).

Lower Extremity (LE) Deep Vein Thrombosis (DVT)

Individuals with a low pretest probability or prevalence: Clinicians should use a D-dimer strategy to rule out DVT, followed by proximal LE or whole-leg ultrasonography in patients requiring additional testing.

Individuals with a low pretest probability or prevalence (≤10%): Positive D-dimer alone should not be used to diagnose DVT, and additional testing following negative proximal or whole-leg ultrasonography should not be conducted.

Individuals with an intermediate pretest probability or prevalence (~25%): Whole-leg or proximal LE ultrasonography should be used. Serial proximal ultrasonographic testing is needed after a negative proximal ultrasonogram. No serial testing is needed after a negative whole-leg ultrasonogram.

Individuals with suspected DVT and a high pretest probability or prevalence (≥50%): Whole-leg or proximal LE ultrasonography should be used. Serial ultrasonography should be used if the initial ultrasonogram is negative and no alternative diagnosis is identified.

Upper Extremity (UE) DVT

Individuals with a low prevalence/unlikely pretest probability: D-dimer testing should be used to exclude UE DVT, followed by duplex ultrasonography if findings are positive.

Individuals with a high prevalence/likely pretest probability: Either D-dimer testing followed by duplex ultrasonography/serial duplex ultrasonography, or duplex ultrasonography/serial duplex ultrasonography alone can be used for assessing patients suspected of having a UE DVT.

A positive D-dimer alone should not be used to diagnose UE DVT.

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Anticoagulation for Venous Thromboembolism

The guidelines on optimal management of anticoagulation therapy for venous thromboembolism (VTE) were released on November 7, 2018, by the American Society of Hematology (ASH). [168]

Initial Anticoagulant Dose Selection

In obese patients receiving low-molecular-weight heparin (LMWH) for treatment of acute VTE, it is suggested that initial LMWH dose selection be based on actual body weight rather than on a fixed maximum daily dose (ie, capped dose).

Drug-Interaction Management

For patients requiring administration of inhibitors or inducers of P-glycoprotein (P-gp) or strong inhibitors or inducers of cytochrome P450 (CYP) enzymes, it is suggested to use an alternative anticoagulant (eg, a vitamin K antagonist [VKA] or LMWH) rather than a direct oral anticoagulant (DOAC) to treat VTE.

Point-of-Care INR Testing

For patients receiving maintenance VKA therapy for VTE, home point-of-care international normalized ratio (INR) testing (patient self-testing [PST]) is suggested in preference to any other INR testing approach except patient self-management (PSM) in suitable patients (those who have demonstrated competency to perform PST and who can afford this option).

For patients receiving maintenance VKA therapy for VTE, point-of-care INR testing by the patient at home with self-adjustment of VKA dose (PSM) is suggested in preference to any other management approach, including PST in suitable patients (those who have demonstrated competency to perform PSM and who can afford this option).

Selection of Timing Between INR Measurements (INR Recall Interval)

For patients receiving VKA therapy for VTE, an INR recall interval of 4 weeks or less is suggested rather than an interval longer than 4 weeks after VKA dose adjustment due to an out-of-target-range INR.

For patients receiving maintenance VKA therapy for VTE, a longer (6-12 weeks) INR recall interval is suggested rather than a shorter (4 weeks) interval during periods of stable INR control.

Laboratory Monitoring of Anticoagulant Response

For patients with renal dysfunction (creatinine clearance, < 30 mL/min) or obesity receiving LMWH therapy for VTE, it is suggested not to use anti–factor Xa concentration monitoring to guide LMWH dose adjustment.

For patients receiving DOAC therapy for VTE, it is suggested not to measure the DOAC anticoagulant effect during management of bleeding.

Transitions Between Anticoagulants

For patients transitioning from DOAC to VKA, overlapping DOAC and VKA therapy until the INR is within the therapeutic range is suggested in preference to LMWH or unfractionated heparin (UFH) "bridging therapy."

Use of Specialized AMS

For patients receiving anticoagulation therapy for VTE, specialized anticoagulation-management service (AMS) care is suggested in preference to care provided by the patient's usual healthcare provider.

Structured Patient Education

For patients receiving oral anticoagulation therapy for VTE, supplementary patient education is suggested in addition to basic education.

Efforts to Improve Adherence to Anticoagulant Regimen

For patients receiving anticoagulation therapy for VTE, it is suggested not to use a daily lottery, electronic reminders, or a combination of the two to improve medication adherence. It is also suggested not to use visual medication schedules (provided to patients at each visit, along with brief counseling) to improve medication adherence.

Invasive Procedure Management

For patients at low-to-moderate risk for recurrent VTE who require interruption of VKA therapy for invasive procedures, VKA interruption alone is recommended in preference to periprocedural bridging with LMWH or UHF.

For patients interrupting DOAC therapy for scheduled invasive procedures, it is suggested not to perform laboratory testing for DOAC effect before procedures.

Excessive Anticoagulation and Bleeding Management

For patients receiving VKA therapy for VTE with INR >4.5 but < 10 and without clinically relevant bleeding, temporary cessation of VKA alone is suggested, without the addition of vitamin K.

For patients with life-threatening bleeding during VKA therapy for VTE and an elevated INR, use of four-factor prothrombin complex concentrates (PCCs) is suggested in preference to fresh frozen plasma (FFP) as an addition to cessation of VKA and IV vitamin K.

For patients with life-threatening bleeding during oral direct Xa inhibitor therapy for VTE, it is suggested to use either four-factor PCC administration as an addition to cessation of oral direct Xa inhibitor or cessation of oral direct Xa inhibitor alone.

For patients with life-threatening bleeding during oral direct Xa inhibitor therapy for VTE, it is suggested to use coagulation factor Xa (recombinant), inactivated-zhzo in addition to cessation of oral direct Xa inhibitor rather than no coagulation factor Xa (recombinant), inactivated-zhzo.

For patients with life-threatening bleeding during dabigatran therapy for VTE, it is suggested to use idarucizumab in addition to cessation of dabigatran rather than no idarucizumab.

For patients with life-threatening bleeding during LMWH or UFH therapy for VTE, it is suggested to use protamine in addition to LMWH/UFH cessation rather than no protamine.

Anticoagulant Resumption Following Bleeding

For patients receiving anticoagulation therapy for VTE who survive an episode of major bleeding, resumption of oral anticoagulation therapy within 90 days is suggested in preference to discontinuance of oral anticoagulation therapy.

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