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VENOUS THROMBOEMBOLISM

Initial Assessment

  1. Deep venous thrombosis (ACCP 2012)

    1. For suspected initial DVT, use Wells score for DVT to determine pretest probability and therefore diagnostic algorithm1

      1. Wells score for DVT (NEJM. 349(13))

        1. Assign one point for each of the following

          1. Active cancer

          2. Immobility of lower extremities

          3. Bedridden 3+ days in past 3 months

          4. Tenderness along deep vein

          5. Swollen leg

          6. Unilateral calf swelling (3 cm larger than other)

          7. Unilateral pitting edema

          8. Collateral venous distention

          9. History of prior DVT

        2. Remove 2 points if an alternate diagnosis is as likely as DVT

    2. Diagnostic algorithms

      1. Low pretest probability, lower extremity DVT: See Figure 2-1

      2. Moderate pretest probability, lower extremity DVT: See Figure 2-2

      3. High pretest probability, lower extremity DVT: See Figure 2-3

      4. Suspicion of recurrent lower extremity DVT: See Figure 2-4

  2. Pulmonary embolism (ACCP 2016)

    1. For suspected pulmonary embolism, use Wells score for PE or revised Geneva score for PE, creatinine clearance, and age-adjusted D-dimer to guide diagnostic strategy

      1. Revised Geneva score for PE (Ann Intern Med. 144(3))

        1. Assign points for HR

          1. 5 points if ≥95

          2. 3 points if 75–94

        2. Assign 4 points for: Tender lower extremity

        3. Assign 3 points for each of

          1. History of DVT/PE

          2. Painful lower extremity

        4. Assign 2 points for each of

          1. Surgery or fractured lower extremity (in past month)

          2. Active malignancy (in past year)

          3. Hemoptysis

        5. Assign 1 point for age >65

    2. For diagnostic algorithm, see Figure 2-5

Acute Medical Management (ACCP 2012, 2016)

  1. Anticoagulation: Decision to anticoagulate, anticoagulant selection, and duration of therapy guided by multiple factors

  2. For DVT: See Table 2-1 for anticoagulant selection

  3. For PE, see Figure 2-6 for treatment algorithm and Table 2-2 for anticoagulant selection

Management After Stabilization (ACCP 2016)

  1. If low-risk PE and home circumstances are adequate, treat at home or discharge early rather than the standard discharge after 5 days of treatment

Sources:

  1. ACCP 2012: Bates SM, Jaeschke R, Stevens SM, et al. Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. February 2012;131(2):351–418. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3278048/]

  2. ACCP 2015: Kearon C, Akl EA, Omelas J, et al. Antithrombotic therapy for VTE disease. CHEST Guideline and Expert Panel Report. Chest. 2016;149(2):315–352. [https://www.ncbi.nlm.nih.gov/pubmed/26867832]

  3. ACP 2015: Raja AS, Greenberg JO, Qaseem A, et al. Evaluation of patients with suspected acute pulmonary embolism: best practice advice from the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. 2015;163:701–711. [https://www.ncbi.nlm.nih.gov/pubmed/26414967]

  4. Wells PS, Anderson DR, Rodger M, et al. Evaluation of D-dimer in the diagnosis of suspected deep-venous thrombosis. NEJM. 2003;394(13):1227–1235. [https://www.ncbi.nlm.nih.gov/pubmed/14507948]

  5. Silveira PC, Ip IK, Goldhaber SZ, et al. Performance of Wells score for deep vein thrombosis in the inpatient setting. JAMA Intern Med. 2015;175(7):1112–1117. [https://www.ncbi.nlm.nih.gov/pubmed/25985219]

  6. Le Gal G, Righini M, Roy PM, et al. Prediction of pulmonary embolism in the emergency department: the revised Geneva ...

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