The management of patients presenting to the ED with deep vein thrombosis (DVT) has changed in several ways over the last decade, and emergency clinicians have more tools to manage a safe and cost-effective disposition.
What are the possible causes of unprovoked versus provoked DVT, and how do they factor into diagnosis and treatment?
How much of a risk factor for DVT does oral contraceptive use and pregnancy present?
When a patient reports a feeling of heaviness and cramping in the leg, what are the historical and physical examination findings that can risk stratify for DVT?
What is the historical finding most likely to point to DVT? What is the least likely finding?
Under what circumstances can a negative D-dimer rule out DVT?
What does the lack of specificity of a positive D-dimer mean for ordering further testing? How does age affect its specificity?
What are the types of ultrasound tests that can be used to rule in or rule out DVT, and which tests need to be repeated?
Which patients should receive warfarin? Heparin? Direct oral anticoagulants? When should a patient be admitted for anticoagulation and when can they be sent home?
What does the evidence show regarding aspirin, compression stockings, IVC filters, and thrombolysis in the treatment of DVT?
Deep vein thrombosis (DVT) can present with a variety of nonspecific signs and symptoms, and can involve the upper or lower extremities. Management of patients with DVT has changed markedly over the last 10 years, moving from hospital admission for initiation of anticoagulation to outpatient management. Diagnosis requires a risk stratification process involving clinical decision rules, D-dimer testing, and ultrasonography. Once the diagnosis is confirmed, the patient should be engaged in shared decision-making regarding treatment options. Recurrent DVT, as well as managing DVT in pregnant women, the elderly population, and patients with malignancies are also discussed.
Case Presentations
A 20-year-old woman presents with a 3-day history of left lower extremity pain and swelling. On examination, her left lower leg is visibly larger than the right. She is concerned that she has a “blood clot,” because her mother had one several years ago. She says that she does not have health insurance and will be self-paying for her visit. She asks you to keep the cost of the visit as low as possible. You wonder whether there is clinical decision rule that could be used to aid in choosing a cost-effective diagnostic strategy…
Your next patient is a 56-year-old man who is also complaining of left lower extremity pain and swelling. A venous duplex ultrasound confirms a deep vein thrombosis (DVT) in the popliteal vein. He notes that he is the primary breadwinner for his family and cannot stay in the hospital for treatment. He asks if there is any way he could be discharged to home with treatment. You recall that patients with an isolated DVT can be discharged home, but you cannot remember the protocol to initiate the discharge process…
Your last patient of the shift is a 76-year-old woman with right lower extremity pain and swelling. On examination, her right lower leg is swollen, but she has no discoloration or loss of pedal pulse. A venous duplex ultrasound confirms an extensive proximal DVT in the extremity. You anticoagulate the patient and call the internist for admission. The internist would like you to discuss the case with a vascular surgeon for possible thrombolysis. You wonder what the evidence is supporting thrombolysis in these patients . . . ….
Introduction
Venous thromboembolism (VTE) is a spectrum of diseases that includes superficial thrombophlebitis, deep vein thrombosis (DVT), and pulmonary embolism. The annual cost of treatment in the United States for these conditions is between $7 and $10 billion, and they represent a major healthcare concern.1 DVT can present a diagnostic dilemma for the emergency clinician due to the overlapping of symptoms with other diseases.
Over the last decade, new treatment paradigms have revolutionized the care of patients with DVT, moving from the inpatient setting to outpatient management; however, despite these advances, a large proportion of patients will develop complications from the disease process. This issue of Emergency Medicine Practice reviews the evidence regarding the pathophysiology, diagnosis, and management of DVT in the emergency department (ED).
Critical Appraisal of the Literature
A literature search was conducted utilizing multiple available databases. A MEDLINE® search with the MeSH heading of deep vein thrombosis restricted to studies involving humans published from January 2014 through June 2020 yielded over 21,000 results, with 1002 being clinical trials, 642 being randomized. Additional databases and search strategies were queried, including Google Scholar and the Cochrane Database of Systematic Reviews. Reference lists from the identified articles and abstracts, as well as major textbooks in internal medicine, emergency medicine, hematology, and critical care were reviewed. Clinical practice guidelines and position statements from major relevant professional organizations were also reviewed.
Boolean operators and MeSH headings were applied to structure the literature search and included: deep vein thrombosis and emergency medicine, deep vein thrombosis and risk stratification, deep vein thrombosis and treatment. Two authors screened these results independently for articles considered to be landmark publications, highly impactful, or from high-quality journals. A total of 97 articles were included in this review.
Epidemiology
Although the true incidence of VTE is unknown, the overall incidence in the general population has been postulated to be 100 cases per 100,000 persons per year, with an annual incidence rate of 0.1% in the United States.2 The overall incidence of VTE increases exponentially with age. Once a patient reaches age 80 years, the incidence of VTE rises to 450 cases per 100,000 per year.3 The incidence of DVT in the general population has been estimated to range from 45 to 117 cases per 100,000 persons per year.4 Much like VTE, the risk for DVT increases with age, and approximately 1% of the population aged > 60 years will develop a DVT.4 Black persons have the highest incidence of DVT (29.3 cases per 100,000), followed by White persons (23 cases per 100,000), Latinos (13.9 cases per 100,000), and Asian-Pacific Islanders (0.6 cases per 100,000).5 Although the incidence of DVT is relatively equal among the sexes, men present more often with a proximal DVT and women present more often with a distal DVT.6,7 There also appears to be a seasonal variation with DVT, with the winter months having a higher number of cases.8 Recurrence rates depend upon the original cause of the thrombus, but have been reported to be 8.6% at 6 months and up to 30.3% at 8 years.4 Post thrombotic syndrome, a complication of DVT, has been reported to be as high as 50%, despite anticoagulation.9 The mortality for those diagnosed with a DVT is 3.8% at 7 days, 5.5% at 30 days, and 14.6% at 1 year.10
Risk Management Pitfalls for Deep Vein Thrombosis in the Emergency Department
1. “The patient’s leg was red and only slightly swollen, but he didn’t have calf pain. I started him on antibiotics for cellulitis and sent him home.”
Although the majority of patients who present with leg pain will be diagnosed with a nonthrombotic condition, the physical examination can be misleading. Patients should be risk stratified using the Wells score to determine a diagnostic strategy.
3. “I use an age-adjusted D-dimer in elderly patients to help rule out DVT.”
The age adjusted D-dimer has been proven to be accurate in patients with pulmonary embolism, but it has not been studied extensively in patients with possible DVT.
5. “The patient had a negative ultrasound and D-dimer, so I sent him home to follow up with his primary care provider in the coming weeks.”
Diagnostic strategies should be based upon the sensitivity of the tests being obtained. If a whole-leg ultrasound was obtained, then further testing is not required. If another form of extremity ultrasound was obtained, then a repeat ultrasound is warranted.
Tables and Figures
References
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. The most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.
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Trinchero A, Scheres LJJ, Prochaska JH, et al. Sex-specific differences in the distal versus proximal presenting location of acute deep vein thrombosis. Thromb Res. 2018;172:74-79. (Meta-analysis; 7 manuscripts)
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American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 196: thromboembolism in pregnancy. Obstet Gynecol. 2018;132(1):e1-e17. (Practice bulletin; updated guidance)
James AH, Jamison MG, Brancazio LR, et al. Venous thromboembolism during pregnancy and the postpartum period: incidence, risk factors, and mortality. Am J Obstet Gynecol. 2006;194(5):1311-1315. (Retrospective study; 17,730 patients)
Jacobsen AF, Skjeldestad FE, Sandset PM. Incidence and risk patterns of venous thromboembolism in pregnancy and puerperium--a register-based case-control study. Am J Obstet Gynecol. 2008;198(2):233.e231-237. (Register-based case-control study; 613,232 pregnancies)
Chandra D, Parisini E, Mozaffarian D. Meta-analysis: travel and risk for venous thromboembolism. Ann Intern Med. 2009;151(3):180-190. (Meta-analysis; 14 studies)
Lapostolle F, Le Toumelin P, Chassery C, et al. Gender as a risk factor for pulmonary embolism after air travel. Thromb Haemost. 2009;102(6):1165-1168. (Retrospective study; 116 patients)
Cannegieter SC, Doggen CJ, van Houwelingen HC, et al. Travel-related venous thrombosis: results from a large population-based case control study (MEGA study). PLoS Med. 2006;3(8):e307. (Retrospective study; 1906 patients)
White RH, Zhou H, Romano PS. Incidence of symptomatic venous thromboembolism after different elective or urgent surgical procedures. Thromb Haemost. 2003;90(3):446-455. (Retrospective study; 1,653,275 patients)
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van Stralen KJ, Rosendaal FR, Doggen CJ. Minor injuries as a risk factor for venous thrombosis. Arch Intern Med. 2008;168(1):21-26. (Retrospective study; 6005 patients)
Geerts WH, Code KI, Jay RM, et al. A prospective study of venous thromboembolism after major trauma. N Engl J Med. 1994;331(24):1601-1606. (Prospective study; 716 patients)
Chang SL, Huang YL, Lee MC, et al. Association of varicose veins with incident venous thromboembolism and peripheral artery disease. JAMA. 2018;319(8):807-817. (Retrospective study; 425,968 patients)
Lindblad B, Tengborn L, Bergqvist D. Deep vein thrombosis of the axillary-subclavian veins: epidemiologic data, effects of different types of treatment and late sequelae. Eur J Vasc Surg. 1988;2(3):161-165. (Retrospective study; 296 patients)
DiFelice GS, Paletta GA Jr, Phillips BB, et al. Effort thrombosis in the elite throwing athlete. Am J Sports Med. 2002;30(5):708-712. (Retrospective review; 4 cases)
Kaltenmeier CT, Erben Y, Indes J, et al. Systematic review of May-Thurner syndrome with emphasis on gender differences. J Vasc Surg Venous Lymphat Disord. 2018;6(3):399-407 e394. (Meta-analysis; 174 studies)
ten Cate-Hoek AJ, van der Velde EF, Toll DB, et al. Common alternative diagnoses in general practice when deep venous thrombosis is excluded. Neth J Med. 2012;70(3):130-135. (Prospective study; 1028 patients)
Adhikari S, Zeger W. Non-thrombotic abnormalities on lower extremity venous duplex ultrasound examinations. West J Emerg Med. 2015;16(2):250-254. (Retrospective study; 2390 patients)
Prandoni P, Kahn SR. Post-thrombotic syndrome: prevalence, prognostication and need for progress. Br J Haematol. 2009;145(3):286-295. (Review)
Goodacre S, Sutton AJ, Sampson FC. Meta-analysis: the value of clinical assessment in the diagnosis of deep venous thrombosis. Ann Intern Med. 2005;143(2):129-139. (Meta-analysis; 51 studies) DOI: 10.7326/0003-4819-143-2-200507190-00012
Joffe HV, Kucher N, Tapson VF, et al. Upper-extremity deep vein thrombosis: a prospective registry of 592 patients. Circulation. 2004;110(12):1605-1611. (Prospective study; 592 patients)
Chastre J, Cornud F, Bouchama A, et al. Thrombosis as a complication of pulmonary-artery catheterization via the internal jugular vein: prospective evaluation by phlebography. N Engl J Med. 1982;306(5):278-281.
American College of Emergency Physicians ACEP Clinical Policies Committee, ACEP Clinical Policies Subcommittee on Suspected Lower-Extremity Deep Venous Thrombosis. Clinical policy: critical issues in the evaluation and management of adult patients presenting with suspected lower-extremity deep venous thrombosis. Ann Emerg Med. 2003;42(1):124-135. (Clinical policy) DOI: 10.1067/mem.2003.181
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Bates SM, Jaeschke R, Stevens SM, et al. Diagnosis of DVT: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2 Suppl):e351S-e418S. (Guideline) DOI: 10.1378/chest.11-2299
Wells PS, Hirsh J, Anderson DR, et al. Accuracy of clinical assessment of deep-vein thrombosis. Lancet. 1995;345(8961):1326-1330. (Prospective study; 529 patients)
Wells PS, Anderson DR, Bormanis J, et al. Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet. 1997;350(9094):1795-1798. (Prospective study; 593 patients) DOI: 10.1016/S0140-6736(9 7)08140-3
Wells PS, Anderson DR, Rodger M, et al. Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. New Engl J Med. 2003;349:1227-1235. (Prospective study; 1096 patients)
Wells PS, Owen C, Doucette S, et al. Does this patient have deep vein thrombosis? JAMA. 2006;295(2):199-207. (Meta-analysis; 14 studies, 8000 patients) DOI: 10.1001/jama.295.2.199
Needleman L, Cronan JJ, Lilly MP, et al. Ultrasound for lower extremity deep venous thrombosis: multidisciplinary recommendations from the Society of Radiologists in Ultrasound consensus conference. Circulation. 2018;137(14):1505-1515. (Guideline)
Wolf SJ, Hahn SA, Nentwich LM, et al. Clinical Policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with suspected acute venous thromboembolic disease. Ann Emerg Med. 2018;71(5):e59-e109. (Clinical Policy) DOI: 10.1016/j.annemergmed.2018.03.006
Kearon C, Akl EA, Omelas J, et al. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. CHEST. 2016;149(2):315-352. (Guideline) DOI: 10.1016/j.chest.2015.11.026
Singer AJ, Zheng H, Francis S, et al. D-dimer levels in VTE patients with distal and proximal clots. Am J Emerg Med. 2019;37(1):33-37. (Prospective study; 1752 patients). )
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Goodacre S, Sampson F, Stevenson M, et al. Measurement of the clinical and cost-effectiveness of non-invasive diagnostic testing strategies for deep vein thrombosis. Health Technol Assess. 2006;10(15):1-168, iii-iv. (Meta-analysis)
Johnson SA, Stevens SM, Woller SC, et al. Risk of deep vein thrombosis following a single negative whole-leg compression ultrasound: a systematic review and meta-analysis. JAMA. 2010;303(5):438-445. (Meta-analysis; 7 studies, 4731 patients)
Zitek T, Baydoun J, Yepez S, et al. Mistakes and pitfalls associated with two-point compression ultrasound for deep vein thrombosis. West J Emerg Med. 2016;17(2):201-208. (Prospective study; 288 patients)
Crisp JG, Lovato LM, Jang TB. Compression ultrasonography of the lower extremity with portable vascular ultrasonography can accurately detect deep venous thrombosis in the emergency department. Ann Emerg Med. 2010;56(6):601-610. (Prospective study; 199 patients)
Lee JH, Lee SH, Yun SJ. Comparison of 2-point and 3-point point-of-care ultrasound techniques for deep vein thrombosis at the emergency department: a meta-analysis. Medicine (Baltimore). 2019;98(22):e15791. (Meta-analysis; 17 studies, 2372 patients)
Burnside PR, Brown MD, Kline JA. Systematic review of emergency physician-performed ultrasonography for lower-extremity deep vein thrombosis. Acad Emerg Med. 2008;15(6):493-498. (Meta-analysis; 6 studies, 936 patients)
Pomero F, Dentali F, Borretta V, et al. Accuracy of emergency physician-performed ultrasonography in the diagnosis of deep-vein thrombosis: a systematic review and meta-analysis. Thromb Haemost. 2013;109(1):137-145. (Meta-analysis and systematic review; 16 studies, 2379 patients)
Di Nisio M, Van Sluis GL, Bossuyt PM, et al. Accuracy of diagnostic tests for clinically suspected upper extremity deep vein thrombosis: a systematic review. J Thromb Haemost. 2010;8(4):684-692. (Meta-analysis and systematic review; 17 papers, 793 patients)
Thomas SM, Goodacre SW, Sampson FC, et al. Diagnostic value of CT for deep vein thrombosis: results of a systematic review and meta-analysis. Clin Radiol. 2008;63(3):299-304. (Meta-analysis; 13 studies)
Sampson FC, Goodacre SW, Thomas SM, et al. The accuracy of MRI in diagnosis of suspected deep vein thrombosis: systematic review and meta-analysis. Eur Radiol. 2007;17(1):175-181. (Systematic review and meta-analysis; 14 studies)
Robertson L, Strachan J. Subcutaneous unfractionated heparin for the initial treatment of venous thromboembolism. Cochrane Database Syst Rev. 2017;2:CD006771. (Systematic review; 16 studies, 3593 patients)
Robertson L, Kesteven P, McCaslin JE. Oral direct thrombin inhibitors or oral factor Xa inhibitors for the treatment of deep vein thrombosis. Cochrane Database Syst Rev. 2015(6):CD010956. (Meta-analysis; 11 studies, 2795 patients)
Kabrhel C, Rosovsky R, Baugh C, et al. Multicenter implementation of a novel management protocol increases the outpatient treatment of pulmonary embolism and deep vein thrombosis. Acad Emerg Med. 2019;26(6):657-669. (Observational study; 2212 patients)
Kahler ZP, Beam DM, Kline JA. Cost of treating venous thromboembolism with heparin and warfarin versus home treatment with rivaroxaban. Acad Emerg Med. 2015;22(7):796-802. (Case control study; 97 patients)
Schulman S, Kearon C, Kakkar AK, et al. Dabigatran versus warfarin in the treatment of acute venous thromboembolism. N Engl J Med. 2009;361(24):2342-2352. (Prospective study; 2539 patients)
Bauersachs R, Berkowitz SD, Brenner B, et al. Oral rivaroxaban for symptomatic venous thromboembolism. N Engl J Med. 2010;363(26):2499-2510. (Prospective study; 3449 patients)
Agnelli G, Buller HR, Cohen A, et al. Apixaban for extended treatment of venous thromboembolism. N Engl J Med. 2013;368(8):699-708. (Prospective study; 6528 patients)
Kakkos SK, Kirkilesis GI, Tsolakis IA. Editor’s choice - efficacy and safety of the new oral anticoagulants dabigatran, rivaroxaban, apixaban, and edoxaban in the treatment and secondary prevention of venous thromboembolism: a systematic review and meta- analysis of phase III trials. Eur J Vasc Endovasc Surg. 2014;48(5):565-575. (Meta-analysis; 10 studies, 38,000 patients)
Gomez-Outes A, Lecumberri R, Suarez-Gea ML, et al. Case fatality rates of recurrent thromboembolism and bleeding in patients receiving direct oral anticoagulants for the initial and extended treatment of venous thromboembolism: a systematic review. J Cardi ovasc Pharmacol Ther. 2015;20(5):490-500. (Systematic review; 10 trials, 35,029 patients)
Pollack CV, Reilly PA, van Ryn J, et al. Idarucizumab for dabigatran reversal — full cohort analysis. N Engl J Med. 2017;377(5):431-441. (Prospective study; 503 patients)
Connolly SJ, Milling TJ Jr, Eikelboom JW, et al. Andexanet alfa for acute major bleeding associated with factor Xa inhibitors. N Engl J Med. 2016;375(12):1131-1141. (Prospective study; 67 patients)
Tritschler T, Kraaijpoel N, Le Gal G, et al. Venous thromboembolism: advances in diagnosis and treatment. JAMA. 2018;320(15):1583-1594. (Meta-analysis; 32 studies)
Becattini C, Agnelli G, Schenone A, et al. Aspirin for preventing the recurrence of venous thromboembolism. N Engl J Med. 2012;366(21):1959-1967. (Prospective study; 402 patients)
Brighton TA, Eikelboom JW, Mann K, et al. Low-dose aspirin for preventing recurrent venous thromboembolism. N Engl J Med. 2012;367(21):1979-1987. (Prospective; 822 patients)
Mismetti P, Laporte S, Pellerin O, et al. Effect of a retrievable inferior vena cava filter plus anticoagulation vs anticoagulation alone on risk of recurrent pulmonary embolism: a randomized clinical trial. JAMA. 2015;313(16):1627-1635. (Prospective; 399 patients)
Vedantham S, Goldhaber SZ, Julian JA, et al. Pharmaco-mechanical catheter-directed thrombolysis for deep-vein thrombosis. N Engl J Med. 2017;377(23):2240-2252. (Prospective study; 692 patients)
Wang L, Zhang C, Mu S, et al. Safety of catheter-directed thrombolysis for the treatment of acute lower extremity deep vein thrombosis: a systematic review and meta-analysis. Medicine (Baltimore). 2017;96(35):e7922. (Systematic review and meta -analysis; 24 studies, 9157 patients)
Lee AY, Levine MN, Baker RI, et al. Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in patients with cancer. N Engl J Med. 2003;349(2):146-153. (Prospective study; 672 patients)
Lee AYY, Kamphuisen PW, Meyer G, et al. Tinzaparin vs warfarin for treatment of acute venous thromboembolism in patients with active cancer: a randomized clinical trial. JAMA. 2015;314(7):677-686. (Prospective study; 900 patients)
Raskob GE, van Es N, Verhamme P, et al. Edoxaban for the treatment of cancer-associated venous thromboembolism. N Engl J Med. 2018;378(7):615-624. (Randomized controlled trial; 1046 patients)
Kline JA, Williams GW, Hernandez-Nino J. D-dimer concentrations in normal pregnancy: new diagnostic thresholds are needed. Clin Chem. 2005;51(5):825-829. (Prospective study; 50 patients)
Schouten HJ, Geersing GJ, Koek HL, et al. Diagnostic accuracy of conventional or age adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism: systematic review and meta-analysis. BMJ. 2013;346:f2492. (Systematic review and meta-analysis; 13 studies, 12,497 patients)
Johnson SA, Eleazer GP, Rondina MT. Pathogenesis, diagnosis, and treatment of venous thromboembolism in older adults. J Am Geriatr Soc. 2016;64(9):1869-1878. (Review)
Chinsakchai K, Ten Duis K, Moll FL, et al. Trends in management of phlegmasia cerulea dolens. Vasc Endovascular Surg. 2011;45(1):5-14. (Review)
Fleck D, Albadawi H, Wallace A, et al. Below-knee deep vein thrombosis (DVT): diagnostic and treatment patterns. Cardiovasc Diagn Ther. 2017;7(Suppl 3):S134-s139. (Retrospective study; 102 patients)
Utter GH, Dhillon TS, Salcedo ES, et al. Therapeutic anticoagulation for isolated calf deep vein thrombosis. JAMA Surg. 2016;151(9):e161770. (Retrospective study; 14,056 patients)
De Martino RR, Wallaert JB, Rossi AP, et al. A meta-analysis of anticoagulation for calf deep venous thrombosis. J Vasc Surg. 2012;56(1):228-237. (Meta-analysis; 2 randomized controlled trials, 6 cohorts; 454 patients)
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Othieno R, Okpo E, Forster R. Home versus in-patient treatment for deep vein thrombosis. Cochrane Database Syst Rev. 2018;1:CD003076. (Cochrane review; 7 randomized controlled trials, 1839 patients) DOI: 10.1002/14651858.CD003 076.pub2
Points and Pearls Excerpt
Pathophysiology for deep vein thrombosis (DVT) is related to the Virchow triad: venous stasis, endothelial vascular injury, and hypercoagulability.
Unprovoked DVT can be due to genetic causes, such as having a non-O blood group, factor V Leiden mutation, prothrombin gene mutation, or protein C and protein S deficiency.
Provoked DVT can result as a complication of cancer, oral contraceptive use, pregnancy, long-distance travel, surgery, or trauma.
Classic signs and symptoms of DVT include pain, swelling, discoloration, heaviness, and cramping sensation.
The Wells criteria, validated and endorsed by the American College of Emergency Physicians (ACEP), stratifies patients as low, moderate, or high pre-test probability of having a DVT.
Goodacre S, Sutton AJ, Sampson FC. Meta-analysis: the value of clinical assessment in the diagnosis of deep venous thrombosis. Ann Intern Med. 2005;143(2):129-139. (Meta-analysis; 51 studies) DOI: 10.7326/0003-4819-143-2-200507190-00012
American College of Emergency Physicians ACEP Clinical Policies Committee, ACEP Clinical Policies Subcommittee on Suspected Lower-Extremity Deep Venous Thrombosis. Clinical policy: critical issues in the evaluation and management of adult patients presenting with suspected lower-extremity deep venous thrombosis. Ann Emerg Med. 2003;42(1):124-135. (Clinical policy) DOI: 10.1067/mem.2003.181
Bates SM, Jaeschke R, Stevens SM, et al. Diagnosis of DVT: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2 Suppl):e351S-e418S. (Guideline) DOI: 10.1378/chest.11-2299
Wells PS, Anderson DR, Bormanis J, et al. Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet. 1997;350(9094):1795-1798. (Prospective study; 593 patients) DOI: 10.1016/S0140-6736(9 7)08140-3
Wells PS, Owen C, Doucette S, et al. Does this patient have deep vein thrombosis? JAMA. 2006;295(2):199-207. (Meta-analysis; 14 studies, 8000 patients) DOI: 10.1001/jama.295.2.199
Wolf SJ, Hahn SA, Nentwich LM, et al. Clinical Policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with suspected acute venous thromboembolic disease. Ann Emerg Med. 2018;71(5):e59-e109. (Clinical Policy) DOI: 10.1016/j.annemergmed.2018.03.006
Kearon C, Akl EA, Omelas J, et al. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. CHEST. 2016;149(2):315-352. (Guideline) DOI: 10.1016/j.chest.2015.11.026
Hanley M, Steigner ML, Ahmed O, et al. ACR Appropriateness Criteria®: suspected lower extremity deep vein thrombosis. J Am Coll Radiol. 2018;15(11):S413-S417. (Guideline) DOI: 10.1016/j.jacr.2018.09.028
Othieno R, Okpo E, Forster R. Home versus in-patient treatment for deep vein thrombosis. Cochrane Database Syst Rev. 2018;1:CD003076. (Cochrane review; 7 randomized controlled trials, 1839 patients) DOI: 10.1002/14651858.CD003 076.pub2
Dr. Ashoo is a practicing emergency physician, board-certified in emergency medicine and clinical informatics. Join him as he takes you through the October 2020 issue of Emergency Medicine Practice: Management of Deep Vein Thrombosis in the Emergency Department
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The Wells criteria for deep vein thrombosis (DVT) stratifies patients suspected of having DVT into risk groups. The tool can be used in outpatient and emergency department settings.
Traditional testing for DVT involved costly and time-intensive multiple lower-extremity ultrasound. The Wells criteria can be used to determine which patients are overall unlikely to have DVT. Further testing with D-dimer can safely rule out DVT without the need for ultrasound. By risk-stratifying a patient to a low-risk category( Wells score < 2) and receiving a negative D-dimer, clinicians can eliminate the need for ultrasound to rule out DVT.
The Wells criteria stratify patients into “DVT unlikely” and “DVT likely” groups. An additional "moderate" risk group can be added, based on the sensitivity of the D-dimer being used. A score of ≤ 0 is associated with “DVT unlikely" (5% prevalence of DVT). These patients should proceed to D-dimer testing. A score of 1 to 2 is considered moderate risk, with a pretest probability of 17%. These patients should proceed to high-sensitivity D-dimer testing, as moderate-sensitivity D-dimer is not sufficient. A score ≥ 3 suggests DVT is likely. Pretest probability is 17% to 53%. All patients found to be “DVT likely” should receive a diagnostic ultrasound.
There is an low prevalence of DVT in patients with low clinical suspicion (< 25%). The Wells score inherently incorporates clinical gestalt, with a -2 score assigned when an alternative diagnosis is more likely than DVT. Sequelae from DVT include pulmonary embolism (PE) and pulmonary hypertension, which have an associated mortality of 1% to 8%. Anticoagulation is the mainstay treatment for DVT, although anticoagulation has its own associated risks of bleeding.
As with all clinical decision aids, the Wells criteria for DVT are meant to aid clinical decision making and not to force management. The criteria should be applied only after a detailed history and physical examination are performed. Likewise, the tool should be applied only to those patients who have been deemed to be at risk for DVT. If there is no concern for DVT, then there is no need for risk stratification.
Calculator Review Authors
Benjamin Slovis, MD
Department of Emergency Medicine, Thomas Jefferson
University, Philadelphia, PA
Evidence Appraisal
The Wells criteria for DVT were derived from a number of studies by Wells et al (Wells 1995, Wells 1997, Wells 2003) in an attempt to stratify risk for DVT in symptomatic outpatients. At the time, the clinical diagnosis of DVT was thought to be inaccurate, leading to widespread overuse of confirmatory imaging.
In their 2003 study, Wells et al identified 1096 outpatients with concern for DVT and randomized them into 2 groups after applying the Wells criteria for DVT. The control group of 520 patients had an ultrasound performed. The other group of 562 patients had D-dimer testing performed. If the D-dimer was positive, they also received an ultrasound; if the D-dimer was negative, no ultrasound was performed. Sixteen percent of the patients in the control group and 15.5% in the test group had DVT or PE, resulting in an overall prevalence of 15.7%. Among the 520 control patients, 279 were considered DVT-unlikely and 241 were considered DVT-likely. Sixteen (5.7%) of the DVT-unlikely patients had DVT or PE. In the control group overall, 6 patients (1.4%) who had been initially ruled out had a diagnosis of DVT on 3-month follow-up. Of the 562 patients in the D-dimer group, 315 were considered unlikely to have DVT and 247 were considered likely to have DVT. Seventy-one patients (28.7%) in the likely group had DVT. In the unlikely group, 38.8% of patients had a negative D-dimer and did not undergo further testing. Two of these patients (0.4%) had confirmed DVT on days 4 and 14 of follow-up. The negative predictive value of D-dimer was 96.1%. This algorithm was then supported by Scarvelis and Wells (Scarvelis 2006).
In 2006, Wells et al performed a systematic review (Wells 2006), which evaluated 8239 patients in 14 studies that used the Wells score to predict risk of DVT, and evaluated for the incidence of DVT in association with moderate- or high-sensitivity D-dimer. This review has been utilized by the American College of Chest physicians to provide guidelines for the evaluation of DVT.
Instructions
The Wells score is less useful in hospitalized patients than in outpatient settings (Silveira 2015). There are several versions of these criteria with minor differences based on the study. The calculator on MDCalc uses the most widely validated criteria, based on the study by Wells et al in 2003 (Wells 2003).
Calculator Creator
Phil Wells, MD, MSc
References
Original/Primary Reference
Wells PS, Hirsh J, Anderson DR, et al. Accuracy of clinical assessment of deep-vein thrombosis. Lancet. 1995;345(8961):1326-1330. DOI: 10.1016/s0140-6736(95)92535-x
Wells PS, Anderson DR, Bormanis J, et al. Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet. 1997;350(9094):1795-1798. DOI: 10.1016/s0140-6736(97)08140-3
Wells PS, Anderson DR, Rodger M, et al. Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. N Engl J Med. 2003;349(13):1227-1235. DOI: 10.1056/nejmoa023153
Validation References
Scarvelis D, Wells PS. Diagnosis and treatment of deep-vein thrombosis. CMAJ. 2006;175(9):1087-1092. Erratum in: CMAJ. 2007;177(11):1392. DOI: 10.1503/cmaj.060366
Additional References
Wells PS, Owen C, Doucette S, et al. Does this patient have deep vein thrombosis? JAMA. 2006;295(2):199-207. DOI: 10.1001/jama.295.2.199
Bates SM, Jaeschke R, Stevens SM, et al. Diagnosis of DVT: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2 Suppl):e351S-e418S. DOI: 10.1378/chest.11-2299
Silveira PC, Ip IK, Goldhaber SZ, et al. Performance of Wells score for deep vein thrombosis in the inpatient setting. JAMA Intern Med. 2015;175(7):1112-1117. DOI: 10.1001/jamainternmed.2015.1687
Upon completion of this article, you should be able to:
Appropriately risk stratify patients suspected of deep vein thrombosis (DVT).
Choose the best diagnostic strategy based on risk stratification.
Describe the different anticoagulant regimens that can be used in the treatment of DVT.
CME Information
Date of Original Release: October 1, 2020. Date of most recent review: September 10, 2020. Termination date: October 1, 2023.
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