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Key Clinical Questions

  • image Why are objective tests needed to diagnose venous thromboembolism (VTE)?

  • image Which tests can be used to diagnose a first deep vein thrombosis (DVT)?

  • image Which tests can be used to diagnose recurrent DVT?

  • image Which tests can be used to diagnose pulmonary embolism (PE)?

  • image Which patients with VTE can be treated as outpatients?

  • image What is the treatment for acute VTE, DVT, and/or PE?

  • image What is the role of thrombolytic therapy in the treatment of PE?

  • image How are patients with acute VTE and bleeding managed?

  • image How is the duration of treatment of VTE determined?

  • image Should I perform a thrombophilic workup?

  • image What is the risk of bleeding associated with long-term anticoagulant therapy?

In 800 BC, Susruta, an Indian healer wrote about a patient with “a swollen and painful leg, which was difficult to treat.” Centuries later, Virchow, a Prussian physician, coined the term “embolism” after discovering the relationship between a blood clot that formed within a blood vessel (thrombus), and a blood clot that breaks loose and travels through the bloodstream to occlude the pulmonary vessels (embolus). The concept of venous thromboembolism was born from these early descriptions and today it remains one of the most important health problems in Europe and North America and is the third leading cause of vascular death after myocardial infarction and stroke.

The risk of venous thromboembolism (VTE) increases by approximately twofold per decade of age, rising from an annual incidence of 30/100,000 at 40 years of age, to 90/100,000 at 60 years, and 260/100,000 at 80 years. Approximately half of patients with untreated, symptomatic proximal deep vein thrombosis (DVT) will develop symptomatic pulmonary embolism (PE), and about 10% of symptomatic PE are fatal within an hour of onset. Left untreated, one-third of patients with initially nonfatal PE will have a fatal recurrence, generally within a few weeks of the original event. Even with optimal treatment, about 5% of patients with PE will die from fatal PE, and about 25% with proximal DVT will develop post-thrombotic syndrome, a chronic condition that is debilitating for patients.

Venous thromboembolism is now recognized as the leading cause of preventable death in hospitalized patients. Almost all hospitalized patients have one or more risk factors for VTE and 40% will have three or more risk factors. VTE prophylaxis (addressed in Chapters 56, 65, and 252) forms the cornerstone for preventing these deaths. In addition, although 75% of venous thromboembolic events are diagnosed in the outpatient setting, about half of all episodes of VTE are associated with recent surgery or hospitalization. These findings stress the importance of having a low threshold to perform diagnostic testing in patients who present with signs and symptoms compatible with VTE within 3 months of hospitalization.

Therefore, VTE is both an acute and a chronic disease that causes substantial patient morbidity and mortality, and it is a major burden on the ...

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