Diagnosis and Management of Acute Deep Vein Thrombosis

Authors:
Mazzolai L, Aboyans V, Ageno W, et al.
Citation:
Diagnosis and Management of Acute Deep Vein Thrombosis: A Joint Consensus Document From the European Society of Cardiology Working Groups of Aorta and Peripheral Circulation and Pulmonary Circulation and Right Ventricular Function. Eur Heart J 2017;Feb 17:[Epub ahead of print].

The following are key points to remember from this joint consensus document from the European Society of Cardiology about the diagnosis and management of acute deep vein thrombosis (DVT):

  1. Clinical signs and symptoms of DVT are highly variable and nonspecific, but remain the cornerstone of diagnostic strategy. Symptoms include pain, swelling, increased skin vein visibility, erythema, and cyanosis accompanied by unexplained fever.
  2. Clinical prediction rule (two-level modified Wells score) is recommended to stratify patients with suspected lower limb DVT.
  3. Enzyme-linked immunosorbent assay (ELISA) D-dimer measurement is recommended in “unlikely” clinical probability patients to exclude DVT.
  4. Venous ultrasound (US) is recommended as the first-line imaging method for DVT diagnosis. Venous computed tomography (CT) scan should be reserved for selected patients only. Venous US should be proposed also in case of confirmed pulmonary embolism (PE), for initial reference venous imaging, useful in case of DVT recurrence suspicion, or further stratification in selected patients.
  5. In general, patients with proximal DVT should be anticoagulated for at least 3 months. Patients with isolated distal DVT at high-risk of recurrence should be anticoagulated, as for proximal DVT; for those at low risk of recurrence, shorter treatment (4-6 weeks), even at lower anticoagulant doses, or US surveillance may be considered.
  6. In the absence of contraindications, direct oral anticoagulants should be preferred as first-line anticoagulant therapy in noncancer patients with proximal DVT. Low molecular weight heparin (LMWH) is recommended for initial and long-term treatment in cancer patients.
  7. Adjuvant catheter-directed thrombolysis may be considered in selected patients with iliocommon femoral DVT, symptoms <14 days, and life expectancy >1 year if performed in experienced centers. Primary acute DVT stenting or mechanical thrombus removal alone are not recommended. Vena cava filters may be considered if anticoagulation is contraindicated; their use in addition to anticoagulation is not recommended.
  8. Compression therapy associated with early mobilization and walking exercise should be considered to relieve acute venous symptoms.
  9. Decision to discontinue or not anticoagulate should be individually tailored, balancing risk of recurrence against bleeding risk, taking into account patients’ preferences and compliance.
  10. During pregnancy, venous US is recommended as first-line DVT imaging test. LMWH is recommended for initial and long-term treatment during pregnancy. Anticoagulant treatment should be continued for at least 6 weeks after delivery with a total of 3 months of treatment.

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