Diagnosis and Management of Acute Deep Vein Thrombosis
- Mazzolai L, Aboyans V, Ageno W, et al.
- Diagnosis and Management of Acute Deep Vein Thrombosis: A Joint Consensus Document From the European Society of Cardiology Working Groups of Aorta and Peripheral Vascular Diseases 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 European Society of Cardiology consensus document about diagnosis and management of acute deep vein thrombosis (DVT):
- Clinical signs and symptoms of acute DVT are highly variable and nonspecific. Use of the Wells score to assess pretest probability is recommended.
- For patients with DVT unlikely pretest probability, a D-dimer test should be ordered. If negative, then acute DVT is ruled out and no treatment is necessary.
- For patients with DVT likely on pretest probability or a positive D-dimer, then a complete venous ultrasound should be performed.
- Patients with isolated distal DVT and a high risk of recurrence should be treated with 3 months of anticoagulation. If the risk of recurrence is low, then they can be treated with a short course (4-6 weeks) of anticoagulation (prophylactic dose or full dose) or with surveillance compression ultrasound.
- Patients with proximal DVT should receive at least 3 months of anticoagulation therapy. An extended course of anticoagulation should be determined based on a combination of venous ultrasound findings, risk/benefit balance, patient compliance with therapy, and the patient’s preference.
- Patients without cancer should be treated with direct oral anticoagulants (DOACs) or warfarin, while patients with cancer should receive low molecular weight heparin (LMWH).
- For acute DVT, initial anticoagulation should be one of the following regimens: 1) apixaban 10 mg twice a day for 7 days, then 5 mg twice a day; 2) dabigatran 150 mg twice a day after a 5- to 10-day lead-in course of LMWH; 3) edoxaban 60 mg daily (30 mg if creatinine clearance 30-50 ml/min or potent proton pump inhibitor use) after a 5- to 10-day lead-in course; 4) rivaroxaban 15 mg twice a day for 21 days, then 20 mg daily; or 5) warfarin with a goal international normalized ratio (INR) 2-3 and LMWH for 5-10 days (until INR >2).
- Various risk prediction models can be used to assess the risk of VTE recurrence. These include the Vienna model, the DASH score, and HERDOO-2.
- For extended secondary prophylaxis against recurrent DVT, patients can be treated with low-dose aspirin, apixaban 2.5 mg twice a day, or rivaroxaban 10 mg daily. In general, anticoagulation is preferred over aspirin therapy.
- For upper extremity DVT, ultrasound is the diagnostic modality of choice and treatment is similar to lower extremity DVT.
- During pregnancy, LMWH is the recommended anticoagulation for initial and long-term treatment. Anticoagulation should be continued for at least 6 weeks after delivery (for a minimum of 3 months of treatment).
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