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):

  1. Clinical signs and symptoms of acute DVT are highly variable and nonspecific. Use of the Wells score to assess pretest probability is recommended.
  2. 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.
  3. For patients with DVT likely on pretest probability or a positive D-dimer, then a complete venous ultrasound should be performed.
  4. 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.
  5. 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.
  6. Patients without cancer should be treated with direct oral anticoagulants (DOACs) or warfarin, while patients with cancer should receive low molecular weight heparin (LMWH).
  7. 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).
  8. 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.
  9. 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.
  10. For upper extremity DVT, ultrasound is the diagnostic modality of choice and treatment is similar to lower extremity DVT.
  11. 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).

Clinical Topics: Anticoagulation Management, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Acute Heart Failure, Echocardiography/Ultrasound

Keywords: Anticoagulants, Aspirin, Consensus, Creatinine, Diagnostic Imaging, Geriatrics, Heart Failure, Heparin, Low-Molecular-Weight, International Normalized Ratio, Neoplasms, Peripheral Vascular Diseases, Pregnancy, Primary Prevention, Proton Pump Inhibitors, Pulmonary Circulation, Ultrasonography, Upper Extremity Deep Vein Thrombosis, Vascular Diseases, Venous Thrombosis, Ventricular Function, Right, Warfarin

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