diagnosing v diagnosing venous thromboembolism in primary

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Diagnosing v Diagnosing venous thromboembolism in primary enous thromboembolism in primary, secondary and tertiary care secondary and tertiary care NICE Pathways bring together everything NICE says on a topic in an interactive flowchart. NICE Pathways are interactive and designed to be used online. They are updated regularly as new NICE guidance is published. To view the latest version of this NICE Pathway see: http://pathways.nice.org.uk/pathways/venous-thromboembolism NICE Pathway last updated: 20 March 2018 This document contains a single flowchart and uses numbering to link the boxes to the associated recommendations. Venous thromboembolism enous thromboembolism © NICE 2018. All rights reserved. Subject to Notice of rights . Page 1 of 17

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Page 1: Diagnosing v Diagnosing venous thromboembolism in primary

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.

VVenous thromboembolismenous thromboembolism© NICE 2018. All rights reserved. Subject to Notice of rights.

Page 1 of 17

Page 2: Diagnosing v Diagnosing venous thromboembolism in primary

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.

Page 2 of 17

Page 3: Diagnosing v Diagnosing venous thromboembolism in primary

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

VVenous thromboembolismenous thromboembolism© NICE 2018. All rights reserved. Subject to Notice of rights.

Page 3 of 17

Page 4: Diagnosing v Diagnosing venous thromboembolism in primary

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

VVenous thromboembolismenous thromboembolism© NICE 2018. All rights reserved. Subject to Notice of rights.

Page 4 of 17

Page 5: Diagnosing v Diagnosing venous thromboembolism in primary

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.

Page 5 of 17

Page 6: Diagnosing v Diagnosing venous thromboembolism in primary

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

VVenous thromboembolismenous thromboembolism© NICE 2018. All rights reserved. Subject to Notice of rights.

Page 6 of 17

Page 7: Diagnosing v Diagnosing venous thromboembolism in primary

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

VVenous thromboembolismenous thromboembolism© NICE 2018. All rights reserved. Subject to Notice of rights.

Page 7 of 17

Page 8: Diagnosing v Diagnosing venous thromboembolism in primary

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

VVenous thromboembolismenous thromboembolism© NICE 2018. All rights reserved. Subject to Notice of rights.

Page 8 of 17

Page 9: Diagnosing v Diagnosing venous thromboembolism in primary

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

VVenous thromboembolismenous thromboembolism© NICE 2018. All rights reserved. Subject to Notice of rights.

Page 9 of 17

Page 10: Diagnosing v Diagnosing venous thromboembolism in primary

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

VVenous thromboembolismenous thromboembolism© NICE 2018. All rights reserved. Subject to Notice of rights.

Page 10 of 17

Page 11: Diagnosing v Diagnosing venous thromboembolism in primary

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.

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.

Page 11 of 17

Page 12: Diagnosing v Diagnosing venous thromboembolism in primary

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

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.

Page 12 of 17

Page 13: Diagnosing v Diagnosing venous thromboembolism in primary

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)

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.

Page 13 of 17

Page 14: Diagnosing v Diagnosing venous thromboembolism in primary

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

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.

Page 14 of 17

Page 15: Diagnosing v Diagnosing venous thromboembolism in primary

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

Guidelines

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

mandatory to apply the recommendations, and the guideline does not override the responsibility

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.

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.

Page 15 of 17

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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.

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.

Page 16 of 17

Page 17: Diagnosing v Diagnosing venous thromboembolism in primary

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

VVenous thromboembolismenous thromboembolism© NICE 2018. All rights reserved. Subject to Notice of rights.

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