New guidelines from the Thrombosis and Haemostasis Society of Australia and New Zealand for the diagnosis and management of venous thromboembolism

Abstract

Introduction Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is the third most common cardiovascular disease and, globally, more than an estimated 10 million people have it yearly. It is a chronic and recurrent disease. The symptoms of VTE are non‐specific and the diagnosis should actively be sought once considered. The mainstay of VTE treatment is anticoagulation, with few patients requiring additional intervention. A working group of experts in the area recently completed an evidence‐based guideline for the diagnosis and management of DVT and PE on behalf of the Thrombosis and Haemostasis Society of Australia and New Zealand (http://www.thanz.org.au/resources/thanz-guidelines). Main recommendations The diagnosis of VTE should be established with imaging; it may be excluded by the use of clinical prediction rules combined with D‐dimer testing. Proximal DVT or PE caused by a major surgery or trauma that is no longer present should be treated with anticoagulant therapy for 3 months. Proximal DVT or PE that is unprovoked or associated with a transient risk factor (non‐surgical) should be treated with anticoagulant therapy for 3–6 months. Proximal DVT or PE that is recurrent (two or more) and provoked by active cancer or antiphospholipid syndrome should receive extended anticoagulation. Distal DVT caused by a major provoking factor that is no longer present should be treated with anticoagulant therapy for 6 weeks. For patients continuing with extended anticoagulant therapy, either therapeutic or low dose direct oral anticoagulants can be prescribed and is preferred over warfarin in the absence of contraindications. Routine thrombophilia testing is not indicated. Thrombolysis or a suitable alternative is indicated for massive (haemodynamically unstable) PE. Changes in management as a result of the guideline Most patients with acute VTE should be treated with a factor Xa inhibitor and be assessed for extended anticoagulation.

Recurrent unilateral cellulitis: is it May-Thurner syndrome (MTS)?

“…In the presence of a lower limb DVT, anticoagulation therapy is recommended. However, current guidelines discourage routine hypercoagulability workup even in the face of recurrent DVT/PE 9 10. Thrombophilia status would not assist with clinical decision-making in the event of a venous thromboembolism and a positive test does little in predicting recurrence of DVT/PE 10…”

D-dimer: A role in ruling out pulmonary embolism in an emergency care department

“…30,31 This implies recommendations that the patients with highly suspected PE should immediately undergo CT-pulmonary angiography and skip the D-dimer testing. 9,32,33 The aim of this study was to determine to what extent D-dimer values help to differentiate PE in emergency care departments and therefore help in making a decision to transfer patients to a higher referential level or not. Furthermore, the aim was to determine whether the D-dimer values correlated with the values of revised Geneva score.…”

Outpatient management of deep vein thrombosis using direct oral anticoagulants is safe and efficient

“…1 The management of deep venous thrombosis (DVT), particularly distal DVT, is, in part, dependent on the circumstance of the clot and can vary between guidelines, from no anticoagulation to varying periods of anticoagulation. 1,2 Since their Pharmaceutical Benefits Schedule listing, VTE treatment with direct oral anticoagulants (DOACs) is increasingly the treatment of choice, given their ease of use and convenience compared to warfarin. 3 DOACs have more predictable pharmacokinetics and pharmacodynamics, less diet and drug interactions and do not require regular monitoring.…”