Key priorities for implementation

Key priorities for implementation

The following recommendations were identified as priorities for implementation in the 2012 guideline and have not been changed in the 2015 update. The full list of recommendations is in the recommendations section.

Diagnosis

Diagnostic investigations for deep vein thrombosis

  • If a patient presents with signs or symptoms of deep vein thrombosis (DVT), carry out an assessment of their general medical history and a physical examination to exclude other causes. [2012]

  • Offer patients in whom DVT is suspected and with a likely two‑level DVT Wells score (for the two‑level DVT Wells score see table 1 in section 1.1) either:

    • a proximal leg vein ultrasound scan carried out within 4 hours of being requested and, if the result is negative, a D‑dimer test or

    • a D‑dimer test and an interim 24‑hour dose of a parenteral anticoagulant (if a proximal leg vein ultrasound scan cannot be carried out within 4 hours) and a proximal leg vein ultrasound scan carried out within 24 hours of being requested.

      Repeat the proximal leg vein ultrasound scan 6–8 days later for all patients with a positive D‑dimer test and a negative proximal leg vein ultrasound scan. [2012]

  • Offer patients in whom DVT is suspected and with an unlikely two‑level DVT Wells score (for the two‑level DVT Wells score see table 1 in section 1.1) a D‑dimer test and if the result is positive offer either:

    • a proximal leg vein ultrasound scan carried out within 4 hours of being requested or

    • an interim 24‑hour dose of a parenteral anticoagulant (if a proximal leg vein ultrasound scan cannot be carried out within 4 hours) and a proximal leg vein ultrasound scan carried out within 24 hours of being requested. [2012]

Diagnostic investigations for pulmonary embolism

  • Offer patients in whom pulmonary embolism (PE) is suspected and with a likely two‑level PE Wells score (for the two‑level PE Wells score see table 2 in section 1.1) either:

    • an immediate computed tomography pulmonary angiogram (CTPA) or

    • immediate interim parenteral anticoagulant therapy followed by a CTPA, if a CTPA cannot be carried out immediately.

      Consider a proximal leg vein ultrasound scan if the CTPA is negative and DVT is suspected. [2012]

  • Offer patients in whom PE is suspected and with an unlikely two‑level PE Wells score (for the two‑level PE Wells score see table 2 in section 1.1) a D‑dimer test and if the result is positive offer either:

    • an immediate CTPA or

    • immediate interim parenteral anticoagulant therapy followed by a CTPA, if a CTPA cannot be carried out immediately. [2012]

Treatment

Pharmacological interventions

Deep vein thrombosis or pulmonary embolism
  • Offer a choice of low molecular weight heparin (LMWH) or fondaparinux to patients with confirmed proximal DVT or PE, taking into account comorbidities, contraindications and drug costs, with the following exceptions:

    • For patients with severe renal impairment or established renal failure (estimated glomerular filtration rate [eGFR] <30 ml/min/1.73 m2) offer unfractionated heparin (UFH) with dose adjustments based on the APTT (activated partial thromboplastin time) or LMWH with dose adjustments based on an anti‑Xa assay.

    • For patients with an increased risk of bleeding consider UFH.

    • For patients with PE and haemodynamic instability, offer UFH and consider thrombolytic therapy (see recommendations 1.2.7 and 1.2.8 on pharmacological systemic thrombolytic therapy in pulmonary embolism).

      Start the LMWH, fondaparinux or UFH as soon as possible and continue it for at least 5 days or until the international normalised ratio (INR) (adjusted by a vitamin K antagonist [VKA]; see recommendation 1.2.3 on VKA for patients with confirmed proximal DVT or PE) is 2 or above for at least 24 hours, whichever is longer. [2012]

  • Offer LMWH to patients with active cancer and confirmed proximal DVT or PE, and continue the LMWH for 6 months[1]. At 6 months, assess the risks and benefits of continuing anticoagulation[2]. [2012]

  • Offer a VKA beyond 3 months to patients with an unprovoked PE, taking into account the patient's risk of VTE recurrence and whether they are at increased risk of bleeding. Discuss with the patient the benefits and risks of extending their VKA treatment. [2012]

  • Consider extending the VKA beyond 3 months for patients with unprovoked proximal DVT if their risk of VTE recurrence is high and there is no additional risk of major bleeding. Discuss with the patient the benefits and risks of extending their VKA treatment. [2012]

Thrombolytic therapy

Deep vein thrombosis
  • Consider catheter-directed thrombolytic therapy for patients with symptomatic iliofemoral DVT who have:

    • symptoms of less than 14 days' duration and

    • good functional status and

    • a life expectancy of 1 year or more and

    • a low risk of bleeding. [2012]

Investigations for cancer

  • Consider further investigations for cancer with an abdomino‑pelvic CT scan (and a mammogram for women) in all patients aged over 40 years with a first unprovoked DVT or PE who do not have signs or symptoms of cancer based on initial investigation (see recommendation 1.5.1 on investigations for cancer). [2012]



[1] At the time of publication (November 2015) some types of LMWH do not have a UK marketing authorisation for 6 months of treatment of DVT or PE in patients with cancer. Prescribers should consult the summary of product characteristics for the individual LMWH and make appropriate adjustments for severe renal impairment or established renal failure. Informed consent for off-label use should be obtained and documented.

[2] Although this use is common in UK clinical practice, at the time of publication (November 2015) none of the anticoagulants has a UK marketing authorisation for the treatment of DVT or PE beyond 6 months in patients with cancer. Informed consent for off-label use should be obtained and documented.

  • National Institute for Health and Care Excellence (NICE)