Diagnosis of DVT: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada.
Chest (Impact Factor: 7.48). 02/2012; 141(2 Suppl):e351S-418S. DOI: 10.1378/chest.11-2299
Source: PubMed


Objective testing for DVT is crucial because clinical assessment alone is unreliable and the consequences of misdiagnosis are serious. This guideline focuses on the identification of optimal strategies for the diagnosis of DVT in ambulatory adults.
The methods of this guideline follow those described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.
We suggest that clinical assessment of pretest probability of DVT, rather than performing the same tests in all patients, should guide the diagnostic process for a first lower extremity DVT (Grade 2B). In patients with a low pretest probability of first lower extremity DVT, we recommend initial testing with D-dimer or ultrasound (US) of the proximal veins over no diagnostic testing (Grade 1B), venography (Grade 1B), or whole-leg US (Grade 2B). In patients with moderate pretest probability, we recommend initial testing with a highly sensitive D-dimer, proximal compression US, or whole-leg US rather than no testing (Grade 1B) or venography (Grade 1B). In patients with a high pretest probability, we recommend proximal compression or whole-leg US over no testing (Grade 1B) or venography (Grade 1B).
Favored strategies for diagnosis of first DVT combine use of pretest probability assessment, D-dimer, and US. There is lower-quality evidence available to guide diagnosis of recurrent DVT, upper extremity DVT, and DVT during pregnancy.

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Available from: Scott M Stevens, Apr 01, 2015
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    • "In fact, past imaging studies most commonly used US and less frequently venography, CT scan, or MRI [15]. The ACCP guideline for diagnosis of DVT recommends treating DVT and performing no further testing over performing confirmatory venography if the proximal vein is positive by US, and suggests no further testing if DVT is negative by US [15]. No associations between potential risk factors and DVT development were detected. "
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    ABSTRACT: Congestive heart failure (CHF) is one of the risk factors for deep vein thrombosis (DVT) according to the Japanese guidelines for DVT treatment and prevention. The purpose of this study is to estimate the frequency of DVT among hospitalized CHF patients, since there have been only limited DVT data in Japanese CHF patients. Patients enrolled in the study were with risk factors for DVT listed in the guidelines as well as with acute exacerbation of CHF, bed rest for at least 4 days, and aged 60 or above. Patients treated by physical prophylaxis or anti-platelet medication were included, while patients treated by any anticoagulant medicines were excluded. Patients with surgery or injury within 3 months before the hospitalization or diagnosed clinically or with obvious past history as having DVT at hospitalization were excluded. The presence of DVT in the eligible patients was determined by ultrasonography and the images were evaluated by an independent central evaluation committee. Forty-four patients were enrolled in the study including 19 males and 25 females. The mean age was 79.0±10.6 years, and the mean duration of bed rest was 8.9±3.2 days. Out of these 44 patients, DVT was detected in 15 (34%) patients. Eight patients were on treatment with physical prophylaxis but DVT was still detected in two patients. Furthermore, 12 out of the rest of the patients were treated by anti-platelet agents and were still with DVT in 3 patients. When evaluated ultrasonographically, the frequency of DVT in hospitalized non-surgical Japanese patients with CHF was approximately 35%. DVT occurred in 25% of patients treated by physical prophylaxis or anti-platelet agents. The results suggest that Japanese hospitalized patients with CHF have a high risk of DVT and thus can be recognized to have potential benefit by preventing and treating DVT according to the guidelines.
    Full-text · Article · Apr 2014 · Journal of Cardiology
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    • "An informal survey of physicians at our family practice teaching clinic revealed only one other case of subclavian thrombosis in the last 16 years, suggesting that in our patient population such presentations are rare. The annual incidence of UEDVT is estimated to be three per 100,000 persons [7], therefore MSK disorders are a much more common cause of arm pain and paresthesias. The majority of UEDEVTs (80%) are secondary to the use of central venous catheters and pacemakers, or to conditions such as malignancy, surgery, trauma, immobilization, OCP use, pregnancy or ovarian hyperstimulation syndrome; only 20% are believed to have primary causes related to anatomical abnormalities (such as a cervical rib or subclavian stenosis) or so-called “effort thrombosis” (Paget–Schröetter syndrome) [10]. "
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    ABSTRACT: Subclavian vein thrombosis is a rare but potentially fatal condition that most often occurs iatrogenically or in the context of malignancy. Here we report the case of an active, healthy 32-year-old woman who presented with subtle findings of arm pain, paresthesias and skin changes of acute onset and was subsequently diagnosed with upper extremity deep vein thrombosis and subclavian stenosis, and was started on a course of oral antithrombotics. A 32-year-old right-handed Caucasian woman presented to her family medicine clinic with left shoulder pain and numbness along her ipsilateral forearm and hand, as well as subtle swelling of the affected limb. Initially diagnosed with medial epicondylitis, she was later diagnosed with subclavian thrombosis caused by Paget-Schroetter syndrome. Presentations such as these are often attributable to soft-tissue injuries that resolve with rest and sometimes physiotherapy. Subclavian thrombosis was a highly unexpected diagnosis in this case; however, family physicians must remain vigilant in considering rare causes of common clinical presentations which could cause patients significant morbidity if left undiagnosed.
    Full-text · Article · Jan 2014 · Journal of Medical Case Reports
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    • "Although secondary analyses of the EINSTEIN studies did not identify any signals or concern for liver toxicity or evidence of unexpected thrombotic events, longer duration of therapy to address a chronic lifelong condition would have been valuable [11, 40]. The most recent update of the ACCP Guidelines on Antithrombotic Therapy from 2012 [2] suggests extending warfarin therapy beyond 3 months in patients with unprovoked VTE who have low-to-moderate risk of bleeding, and if bleeding risk is high, then therapy is limited to 3 months. Having a trial that compares the bleeding risk of a new agent against standard VKA therapy during extension of therapy would help refine these recommendations even further, especially if bleeding risk is lower with the NOACs compared to VKA. "
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    ABSTRACT: Anticoagulation therapy is mandatory in patients with pulmonary embolism to prevent significant morbidity and mortality. The mainstay of therapy has been vitamin-K antagonist therapy bridged with parenteral anticoagulants. The recent approval of new oral anticoagulants (NOACs: apixaban, dabigatran, and rivaroxaban) has generated significant interest in their role in managing venous thromboembolism, especially pulmonary embolism due to their improved pharmacokinetic and pharmacodynamic profiles, predictable anticoagulant response, and lack of required efficacy monitoring. This paper addresses the available literature, on-going clinical trials, highlights critical points, and discusses potential advantages and disadvantages of the new oral anticoagulants in patients with pulmonary embolism.
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