diagnosing v diagnosing venous thromboembolism in primary
TRANSCRIPT
Diagnosing vDiagnosing venous thromboembolism in primaryenous thromboembolism in primary,,secondary and tertiary caresecondary and tertiary care
NICE Pathways bring together everything NICE says on a topic in an interactiveflowchart. NICE Pathways are interactive and designed to be used online.
They are updated regularly as new NICE guidance is published. To view the latestversion of this NICE Pathway see:
http://pathways.nice.org.uk/pathways/venous-thromboembolismNICE Pathway last updated: 20 March 2018
This document contains a single flowchart and uses numbering to link the boxes to theassociated recommendations.
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Diagnosing vDiagnosing venous thromboembolism in primaryenous thromboembolism in primary, secondary and tertiary care, secondary and tertiary care NICE Pathways
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1 Adult with signs or symptoms of deep vein thrombosis or pulmonaryembolism
No additional information
2 Initial diagnostic investigations
Deep vein thrombosis
If a patient presents with signs or symptoms of DVT, carry out an assessment of their general
medical history and a physical examination to exclude other causes.
Pulmonary embolism
If a patient presents with signs or symptoms of PE, carry out an assessment of their general
medical history, a physical examination and a chest X-ray to exclude other causes.
Patient with signs and symptoms of both deep vein thrombosis and pulmonary embolism
If a patient presents with signs or symptoms of both DVT (for example a swollen and/or painful
leg) and PE (for example chest pain, shortness of breath or haemoptysis), carry out initial
diagnostic investigations for either DVT or PE, basing the choice of diagnostic investigations on
clinical judgement.
Quality standards
The following quality statements are relevant to this part of the interactive flowchart.
Venous thromboembolism in adults: diagnosis and management quality standard
1. Interim therapeutic dose of anticoagulation therapy for suspected deep vein thrombosis
2. Diagnosis of deep vein thrombosis
3. Interim therapeutic dose of anticoagulation therapy for suspected pulmonary embolism
Diagnosing vDiagnosing venous thromboembolism in primaryenous thromboembolism in primary, secondary and tertiary care, secondary and tertiary care NICE Pathways
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3 Estimate clinical probability using two-level Wells score
Deep vein thrombosis
If DVT is suspected, use the two-level DVT Wells score [See page 9] to estimate the clinical
probability of DVT.
Pulmonary embolism
If PE is suspected, use the two-level PE Wells score [See page 10] to estimate the clinical
probability of PE.
Quality standards
The following quality statements are relevant to this part of the interactive flowchart.
Venous thromboembolism in adults: diagnosis and management quality standard
1. Interim therapeutic dose of anticoagulation therapy for suspected deep vein thrombosis
2. Diagnosis of deep vein thrombosis
3. Interim therapeutic dose of anticoagulation therapy for suspected pulmonary embolism
4 Deep vein thrombosis likely
Offer patients in whom DVT is suspected and with a likely two-level DVT Wells score [See page
9] either:
a proximal leg vein ultrasound scan carried out within 4 hours of being requested and, if theresult is negative, a D-dimer test [See page 12] or
a D-dimer test and an interim 24-hour dose of a parenteral anticoagulant (if a proximal legvein ultrasound scan cannot be carried out within 4 hours) and a proximal leg veinultrasound scan carried out within 24 hours of being requested.
Repeat the proximal leg vein ultrasound scan 6–8 days later for all patients with a positive D-
dimer test and a negative proximal leg vein ultrasound scan.
Diagnose DVT and treat patients with a positive proximal leg vein ultrasound scan (see treating
venous thromboembolism).
Diagnosing vDiagnosing venous thromboembolism in primaryenous thromboembolism in primary, secondary and tertiary care, secondary and tertiary care NICE Pathways
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When to consider alternative diagnoses
Take into consideration alternative diagnoses in patients with:
a likely two-level DVT Wells score [See page 9] and
a negative proximal leg vein ultrasound scan and a negative D-dimer test or
a repeat negative proximal leg vein ultrasound scan.
Advise patients that it is not likely they have DVT, and discuss with them the signs and
symptoms of DVT and when and where to seek further medical help.
Quality standards
The following quality statements are relevant to this part of the interactive flowchart.
Venous thromboembolism in adults: diagnosis and management quality standard
1. Interim therapeutic dose of anticoagulation therapy for suspected deep vein thrombosis
2. Diagnosis of deep vein thrombosis
5 Deep vein thrombosis unlikely
Offer patients in whom DVT is suspected and with an unlikely two-level DVT Wells score [See
page 9] a D-dimer test [See page 12] and if the result is positive offer either:
a proximal leg vein ultrasound scan carried out within 4 hours of being requested or
an interim 24-hour dose of a parenteral anticoagulant (if a proximal leg vein ultrasound scancannot be carried out within 4 hours and a proximal leg vein ultrasound scan carried outwithin 24 hours of being requested.
Diagnose DVT and treat patients with a positive proximal leg vein ultrasound scan (see treating
venous thromboembolism).
When to consider alternative diagnoses
Take into consideration alternative diagnoses in patients with:
an unlikely two-level DVT Wells score [See page 9] and
a negative D-dimer test or
a positive D-dimer test and a negative proximal leg vein ultrasound scan.
Diagnosing vDiagnosing venous thromboembolism in primaryenous thromboembolism in primary, secondary and tertiary care, secondary and tertiary care NICE Pathways
VVenous thromboembolismenous thromboembolism© NICE 2018. All rights reserved. Subject to Notice of rights.
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Advise patients that it is not likely they have DVT, and discuss with them the signs and
symptoms of DVT and when and where to seek further medical help.
Quality standards
The following quality statements are relevant to this part of the interactive flowchart.
Venous thromboembolism in adults: diagnosis and management quality standard
1. Interim therapeutic dose of anticoagulation therapy for suspected deep vein thrombosis
2. Diagnosis of deep vein thrombosis
6 Pulmonary embolism likely
Offer patients in whom PE is suspected and with a likely two-level PE Wells score [See page
10] either:
an immediate CTPA or
immediate interim parenteral anticoagulant therapy followed by a CTPA, if a CTPA cannotbe carried out immediately.
Consider a proximal leg vein ultrasound scan if the CTPA is negative and DVT is suspected.
For patients who have an allergy to contrast media, or who have renal impairment, or whose
risk from irradiation is high:
Assess the suitability of a V/Q SPECT scan or, if a V/Q SPECT scan is not available, a V/Qplanar scan, as an alternative to CTPA.
If offering a V/Q SPECT or planar scan that will not be available immediately, offerimmediate interim parenteral anticoagulant therapy.
Diagnose PE and treat patients with a positive CTPA or in whom PE is identified with a V/Q
SPECT or planar scan (see the recommendations on treatment).
When to consider alternative diagnoses
Take into consideration alternative diagnoses in patients with a likely two-level PE Wells score
[See page 10] and both:
a negative CTPA and
Diagnosing vDiagnosing venous thromboembolism in primaryenous thromboembolism in primary, secondary and tertiary care, secondary and tertiary care NICE Pathways
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no suspected DVT.
Advise these patients that it is not likely they have PE and discuss with them the signs and
symptoms of PE, and when and where to seek further medical help.
Quality standards
The following quality statement is relevant to this part of the interactive flowchart.
Venous thromboembolism in adults: diagnosis and management quality standard
3. Interim therapeutic dose of anticoagulation therapy for suspected pulmonary embolism
7 Pulmonary embolism unlikely
Offer patients in whom PE is suspected and with an unlikely two-level PE Wells score [See
page 10] a D-dimer test [See page 12] and if the result is positive offer either:
an immediate CTPA or
immediate interim parenteral anticoagulant therapy followed by a CTPA, if a CTPA cannotbe carried out immediately.
For patients who have an allergy to contrast media, or who have renal impairment, or whose
risk from irradiation is high:
Assess the suitability of a V/Q SPECT scan or, if a V/Q SPECT scan is not available, a V/Qplanar scan, as an alternative to CTPA.
If offering a V/Q SPECT or planar scan that will not be available immediately, offerimmediate interim parenteral anticoagulant therapy.
Diagnose PE and treat patients with a positive CTPA or in whom PE is identified with a V/Q
SPECT or planar scan (see the recommendations on treatment).
When to consider alternative diagnoses
Take into consideration alternative diagnoses in patients with an unlikely two-level PE Wells
score [See page 10] and either:
a negative D-dimer test or
a positive D-dimer test and a negative CTPA.
Diagnosing vDiagnosing venous thromboembolism in primaryenous thromboembolism in primary, secondary and tertiary care, secondary and tertiary care NICE Pathways
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Advise these patients that it is not likely they have PE and discuss with them the signs and
symptoms of PE, and when and where to seek further medical help.
Quality standards
The following quality statement is relevant to this part of the interactive flowchart.
Venous thromboembolism in adults: diagnosis and management quality standard
3. Interim therapeutic dose of anticoagulation therapy for suspected pulmonary embolism
8 Treatment
See Venous thromboembolism / Treating venous thromboembolism
Diagnosing vDiagnosing venous thromboembolism in primaryenous thromboembolism in primary, secondary and tertiary care, secondary and tertiary care NICE Pathways
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Two-level DVT Wells score1
Clinical feature Points
Active cancer (treatment ongoing, within 6 months, or palliative) 1
Paralysis, paresis or recent plaster immobilisation of the lower extremities 1
Recently bedridden for 3 days or more, or major surgery within 12 weeks
requiring general or regional anaesthesia1
Localised tenderness along the distribution of the deep venous system 1
Entire leg swollen 1
Calf swelling 3 cm larger than asymptomatic side 1
Pitting oedema confined to the symptomatic leg 1
Collateral superficial veins (non-varicose) 1
Previously documented DVT 1
An alternative diagnosis is at least as likely as DVT −2
Clinical probability simplified score Points
DVT likely2 points or
more
1 Adapted with permission from Wells PS et al. (2003) Evaluation of D-dimer in the diagnosis of suspected deep-
vein thrombosis.
Diagnosing vDiagnosing venous thromboembolism in primaryenous thromboembolism in primary, secondary and tertiary care, secondary and tertiary care NICE Pathways
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DVT unlikely1 point or
less
Two-level PE Wells score1
Clinical feature Points
Clinical signs and symptoms of DVT (minimum of leg swelling and pain with
palpation of the deep veins)3
An alternative diagnosis is less likely than PE 3
Heart rate > 100 beats per minute 1.5
Immobilisation for more than 3 days or surgery in the previous 4 weeks 1.5
Previous DVT/PE 1.5
Haemoptysis 1
Malignancy (on treatment, treated in the last 6 months, or palliative) 1
Clinical probability simplified score Points
PE likelyMore than 4
points
PE unlikely4 points or
less
Diagnosing vDiagnosing venous thromboembolism in primaryenous thromboembolism in primary, secondary and tertiary care, secondary and tertiary care NICE Pathways
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1 Adapted with permission from Wells PS et al. (2000) Derivation of a simple clinical model to categorize patients'
probability of pulmonary embolism: increasing the model's utility with the SimpliRED D-dimer.
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D-dimer is a product formed in the body when a blood clot (such as those found in DVT or PE)
is broken down. A laboratory or point of care test can be done to assess the concentration of D-
dimer in a person's blood. The threshold for a positive result varies with the type of D-dimer test
used and is determined locally. The result of the D-dimer test can be used as part of probability
assessment when DVT or PE is suspected.
Glossary
APTT
activated partial thromboplastin time
CTPA
computed tomography pulmonary angiogram
Discharge
(in these recommendations, 'discharge' refers to discharge from hospital as an inpatient or after
a day procedure)
Discharged
(in these recommendations, 'discharge' refers to discharge from hospital as an inpatient or after
a day procedure)
DVT
deep vein thrombosis
Fondaparinux
fondaparinux sodium
HRT
hormone replacement therapy
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INR
international normalised ratio (a standardised laboratory measure of blood coagulation used to
monitor the adequacy of anticoagulation in patients who are having treatment with a vitamin K
antagonist)
LMWH
low molecular weight heparin
LMWHs
low molecular weight heparins
Major bleeding
a bleeding event that results in one or more of the following: death, a decrease in haemoglobin
concentration of ≥ 2 g/dl, transfusion of ≥ 2 units of blood, bleeding into a retroperitoneal,
intracranial or intraocular site, a serious or life-threatening clinical event, a surgical or medical
intervention
PE
pulmonary embolism
Proximal
in the popliteal vein or above; sometimes referred to as 'above-knee'
Provoked
occurring in a patient with an antecedent (within 3 months) and transient major clinical risk
factor for venous thromboembolism – for example surgery, trauma, significant immobility
(bedbound, unable to walk unaided or likely to spend a substantial proportion of the day in bed
or in a chair), pregnancy or puerperium – or in a patient who is having hormonal therapy (oral
contraceptive or hormone replacement therapy)
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Renal impairment
an estimated glomerular filtration rate (eGFR) of less than 30 ml/min/1.73 m2. (For more
detailed information on renal impairment, see what NICE says on chronic kidney disease in
adults.)
Severe renal impairment or established renal failure
estimated glomerular filtration rate of less than 30 ml/min/1.73m2
Significantly reduced mobility
bedbound, unable to walk unaided or likely to spend a substantial proportion of the day in bed
or in a chair
UFH
unfractionated heparin
Unprovoked
occurring in a patient with: no antecedent major clinical risk factor for venous thromboembolism
– for example surgery, trauma, significant immobility (bedbound, unable to walk unaided or likely
to spend a substantial proportion of the day in bed or in a chair), pregnancy or puerperium –
who is not having hormonal therapy (oral contraceptive or hormone replacement therapy) or
active cancer, thrombophilia or a family history of venous thromboembolism, because these are
underlying risks that remain constant in the patient
V/Q SPECT
ventilation/perfusion single photon emission computed tomography
VTE
venous thromboembolism
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Wells score
a clinical prediction rule for estimating the probability of DVT or PE– there are a number of
versions of Wells scores available; this guidance recommends the two-level DVT Wells score
and the two-level PE Wells score
Sources
Venous thromboembolic diseases: diagnosis, management and thrombophilia testing (2012
updated 2015) NICE guideline CG144
Your responsibility
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The recommendations in this guideline represent the view of NICE, arrived at after careful
consideration of the evidence available. When exercising their judgement, professionals and
practitioners are expected to take this guideline fully into account, alongside the individual
needs, preferences and values of their patients or the people using their service. It is not
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to make decisions appropriate to the circumstances of the individual, in consultation with them
and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline
to be applied when individual professionals and people using services wish to use it. They
should do so in the context of local and national priorities for funding and developing services,
and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to
advance equality of opportunity and to reduce health inequalities. Nothing in this guideline
should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable
health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.
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Technology appraisals
The recommendations in this interactive flowchart represent the view of NICE, arrived at after
careful consideration of the evidence available. When exercising their judgement, health
professionals are expected to take these recommendations fully into account, alongside the
individual needs, preferences and values of their patients. The application of the
recommendations in this interactive flowchart is at the discretion of health professionals and
their individual patients and do not override the responsibility of healthcare professionals to
make decisions appropriate to the circumstances of the individual patient, in consultation with
the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable
the recommendations to be applied when individual health professionals and their patients wish
to use it, in accordance with the NHS Constitution. They should do so in light of their duties to
have due regard to the need to eliminate unlawful discrimination, to advance equality of
opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable
health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.
Medical technologies guidance, diagnostics guidance and interventional proceduresguidance
The recommendations in this interactive flowchart represent the view of NICE, arrived at after
careful consideration of the evidence available. When exercising their judgement, healthcare
professionals are expected to take these recommendations fully into account. However, the
interactive flowchart does not override the individual responsibility of healthcare professionals to
make decisions appropriate to the circumstances of the individual patient, in consultation with
the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in
their local context, in light of their duties to have due regard to the need to eliminate unlawful
discrimination, advance equality of opportunity, and foster good relations. Nothing in this
interactive flowchart should be interpreted in a way that would be inconsistent with compliance
with those duties.
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Commissioners and providers have a responsibility to promote an environmentally sustainable
health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.
Diagnosing vDiagnosing venous thromboembolism in primaryenous thromboembolism in primary, secondary and tertiary care, secondary and tertiary care NICE Pathways
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