Nice | Venous thromboembolism (DVT) investigation and management

This guideline is a good summary of the management of the investigation and management of venous thromboembolism . Different areas locally vary a lot in how they manage patients (eg anticoagulation clinics vs GP led services), so you may think most of this is done in the clinics – but if you work in Southampton – it may be you!

Remember that SIGN released some excellent guidance last year which covers VTE in special groups – eg pregnant women / flying etc.

The big changes here are in clarifying who needs what investigations for cancer and thrombophilia after a VTE. The rest is probably familiar to everyone.

There is an excellent appendix here which contains the Wells Scoring systems and flow charts for what to do after you’ve done your Wells Score.

If you suspect a DVT

Do the Wells Score for DVT.

Likely DVT from Well’s Score?

  • Refer for proximal leg ultrasound (USS).
  • Can’t get the USS within 4 hrs?  Use LMWH and get the scan within 24 hrs.
  • If the scan is negative, do a D-dimer. If that is positive, rescan at 6 to 8 days.

Unlikely DVT from Well’s Score?

  • Do a D-dimer.
  • If negative, reassure the patient that DVT is unlikely.
  • If positive, revert to the same pathway as if the Well’s score was likely.

If you suspect a PE

Do the Wells Score for PE.

  • Likely PE from Well’s Score? We’ll be referring into hospital.
  • Unlikely PE from Well’s Score? Do a D-dimer. It doesn’t give a time scale for this. If it comes back positive, you will obviously be referring into hospital. If it is negative, you can reassure the patient. I guess it therefore comes down to clinical judgement and access to d-dimer as to whether you still refer into hospital.

Treatment of VTE

  • LMWH or fondaparinux, which is normally started in hospital. There are some contraindications (eg GFR < 30 or increased risk of bleeding).
  • Warfarin – continue on LMWH until INR is > 2 for 24 hrs or 5 days, whichever is longer.
  • Cancer – Use LMWH if they have active cancer, rather than warfarin.
  • Rivaroxaban – see next month’s guidance, but can now be considered for treatment of DVT.
  • Stockings – for everyone who’s had a DVT, start a week afterwards and use for 2 yrs. Only use on the affected leg.

 How long do you treat for?

  • Normal (eg provoked) – 3m
  • Cancer – 6m and maybe more
  • Unprovoked – consider treatment beyond 3m if risk of recurrence is high (it doesn’t say how to assess this) and risk of bleeding is low.

 Looking for the cause

Cancer:  Consider assessment and investigation in anyone with an unprovoked VTE who doesn’t have active cancer:

  • All: CXR, urinalysis, bloods (FBC / LFT / Bone profile).
  • Over 40: Consider if unprovoked first PE or DVT in patient over 40 who does not have signs or symptoms of cancer. Consider Abdo / Pelvic CT and mammogram.

Thrombophilia testing:  Don't test whilst on anticoagulation if you are planning to continue it, nor if the VTE was provoked.

  • Antiphospholipid – consider testing if unprovoked VTE  you are planning to stop anticoagulation
  • Hereditary Thrombophilia screen – consider testing if unprovoked VTE and 1st degree relative with VTE if you are planning to stop anticoagulation.
  • Do not routinely screen 1st degree  relatives of people with a history of VTE and thrombophilia.

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