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NICE calls for better diagnosis and treatment of blood clots

In draft guidance published today (Wednesday 26 October) for consultation, NICE has called for improvements in the way venous thromboembolic diseases are diagnosed and managed in England and Wales.

Venous thromboembolism (VTE) is the term used to describe a condition in which a blood clot (a thrombus) forms in a vein and then dislodges to travel in the blood (an embolus). A venous thrombus most commonly occurs in the deep veins of the legs or pelvis; this is then called a deep vein thrombosis (DVT). Blood flow through the affected vein can be limited by the clot, and it can cause swelling and pain in the leg. If the thrombus dislodges and travels to the lungs, this can lead to a potentially fatal pulmonary embolism (PE) when the clot blocks the blood supply to the lungs. Non-fatal venous thromboembolism may produce long-term illness, including chronic venous insufficiency. This is a condition in which the veins have problems sending blood from the legs back to the heart, causing venous ulceration and development of a post-thrombotic limb (chronic pain, swelling and skin changes in the affected limb).

The Hospital Episodes Statistics for 2008/09 reported over 56,000 finished consultant episodes of PE in England alone, and it is estimated that every year over 25,000 people die in the UK as the result of preventable hospital-acquired VTE. Risk factors for venous thromboembolism include a history of DVT, age over 60 years, surgery, obesity, prolonged travel, acute medical illness, cancer, immobility, thrombophiliai and pregnancy. Although treatments for VTE are well established, there is currently a wide variation in how such treatments are provided. There is also wide variation in practice as to when to test for thrombophilia in patients who have had a VTE.

The draft recommendations in the guideline cover:

  • The use of clinical diagnostic scores such as the Wells Scoreii, diagnostic tests for DVT and PE, including ultrasound and D-dimer testingiii
  • Pharmacological interventions for the treatment of DVT and PE, including the use of anticoagulants (low molecular weight heparin, unfractionated heparin, fondaparinux and vitamin k antagonists).
  • The use of thrombolytic (‘clot-busting') drugs to treat DVT and PE
  • Mechanical interventions, such as the use of vena cava filters and compression stockings
  • Thrombophilia testing in patients diagnosed with a DVT or PE
  • What investigations for cancer should be carried out in patients who have been diagnosed with a DVT or PE.

Dr Fergus Macbeth, Director of the Centre for Clinical Practice at NICE said: “NICE published guidance in 2010 on reducing the risk of VTE in patients who are admitted to hospital which, together with the Department of Health's prioritisation of the prevention of VTE in these patients, aims to significantly reduce the unacceptably high number of deaths each year that are due to hospital-acquired VTE. But there is clearly a real clinical need for this guideline. Diagnosis of VTE is not always straightforward and unfortunately the consequences of a misdiagnosis can be devastating. The treatment for VTE, once a diagnosis of VTE has been confirmed, is itself not without risk since anticoagulants and thrombolytic drugs can cause serious bleeding in some patients. This draft guideline on the management of VTE diseases therefore aims to help reduce the toll of long-term ill health or even death by clarifying what combination of tests and treatments results in the most cost effective VTE diagnostic and treatment pathways.”

Stakeholders have until 21 December 2011 to comment on the recommendations in the draft guideline. Organisations can register as stakeholders at any time during the development of the guideline and comments must be submitted via the NICE website; www.nice.org.uk. Until the final guideline is published, recommendations could change depending on feedback received during the development of this guideline.

Ends

Notes to Editors

1. The draft guideline on the management of venous thromboembolic diseases and the role of thrombophilia testing is available from the NICE website at: http://guidance.nice.org.uk/CG/Wave21/5 (from Wednesday 26 October 2011)

References

i. Thrombophilia is an abnormal tendency for the blood to clot, which can cause VTE in some people. Some types of thrombophilia are inherited, others develop later in life.

ii. Clinical prediction rules/probability scoring for diagnosing DVT and PE.

iii. A blood test to determine the concentration of a small protein fragment present in the blood after a blood clot is degraded by fibrinolysis.

About NICE

1. The National Institute for Health and Care Excellence (NICE) is the independent organisation responsible for providing national guidance and standards on the promotion of good health and the prevention and treatment of ill health

2. NICE produces guidance in three areas of health:

  • public health - guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector
  • health technologies - guidance on the use of new and existing medicines, treatments, medical technologies (including devices and diagnostics) and procedures within the NHS
  • clinical practice - guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.

3. NICE produces standards for patient care:

  • quality standards - these reflect the very best in high quality patient care, to help healthcare practitioners and commissioners of care deliver excellent services
  • Quality and Outcomes Framework - NICE develops the clinical and health improvement indicators in the QOF, the Department of Health scheme which rewards GPs for how well they care for patients

4. NICE provides advice and support on putting NICE guidance and standards into practice through its implementation programme, and it collates and accredits high quality health guidance, research and information to help health professionals deliver the best patient care through NHS Evidence.

This page was last updated: 26 October 2011

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Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.