NICE clinical guideline set to save lives by improving the diagnosis and management of blood clots
New guidance published today by NICE aims to reduce the current high toll of long-term ill health or death caused by blood clots in the legs or lungs (venous thromboembolic diseases) by clarifying for the first time what combination of tests and treatments results in the most clinically and cost effective diagnosis and management of the conditions.
Venous thromboembolic (VTE) diseases cover a spectrum ranging from asymptomatic deep vein thrombosis (DVT) to fatal pulmonary embolism (PE). They are the result of a blood clot (a thrombus) forming in a vein and then dislodging to travel in the blood (an embolus). If the blood clot dislodges and travels to the lungs, this can lead to a potentially fatal PE. Even if blood clots are non fatal, they can still result in long-term illness, including venous ulceration and development of a post-thrombotic limb (chronic pain, swelling and skin changes in the affected limb) and have a significant impact on quality of life. Thrombophilia, an inherited or acquired disorder in which the blood is prone to clot abnormally, and cancer are major risk factors for blood clots. Other risk factors include a history of DVT, age over 60 years, recent surgery/serious injury, obesity, prolonged travel, acute medical illness, immobility and pregnancy.
Latest figures (from 2010/11i) show that over 56,000 people - around 1000 per week - were diagnosed with blood clots in their legs or lungs. However, diagnosis is often far from straightforward and in many cases they are only diagnosed post-mortem (in 2007 nearly 17,000 recorded deaths in England and Wales mentioned DVT or PE as either the primary cause of death or a contributory factorii). Evidence suggests that as many as 50% of people in whom a blood clot in the leg is left untreated will go on to develop a blood clot in their lung. In addition, although treatments for blood clots are well established once a diagnosis is suspected or has been made, 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 and cancer in patients who have had a blood clot.
Importantly, the guideline is the first of its kind to recommend that investigations for cancer should be carried out in people aged over 40 years who are not already known to have cancer and who have a blood clot in their leg or lung where there is no obvious cause. This is because cancer is a significant risk factor for blood clots (people with cancer have an estimated fourfold increased rate of blood clots compared with people who do not have cancer) and because the guideline recommends that patients with cancer are given low molecular weight heparin instead of a Vitamin K antagonist to treat their blood clot to reduce the risk of its recurrence.
Other recommendations in the guideline cover:
- Diagnostic investigations for DVT including use of the two-level DVT Wells scoreiii, leg vein ultrasound scanning, D-dimer testingiv and interim anticoagulant therapy.
- Diagnostic investigations for PE including use of the two-level PE Wells scoreiii, computed tomography pulmonary angiogramv, ultrasound scanning of the large veins in the legvi and interim anticoagulant therapy.
- Pharmacological interventions to treat DVT or PE including the use of anticoagulants to prevent blood clots forming or enlarging (low molecular weight heparin, fondaparinux, unfractionated heparin, vitamin K antagonists (e.g. warfarin)), different treatments for people with active cancer (low molecular weight heparin for at least 6 months), and thrombolytic drugs to help dissolve blood clots.
- The use of graduated compression stockings for proximal DVTvii
- Thrombophilia testing
Professor Mark Baker, Director of the Centre for Clinical Practice at NICE said: "Whether hospital-acquired or community-acquired, blood clots in the leg or lung can have the same devastating consequences. Their prevention in people who are admitted to hospital has quite rightly become a priority for the NHS in recent years. But despite progress in this area, particularly following the publication of the 2010 NICE guideline, every year thousands of people die in the UK of as the result of a blood clot. The majority of these are as the result of preventable hospital-acquired blood clots but many are the result of a blood clot acquired in the community. Early diagnosis and appropriate management improves outcomes but is sometimes more difficult to achieve than might be imagined. For example, the treatment for a blood clot in the leg or the lung, once a diagnosis has been confirmed, is itself not without risk since anticoagulants and thrombolytic drugs can cause serious bleeding in some patients. This new guideline, based on a review of the most up-to-date research, clarifies what combination of tests and treatments are most clinically and cost effective in reducing the unacceptable toll of long-term ill health or even death from blood clots."
Gerard Stansby, Professor of Vascular Surgery and Chair of the Guideline Development Group, said: "Blood clots in the leg or lung are a common and serious problem for the NHS; unfortunately they are often misdiagnosed leading to high rates of mortality and long term disability. By giving clear guidance on how they should be investigated and then treated, this new guideline will lead to improved outcomes for people with these conditions in the NHS."
Beverley Hunt, Professor of Thrombosis and Haemostasis, Medical Director of Lifeblood and member of the Guideline Development Group, said: "This new NICE guideline on the management of blood clots is a major advance in improving the quality of care patients with a new deep vein thrombosis or pulmonary embolism in England and Wales receive. This is because it sets a clear standard of care that will ensure patients are managed according to the best evidence, and demand that diagnostic investigations are performed in a timely fashion."
Hayley Flavell, Anticoagulant and Thrombosis Consultant Nurse and member of the Guideline Development Group, said: "This new NICE guideline provides clinicians with a pathway for the safe and effective investigation and management of patients with a blood clot. It will improve the quality of care for patients with deep vein thrombosis or pulmonary embolism by providing clear comprehensive standards of care that ensure patients are managed according to the best evidence."
Dr Roshan Agarwal, Senior Lecturer and Consultant Medical Oncologist and member of the Guideline Development Group, said: "This new guideline represents an important milestone in improving the quality of care received by patients with cancer associated blood clots. It clarifies the differences in the best treatment options for cancer and non-cancer patients, and critically for the first time sets clear standards for the investigation of underlying cancer in patients with a blood clot."
Susan Ballard, patient and carer representative on the Guideline Development Group, said: "These guidelines are important as they ensure that all patients who may have DVT or PE get access to prompt diagnosis and possibly lifesaving treatment and, in those with DVT, follow-up to improve quality of life in terms of interventions to reduce post-thrombotic syndrome. Also venous thromboembolism is a major complication of cancer that occurs in up to 20% of patients, a fact that may not be known by many healthcare professionals and certainly not by the public. It is good that this guideline highlights the link between cancer and blood clots so that the public, patients and healthcare professionals can be alerted to the possibility of it occurring, the symptoms and the different treatment for patients with active cancer."
Notes to Editors
About the guidance
1. 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.
2. The 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/CG144 (from Wednesday 27 June 2012).
3. NICE has also produced a suite of tools for healthcare professionals to support implementation of the guideline. An educational resource for DVT and PE includes clinical case scenarios and slide set. Clinical audit tools covering the diagnosis of DVT, diagnosis of PE, treatment of VTE and investigations for cancer and thrombophilia testing are also available. All the implementation tools are available on the NICE website at http://guidance.nice.org.uk/CG144. In addition NICE has also begun development of a VTE diseases quality standard. Further information about the in-development quality standard is also available on the NICE website
4. In 2010 NICE published its clinical guideline on reducing the risk of VTE in patients admitted to hospital. The guideline is available on the NICE website.
i. Hospital Episodes Statistics for 2010/11
ii. Office for National Statistics
iii. Clinical prediction rules for estimating the probability of DVT and PE.
iv. A blood test to determine the concentration of a small protein fragment present in the blood after a blood clot is degraded by fibrinolysis.
v. A medical diagnostic test that employs computed tomography to obtain an image of the pulmonary arteries
vi. Veins above the knee e.g. popliteal vein.
vii. DVT in the veins at the knee, or above. Proximal DVT is sometimes referred to as ‘above-knee DVT'
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:
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- 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
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This page was last updated: 26 June 2012