American Society of Hematology 2018 guidelines for management of venous thromboembolism: diagnosis of venous thromboembolism

Abstract

Background: Modern diagnostic strategies for venous thromboembolism (VTE) incorporate pretest probability (PTP; prevalence) assessment. The ability of diagnostic tests to correctly identify or exclude VTE is influenced by VTE prevalence and test accuracy characteristics. Objective: These evidence-based guidelines are intended to support patients, clinicians, and health care professionals in VTE diagnosis. Diagnostic strategies were evaluated for pulmonary embolism (PE), deep vein thrombosis (DVT) of the lower and upper extremity, and recurrent VTE. Methods: The American Society of Hematology (ASH) formed a multidisciplinary panel including patient representatives. The McMaster University GRADE Centre completed systematic reviews up to 1 October 2017. The panel prioritized questions and outcomes and used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess evidence and make recommendations. Test accuracy estimates and VTE population prevalence were used to model expected outcomes in diagnostic pathways. Where modeling was not feasible, management and accuracy studies were used to formulate recommendations. Results: Ten recommendations are presented, by PTP for patients with suspected PE and lower extremity DVT, and for recurrent VTE and upper extremity DVT. Conclusions: For patients at low (unlikely) VTE risk, using D-dimer as the initial test reduces the need for diagnostic imaging. For patients at high (likely) VTE risk, imaging is warranted. For PE diagnosis, ventilation-perfusion scanning and computed tomography pulmonary angiography are the most validated tests, whereas lower or upper extremity DVT diagnosis uses ultrasonography. Research is needed on new diagnostic modalities and to validate clinical decision rules for patients with suspected recurrent VTE.

Age‐adjusted D‐dimer cutoff for the diagnosis of pulmonary embolism: A cost‐effectiveness analysis

“…At the scale of the US health care system, we estimated very large cost savings (US$75‐98 million/year) with the use of the AADD. Although current guidelines and best clinical practice recommendations support the wide use of the AADD cutoff, reports from emergency departments indicate a low adequacy of PE diagnostic strategies, with poor uses of clinical decision rules or D‐dimer. Consequently, efforts should be focused on maximizing the implementation of proper diagnostic strategies including the AADD cutoff.…”

Assessment of D-dimer for ruling out peripherally inserted central catheter-associated upper extremity venous thrombosis: a diagnostic accuracy study

“…Diagnostic guidelines for DVT recommend using D-dimer levels to initially screen for the risk of DVT before using CDU [8]. In this study, we investigated whether the D-dimer concentration could be used as a key diagnostic marker for excluding PICC-associated VT. We evaluated patients with a PICC who had a modi ed Wells score of DVT < 2 points (DVT unlikely) and D-dimer < 0.5 mgL − 1 and found that a large proportion of these patients had PICC-associated VT.…”

“…D-dimer, the minimal degradation product of brin, is produced by brinolytic protein hydrolysis of brin. It has been established as a sensitive biomarker for activation of the brinolytic system [8]. In VTE events, D-dimer levels can rise abnormally; accordingly, the diagnosis of VTE can be assisted by determining the D-dimer levels.…”

Complicated upper extremity deep vein thrombosis (Paget-Schroetter disease): a case report

“…Агрессивный подход в лечении данной группы пациентов, включающий катетерный продленный тромболизис в сочетании с хирургическим лечением (резекция I ребра и/или стентирование подключичной вены) базируется на мнении ряда авторов [2,3], однако сопровождается риском интра-и периоперационных осложнений, риском кровотечений на фоне продленного тромболизиса. При ведении пациентки избрана консервативная тактика лечения, с назначением антикоагулянтов согласно рекомендованным схемам лечения [4,5], спазмолитической и противовоспалительной терапии, венотонических препаратов, применения индивидуального эластического трикотажа, что определило благоприятный прогноз, но потребовало изменения привычного образа жизни.…”