Presentation on theme: "Venous thromboembolic diseases: Deep vein thrombosis"— Presentation transcript:
1Venous thromboembolic diseases: Deep vein thrombosis This slide set was updated in October 2013 and includes details of the NICE quality standard for management of venous thromboembolic diseases. The NICE clinical guideline has not changedABOUT THIS PRESENTATION:This educational slide set has been developed to support education and learning about the NICE clinical guideline on venous thromboembolic diseases (VTE) diseases. It focuses on the recommendations for deep vein thrombosis and is a component of the workshop set out in the NICE education and learning deep vein thrombosis (DVT) training plan (http://guidance.nice.org.uk/CG144/EducationResource/DVTTrainingPlan/doc/English).This guideline has been written for healthcare professionals caring for adults with VTE diseases in primary, secondary and tertiary care settings.The guideline is available in a range of formats (from including a NICE Pathway. You may want to print copies of the guideline for your training session, for the audience to refer to.You can add your own organisation’s logo alongside the NICE logo.DISCLAIMERThis educational slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself.PROMOTING EQUALITYImplementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties.Support for education and learning slide set2013NICE clinical guideline 144
2What this presentation covers BackgroundScopeRecommendationsDiscussionNICE quality standardNICE Evidence ServicesNICE PathwayFind out moreNOTES FOR PRESENTERS:In this presentation, we will start by providing some background to the guideline and why it is important.We will then present details of the DVT-related recommendations with information and rationale to support the recommendations.Then we will open the meeting up with a list of questions to help prompt a discussion on local issues for incorporating the guidance into practice.Links to the NICE quality standard, NICE Evidence Services and the NICE Pathway are provided.Finally, we will end the presentation with further information about the support provided by NICE.
3Glossary INR: International normalised ratio VTE: Venous thromboembolismPE: Pulmonary embolismDVT: Deep vein thrombosisCTPA: CT pulmonary angiogramV/Q SPECT: Ventilation perfusion scanPTS: Post-thrombotic syndromeVKA: Vitamin K antagonistUFH: Unfractionated heparinLMWH: Low molecular weight heparinNOTES FOR PRESENTERS:International normalised ratio (INR) A standardised laboratory measure of blood coagulation used to monitor the adequacy of anticoagulation in patients who are having treatment with a vitamin K antagonist.V/Q SPECT Ventilation perfusion scan (single photon emission computerised tomography)Post-thrombotic syndrome (PTS) A chronic condition characterised by symptoms and signs that develop after DVT as a result of damage to the deep veins and their valves.Vitamin K antagonist (VKA) Warfarin is an example of this.
4DefinitionsProvoked DVT or PE: DVT or PE in patients with recent occurrence of major clinical risk factor for VTEProximal DVT: DVT in popliteal vein or aboveRenal impairment: eGFR of less than 90 ml/minute/1.73 m2 (see notes)Unprovoked DVT or PE: DVT or PE in patients with no recently occurring major clinical risk factors for VTE or patients with active cancer, thrombophilia or family history of DVT (these are risks, but they are constant)Wells score: clinical prediction rules for estimating probability of DVT and PENOTES FOR PRESENTERS:The following terms are used in this guideline.Provoked deep vein thrombosis (DVT) or pulmonary embolism (PE) DVT or PE in a patient with an antecedent (within 3 months) and transient major clinical risk factor for VTE – for example surgery, trauma, significant immobility (bedbound, unable to walk unaided or likely to spend a substantial proportion of the day in bed or in a chair), pregnancy or puerperium – or in a patient who is having hormonal therapy (oral contraceptive or hormone replacement therapy).Proximal DVT DVT in the popliteal vein or above. Proximal DVT is sometimes referred to as ‘above-knee DVT’.Renal impairment Reduced renal function that may be acute or chronic. An estimated glomerular filtration rate of less than 90 ml/minute/1.73 m2 indicates a degree of renal impairment in chronic kidney disease. (For NICE guidance on the classification of chronic kidney disease, see ‘Chronic kidney disease’ [NICE clinical guideline 73]).Unprovoked DVT or PE DVT or PE in a patient with:no antecedent major clinical risk factor for VTE (see ‘Provoked deep vein thrombosis or pulmonary embolism’ above) who is not having hormonal therapy (oral contraceptive or hormone replacement therapy) oractive cancer, thrombophilia or a family history of VTE, because these are underlying risks that remain constant in the patient.Wells scores Clinical prediction rules for estimating the probability of DVT and PE. There are a number of versions of Wells scores available. This guideline recommends the two-level DVT Wells score and the two-level PE Wells score.
5Background Thrombus (blood clot) forms in a vein Deep vein thrombosis – in deep veins of leg or pelvisPulmonary embolism – thrombus dislodges and travels to pulmonary arteriesTerm ‘venous thromboembolism’ includes DVT and PERisk factors include: thrombophilia, history of DVT, surgery, obesity, acute illness, cancer and immobility500,000 people in Europe die from preventable hospital-acquired VTE every yearNOTES FOR PRESENTERS:Key points to raise:Venous thromboembolism (VTE) is a condition in which a blood clot (a thrombus) forms in a vein, most commonly in the deep veins of the legs or pelvis. This is known as deep vein thrombosis, or DVT. The thrombus can dislodge and travel in the blood, particularly to the pulmonary arteries. This is known as pulmonary embolism, or PE. The term ‘VTE’ includes both DVT and PE.Venous thromboembolic diseases cover a spectrum ranging from asymptomatic calf vein thrombosis to symptomatic DVT. They can be fatal if they lead to PE, in which the blood supply to the lungs is badly blocked by the thrombus. Non-fatal VTE can cause serious long-term conditions such as post-thrombotic syndrome.Thrombophilia is a major risk factor for VTE. It is an inherited or acquired prothrombotic state that predisposes to venous thromboembolism. Other major risk factors for VTE include a history of DVT, age over 60 years, surgery, obesity, prolonged travel, acute medical illness, cancer, immobility and pregnancy.Failure to diagnose and treat VTE correctly can result in fatal PE. However, diagnosis of VTE is not always straightforward.It has been estimated that every year preventable hospital-acquired VTE causes more than 500,000 deaths in Europe (Cohen et al. 2007).ReferencesCohen AT, Agnelli G, Anderson FA et al. (2007) Venous thromboembolism (VTE) in Europe. The number of VTE events and associated morbidity and mortality. Thrombosis & Haemostasis 98: 756–64.
6ScopeGuidance on management of VTE, investigations for cancer in patients with VTE and thrombophilia testingCovers adults with suspected or confirmed DVT or PEIncludes advice on the Wells score, D-dimer measurement, ultrasound and radiological imagingDoes not cover those younger than 18, or women who are pregnantNOTES FOR PRESENTERS.Key points to raise:The Venous thromboembolic diseases clinical guideline includes advice on the Wells score, D-dimer measurement, ultrasound and radiological imaging.It also offers guidance on the management of VTE, investigations for cancer in patients with VTE and thrombophilia testing.The guideline covers adults with suspected or confirmed DVT or PE. It does not cover children or young people aged under 18, or women who are pregnant.Additional informationTo ensure comprehensive management and continuity when developing a programme of care for patients who are at risk of or who develop VTE, users of this guideline are encouraged to refer to NICE guidance on Venous thromboembolism: reducing the risk (NICE clinical guideline 92), Rivaroxaban for the prevention of venous thromboembolism after total hip or total knee replacement in adults (NICE technology appraisal guidance 170), Dabigatran etexilate for the prevention of venous thromboembolism after hip or knee replacement surgery in adults (NICE technology appraisal guidance 157) and Medicines adherence (NICE clinical guideline 76) (see also section 6 of the NICE clinical guideline 144).The guideline will assume that prescribers will use a drug’s summary of product characteristics to inform decisions made with individual patients. This guideline recommends some drugs for indications for which they do not have a UK marketing authorisation at the date of publication, if there is good evidence to support that use. Where recommendations have been made for the use of drugs outside their licensed indications (‘off-label use’), these drugs are marked with a footnote in the recommendations.
7Recommendations for DVT Diagnostic investigations and diagnosisTreatments:pharmacological interventionsthrombolytic therapymechanical interventionsPatient informationverbal and writtenself-managementInvestigations for cancerThrombophilia testingNOTES FOR PRESENTERS:The NICE guideline contains 38 recommendations of which 28 are related to the diagnosis, treatment and management of DVT. The DVT-related recommendations are divided into 8 sections:Diagnostic investigations and diagnosisTreatments (pharmacological interventions, thrombolytic therapy, and mechanical interventions)Patient informationverbal and writtenself-managementSelf-management and monitoringInvestigations for cancerThrombophilia testing
8Diagnostic investigations (1) If a patient presents with signs or symptoms of DVT, carry out the following to exclude other causes:an assessment of their general medical history anda physical examination.If DVT is suspected, use the two-level DVT Wells score.NOTES FOR PRESENTERS:Recommendations in fullIf a patient presents with signs or symptoms of deep vein thrombosis (DVT), carry out an assessment of their general medical history and a physical examination to exclude other causes. [KPI ]If DVT is suspected, use the two-level DVT Wells score (see hyperlink in slide or table 1 in NICE clinical guideline) to estimate the clinical probability of DVT. [1.1.2]Related recommendationIf a patient presents with signs or symptoms of both DVT (for example a swollen and/or painful leg) and PE (for example chest pain, shortness of breath or haemoptysis), carry out initial diagnostic investigations for either DVT or PE, basing the choice of diagnostic investigations on clinical judgement. [1.1.14]Additional information:Patient with DVT may present with signs and symptoms such as swelling, pain, redness and warmth in the leg.Assessing general medical history and physical examination does not present any harm to the patient and may pick up or exclude other possible causes for suspected DVT. Completing this step of the diagnosis is crucial, as it will direct the consecutive diagnostic pathway to be undertaken.Clinical experience of the guidance developers suggests that not all patients receive a medical and physical examination to exclude other possible causes. This should be standard practice and needs to be implemented for all patients presenting with DVT signs and symptoms.The two-level DVT Wells score was recommended because it: includes new criteria, has been widely used in the NHS, is well validated and is less confusing (than the older system using ‘moderate’).Healthcare professionals completing the score need to be trained owing to the presence of a subjective item ‘alternative diagnosis as likely as DVT’.
9Diagnostic investigations (2) Wells score = DVT unlikelyOffer a D-dimer test and if the result is positive, offer either:proximal leg vein ultrasound scan (within 4 hours of request) orif proximal leg vein scan not available within 4 hours, interim 24-hour dose of a parenteral anticoagulant followed by proximal leg vein ultrasound within 24 hours of request.NOTES FOR PRESENTERS:Recommendations in fullOffer patients in whom DVT is suspected and with an unlikely two-level DVT Wells score a D- dimer test and if the result is positive offer either:a proximal leg vein ultrasound scan carried out within 4 hours of being requested oran interim 24-hour dose of a parenteral anticoagulant (if a proximal leg vein ultrasound scan cannot be carried out within 4 hours) and a proximal leg vein ultrasound scan carried out within 24 hours of being requested. [KPI 1.1.4]Additional information:Evidence suggests that when used in combination with D-dimer test, an “unlikely” Wells score, which puts a patient at a low pre-test probability, could safely rule out DVT.A negative D-dimer may be useful in excluding DVT.
10Diagnostic investigations (3) Wells score = DVT likelyOffer either:proximal leg vein ultrasound scan (within 4 hours of request), if negative, a D-dimer test orif proximal leg vein scan not available within 4 hours, D-dimer test and an interim 24-hour dose of a parenteral followed by proximal leg vein ultrasound within 24 hours of requestRepeat proximal leg vein ultrasound scan 6–8 days later for all patients with positive D-dimer test and negative proximal leg vein ultrasound scan.NOTES FOR PRESENTERS:Recommendations in fullOffer patients in whom DVT is suspected and with a likely two-level DVT Wells score either:a proximal leg vein ultrasound scan carried out within 4 hours of being requested and, if the result is negative, a D-dimer test ora D-dimer test and an interim 24-hour dose of a parenteral anticoagulant (if a proximal leg vein ultrasound scan cannot be carried out within 4 hours) and a proximal leg vein ultrasound scan carried out within 24 hours of being requested.Repeat the proximal leg vein ultrasound scan 6–8 days later for all patients with a positive D-dimer test and a negative proximal leg vein ultrasound scan. [KPI 1.1.3]Additional informationA positive D-dimer is of no diagnostic value, it merely mandates further testing. Whilst a negative D- dimer test is good enough to exclude the diagnosis of DVT in a patient with an “unlikely” pre-test clinical probability it is not good enough in those with a “likely” pre-test probabilityIt is important to follow the sequence recommended to minimise the unnecessary use of ultrasound scans so that patients who need these scans can access them as soon as possible. Patients can be at risk of deterioration or at risk of a PE if a quick confirmation scan is not available. That is why anticoagulants are recommended if there is a delay in getting access to a scan.D-dimer is offered to ‘likely’ patients with negative ultrasound scan to double check that there is a low risk of DVT before being sent home.The Guideline Development Group had considered that since patients assessed as having a high risk of DVT will not be sent home even if a D-dimer is negative, it is best to prioritise sending this group of patients to ultrasound scans so that a diagnosis can be confirmed and treatment initiated promptly.Repeat proximal vein ultrasound scan is recommended to ensure that any clots propagating to the proximal veins are not missed.
11DiagnosisDiagnose DVT and treat patients with positive proximal leg vein ultrasoundTake into consideration alternative diagnoses in patients with:unlikely two-level DVT Wells score and negative D-dimer test or positive D-dimer test and negative proximal leg vein ultrasound scanlikely two-level DVT Wells score and negative proximal leg vein ultrasound scan and negative D-dimer test or repeat negative proximal leg vein ultrasound scan.NOTES FOR PRESENTERS:Recommendations in fullDiagnose DVT and start treatment (see slides 12–16 or section 1.2 of the NICE clinical guideline) in patients with a positive proximal leg vein ultrasound scan. [1.1.5]Take into consideration alternative diagnoses in patients with:an unlikely two-level DVT Wells score anda negative D-dimer test ora positive D-dimer test and a negative proximal leg vein ultrasound scan.a likely two-level DVT Wells score anda negative proximal leg vein ultrasound scan and a negative D-dimer test ora repeat negative proximal leg vein ultrasound scan.Advise patients in these two groups that it is not likely they have DVT, and discuss with them the signs and symptoms of DVT and when and where to seek further medical help. [1.1.6]Additional information: confirmation of diagnosisProximal leg vein ultrasound scans are used as confirmatory tests in this pathwayThe GDG recommended proximal ultrasound scans as the clinical importance of picking up extra calf vein blood clots through whole leg scan is uncertain.Additional information: access to ultrasoundIt is important to diagnose and confirm DVT quickly. Treatment with LMWH exposes patients to side effects and is expensive (cost of drug and nurse time). It is important not to put patients needlessly on LMWH.Delays in accessing ultrasound scans are a potential problem (especially outside normal working hours) and these delays need to be addressed and avoided. In situations where delay in access is unavoidable, strategies are required to ensure that patients are treated in the interim.
12Pharmacological interventions (1) Confirmed PE or proximal DVTOffer low molecular weight heparin (LMWH) or fondaparinux as soon as possible, unless:severe renal impairmentincreased risk of bleedinghaemodynamically unstableConfirmed PE or proximal DVT and active cancerOffer LMWH, continue for 6 monthsNOTES FOR PRESENTERS:Recommendations in fullOffer a choice of low molecular weight heparin (LMWH) or fondaparinux to patients with confirmed proximal DVT or PE, taking into account comorbidities, contraindications and drug costs, with the following exceptions:For patients with severe renal impairment or established renal failure (estimated glomerular filtration rate [eGFR] < 30 ml/min/1.73 m2) offer unfractionated heparin (UFH) with dose adjustments based on the APTT (activated partial thromboplastin time) or LMWH with dose adjustments based on an anti-Xa assay.For patients with an increased risk of bleeding consider UFH.For patients with PE and haemodynamic instability, offer UFH and consider thrombolytic therapy (see recommendations and in the NICE clinical guideline).Start the LMWH, fondaparinux or UFH as soon as possible and continue it for at least 5 days or until the international normalised ratio (INR) (adjusted by a vitamin K antagonist [VKA]; see recommendation on slide 13 or in the NICE clinical guideline) is 2 or above for at least 24 hours, whichever is longer. [KPI 1.2.1]Offer LMWH to patients with active cancer and confirmed proximal DVT or PE, and continue the LMWH for 6 months1. At 6 months, assess the risks and benefits of continuing anticoagulation2. [KPI 1.2.2]Footnotes to recommendation 1.2.21: At the time of publication (June 2012) some types of low molecular weight heparin (LMWH) do not have a UK marketing authorisation for 6 months of treatment of DVT or PE in patients with cancer. Prescribers should consult the summary of product characteristics for the individual LMWH and make appropriate adjustments for renal impairment. Informed consent for off-label use should be obtained and documented.2: Although this use is common in UK clinical practice, at the time of publication (June 2012) none of the anticoagulants has a UK marketing authorisation for the treatment of DVT or PE beyond 6 months in patients with cancer. Informed consent for off-label use should be obtained and documented.Additional informationIt is important that parenteral anticoagulation is achieved quickly for patients with VTE in order to reduce the risk of clot propagation or further embolic events.The economic evidence shows that LMWH is more cost-effective or cost-saving compared to UFH as a short-term treatment for PE or DVT.Advantages of LMWH and fondaparinux such as IM and no need for APTT monitoring over UFH mean that patients on LMWH and fondaparinux have a shorted hospital stay than those receive UFHConsider individual circumstances in order to offer most suitable agent for example; renal status; risk of bleeding or need for surgery or thrombolysis, risk of heparin induced thrombocytopaenia, appropriate dose and patient preference.In patients with cancer, the evidence suggests that anticoagulation for 6 months with LMWH leads to better outcomes compared to switching to a VKA after initial LMWH treatment. At 6 months, the need to continue anticoagulation should be reassessed and discussed with the patient. The current recommendation of international guidelines and UK clinical practice is to continue anticoagulation lifelong in patients with active cancer.
13Pharmacological treatment (2) Confirmed PE or proximal DVT Offer a VKA to patients with confirmed proximal DVT or PE within 24 hours of diagnosis and continue the VKA for at least 3 monthsNOTES FOR PRESENTERS:Recommendations in fullOffer a VKA to patients with confirmed proximal DVT or PE within 24 hours of diagnosis and continue the VKA for 3 months. At 3 months, assess the risks and benefits of continuing VKA treatment (see recommendations and below). [1.2.3]Related recommendationsOffer a VKA beyond 3 months to patients with an unprovoked PE, taking into account the patient’s risk of VTE recurrence and whether they are at increased risk of bleeding. Discuss with the patient the benefits and risks of extending their VKA treatment. [KPI 1.2.4]Consider extending the VKA beyond 3 months for patients with unprovoked proximal DVT if their risk of VTE recurrence is high and there is no additional risk of major bleeding. Discuss with the patient the benefits and risks of extending their VKA treatment. [KPI 1.2.5]Additional information rivaroxabanNICE Technology Appraisal 261 (July 2012) ‘Rivaroxaban for the treatment of deep vein thrombosis and prevention of recurrent deep vein thrombosis and pulmonary embolism’ is available atAdditional information: VKAOral VKAs may take a few days to reach a level that is effective for anticoagulation, which is why the initial parenteral anticoagulation should be continued as in recommendation This will ensure adequate anticoagulation at all times.VKA potentially improves VTE-related mortality in patients (without cancer) compared with LMWH.The additional benefits of extending treatment beyond 3 months are less clear and need to be considered for each patient based on their risk of recurrences and bleeding.Patients who do not adhere to follow up visits and INR monitoring may be at higher risk of poor anticoagulation control, bleeding and VTE recurrences. This needs to be assessed when deciding treatment choices. VKA use also needs to be considered in groups prone to falls, such as the elderly, as they will be at an increased risk of bleeds. In patients where VKA cannot be adequately monitored, alternative treatments may be required.
14Thrombolytic therapyConsider catheter-directed thrombolytic therapy for patients with symptomatic iliofemoral DVT who have:symptoms of less than 14 days’ duration andgood functional status anda life expectancy of 1 year or more anda low risk of bleeding.NOTES FOR PRESENTERS:Recommendations in fullConsider catheter-directed thrombolytic therapy for patients with symptomatic iliofemoral DVT who have:symptoms of less than 14 days’ duration andgood functional status anda life expectancy of 1 year or more anda low risk of bleeding. [KPI 1.2.6]Additional informationThrombolysis aims to bring about clot lysis and rapid normalisation of venous blood flow. Catheter directed administration involves the infusion of the drug by a catheter inserted directly into the affect veins.Catheter directed thrombolysis could potentially bring important benefits to patients. Selecting the patients that can benefit the most from this treatment which makes the intervention have a favourable risk-benefit ratio, is key.
15Mechanical interventions (1) Temporary inferior vena caval filters:offer to patients with proximal DVT or PE who cannot have anticoagulation treatmentconsider for patients with recurrent proximal DVT or PE despite adequate anticoagulation treatment (after considering alternatives).Ensure strategy for removing filter at earliest possible opportunity is planned and documented when filter is placedNOTES FOR PRESENTERS:Recommendations in fullOffer temporary inferior vena caval filters to patients with proximal DVT or PE who cannot have anticoagulation treatment, and remove the inferior vena caval filter when the patient becomes eligible for anticoagulation treatment. [1.2.10]Consider inferior vena caval filters for patients with recurrent proximal DVT or PE despite adequate anticoagulation treatment only after considering alternative treatments such as:increasing target INR to 3–4 for long-term high-intensity oral anticoagulant therapy orswitching treatment to LMWH. [1.2.11]Ensure that a strategy for removing the inferior vena caval filter at the earliest possible opportunity is planned and documented when the filter is placed, and that the strategy is reviewed regularly. [1.2.12]Additional informationInferior vena caval filters are designed to trap fragmented thromboemboli from the deep leg veins en route to the pulmonary circulation (while preserving blood flow in the IVC filter).Vena caval filters are usually placed under radiological guidance, approached from either the jugular or femoral vein.The risk of mortality from PE was considered to be high when left untreated. Some patients may not be able to tolerate anticoagulation because of excessive bleeding.The GDG identified circumstances where IVC filter maybe considered; patients who have had recent upper GI bleed or stroke (where use of anticoagulation significantly increases the risk of a repeat bleed), those needing surgery (high bleeding risk) those prone to falls or injury or those unwilling to attend anticoagulation clinics to have regulation of anticoagulation.Some people may have recurrent VTE despite adequate anticoagulation. For some patient insertion of a filter may influence the patient’s quality of life because it may be preferable to lifelong injections (although this must be balanced against higher risk of DVT or PE).Many filters are left in situ and forgotten. At the time of insertion of IVC filters there should be a clear management plan, including the indication for insertion, the intended length of time that the filter is likely to be necessary and the intended point at which the filter should be removed. As circumstances change, this management plan should be reviewed.
16Mechanical interventions (2) Offer below-knee graduated compression stockings (ankle pressure greater than 23 mmHg) to patients with proximal DVT a week after diagnosis or when swelling is reduced sufficiently, and:advise patients to continue wearing the stockings for at least 2 yearsensure that the stockings are replaced 2 or 3 times per year or according to the manufacturer’s instructionsadvise patients that the stockings need to be worn only on the affected leg or legs.NOTES FOR PRESENTERS:Recommendation in fullOffer below-knee graduated compression stockings with an ankle pressure greater than 23 mmHg to patients with proximal DVT a week after diagnosis or when swelling is reduced sufficiently and if there are no contraindications1, and:advise patients to continue wearing the stockings for at least 2 yearsensure that the stockings are replaced two or three times per year or according to the manufacturer’s instructionsadvise patients that the stockings need to be worn only on the affected leg or legs. [KPI 1.2.9]Additional information:The GDG considered the reduction in incidence of PTS brought about by stocking use as recommended is likely to be more important to patients than the potential harms from adverse events such as skin disorders, or inconvenience to patients (adherence).When deciding on the pressure, length of stockings, continuation beyond two years, wearing of stockings on non affected legs patient preference and need should be taken into account when developing the care planPatients should be encouraged to wear graduated compression stockings for as long as is practical in waking hours and to remove stockings when they go to bed. This allows for regular inspection of the skin and the use of emollient cream if requiredWhen patients experience adverse effects from the stockings such as marking, blistering, discoloration pain and discomfort. Stockings should be discontinued and further medical advice sought on whether a refitting is required or discontinuation is more appropriate.The guidance developers identified that the contraindications for the use of graduated compressions stockings and the information required by patients using them were the same as for anti embolism stockings. Therefore, the recommendations NICE guideline 92, Venous Thromboembolism: Reducing the Risk (2010) (http://guidance.nice.org.uk/CG92) about these issues are relevant to this guidance.Footnote:1: Prescribers should refer to specific product information and contraindications before offering graduated compression stockings. Prescribing details can be found on the drug tariff.
17Patient information: verbal and written How to use anticoagulantsDuration of treatmentPossible side effects and what to doEffects of other drugs, foods and alcoholMonitoringHow anticoagulants may affect dental treatmentTaking anticoagulants if they are planning pregnancy or become pregnantHow activities may be affectedWhen and how to seek medical helpNOTES FOR PRESENTERS:Recommendation in fullGive patients having anticoagulation treatment verbal and written information about:how to use anticoagulantsduration of anticoagulation treatmentpossible side effects of anticoagulant treatment and what to do if these occurthe effects of other medications, foods and alcohol on oral anticoagulation treatmentmonitoring their anticoagulant treatmenthow anticoagulants may affect their dental treatmenttaking anticoagulants if they are planning pregnancy or become pregnanthow anticoagulants may affect activities such as sports and travelwhen and how to seek medical help. [1.3.1]
18Patient information: self management Information and advicePatients on anticoagulant treatment should receive an ‘anticoagulant information booklet’ and an ‘anticoagulant alert card’Advise patients about the correct application and use of below-knee graduated compression stockingsSelf-monitoring of INRDo not routinely offer to PE or DVT patientsNOTES FOR PRESENTERS:Recommendations in fullProvide patients who are having anticoagulation treatment with an ‘anticoagulant information booklet’ and an ‘anticoagulant alert card’ and advise them to carry the ‘anticoagulant alert card’ at all times. [1.3.2]Advise patients about the correct application and use of below-knee graduated compression stockings, how long they should be worn and when they should be replaced. [1.3.4]Do not routinely offer self-management or self-monitoring of INR to patients who have had DVT or PE and are having treatment with a VKA. [1.4.1]Related recommendationBe aware that heparins are of animal origin and this may be of concern to some patients. (see Religion or belief: a practical guide for the NHS). For patients who have concerns about using animal products, consider offering synthetic alternatives based on clinical judgement after discussing their suitability, advantages and disadvantages with the patient. [This recommendation is from Venous thromboembolism: reducing the risk (NICE clinical guideline 92).] [1.3.3]Additional informationEducating patients about their condition could increase patient knowledge and awareness and lead to improved patient outcomes.To improve the adherence with carrying the card it is important to explain to patients the rationale and the benefit of carrying it.Source of information already available: National Patient Safety Agency. Oral anticoagulant therapy: important information for patients Available from:Note – On 1 June 2012, the key functions and expertise for patient safety developed by the National Patient Safety Agency (NPSA) transferred to the NHS Commissioning Board Special Health Authority. The hyperlink and information provided continued to be valid at the time of publication.
19Investigations for cancer (1) Offer all patients with unprovoked DVT or PE, who are not known to have cancer:physical examination (guided by patient’s full history) andchest X-ray andblood tests (full blood count, serum calcium and liver function tests) andUrinalysis.NOTES FOR PRESENTERS:Recommendations in fullOffer all patients diagnosed with unprovoked DVT or PE who are not already known to have cancer the following investigations for cancer:a physical examination (guided by the patient’s full history) anda chest X-ray andblood tests (full blood count, serum calcium and liver function tests) andurinalysis. [1.5.1]Additional informationDuring the process of malignant transformation, tumours produce several proteins, such as tissue factor, which enable the tumour cells to invade and metastasise. Tissue factor simultaneously activates the coagulation cascade leading to VTE.The clearest benefit of the recommended cancer screening is in the change in pharmacological management and duration of anticoagulation for VTE, in those whose underlying cancer is diagnosed, leading to a significant reduction in VTE recurrence rates. Early diagnosis of underlying cancer may lead to diagnosis at an earlier, curative stage and improvement in cancer-related mortality.Physical examination, medical history documentation and baseline tests should be conducted and interpreted with a focus on the possibility that a patient with unprovoked VTE (no obvious risk factor identified) may have an underlying cancer. This should be performed in all patients, because there are few disadvantages and cancer can be effectively detected in up to half of all patients who present with VTE and have an underlying cancer.
20Investigations for cancer (2) First unprovoked DVT or PE?No signs or symptoms of cancer based on initial investigation?Over 40?Consider further investigations for cancer:abdomino-pelvic CT scanmammogram for womenNOTES FOR PRESENTERS:Recommendation in fullConsider further investigations for cancer with an abdomino-pelvic CT scan (and a mammogram for women) in all patients aged over 40 years with a first unprovoked DVT or PE who do not have signs or symptoms of cancer based on initial investigation (see recommendation on previous slide). [KPI 1.5.2]Additional informationThe GDG agreed that consideration of further investigations for cancer was most appropriate for patients over 40 years old with an apparently unprovoked VTE. The most effective and cost-effective investigations for cancer, that balance sensitivity and specificity, include abdominal/pelvic CT, mammography and sputum cytology (sputum cytology is not recommended, in line with NICE clinical guideline 121 ‘Treatment and diagnosis of lung cancer’).Studies suggest that among patients with VTE, the cancers most commonly found are in the abdomen and pelvic areas (ovary, pancreas, liver, kidney and colon).
21Thrombophilia testing X Do not offer to patients who are continuing anticoagulation treatmentX Do not offer to patients who have had provoked DVT or PEX Do not routinely offer to first-degree relatives of people with a history of DVT or PE and thrombophilia Consider for patients with unprovoked PE or PE if it is planned to stop anticoagulation treatmentNOTES FOR PRESENTERS:Recommendations in fullDo not offer thrombophilia testing to patients who are continuing anticoagulation treatment. [1.6.1]Do not offer thrombophilia testing to patients who have had provoked DVT or PE. [1.6.4]Do not routinely offer thrombophilia testing to first-degree relatives of people with a history of DVT or PE and thrombophilia. [1.6.5]Consider testing for antiphospholipid antibodies in patients who have had unprovoked DVT or PE if it is planned to stop anticoagulation treatment. [1.6.2]Related recommendationConsider testing for hereditary thrombophilia in patients who have had unprovoked DVT or PE and who have a first-degree relative who has had DVT or PE if it is planned to stop anticoagulation treatment. [1.6.3]Additional informationThrombophilia is an acquired or inherited predisposition to venous thrombosis. The only important acquired thrombophilia is the presence of antiphospholipid antibodies (detected as a lupus anticoagulant or as antibodies against cardiolipin or β2-glycoprotein I).If a decision is made to continue anticoagulation treatment, it is unnecessary to offer thrombophilia testing as the results would not alter management.The additional risk associated with antiphospholipid syndrome is not large. Testing should therefore be considered only if, after assessment of the other risk factors in an individual patient with an unprovoked VTE, the plan is to stop anticoagulation (see recommendation 1.6.2).Thrombophilia testing for first degree relatives of people who have had thromboembolic disease and thrombophilia could theoretically lead to the reduction of VTE risk, if there are suitable interventions which can be applied to the relatives who are affected. However a family history of VTE increases a person’s risk of having a VTE whether they have a thrombophilia or not. These relatives would receive thromboprophylaxis in at risk situations; such as surgery, trauma or immobilisation.The test for hereditary thrombophilia should be offered to people of any age with unprovoked VTE who have a first degree relative with VTE, to reduce the risk of any patient who may have a hereditary thrombophilia being missed (see recommendation 1.6.3).
22DiscussionHow can we modify our service to allow us to offer proximal leg vein ultrasound within 4 hours of request?Do we have the appropriate systems in place to ensure patients with a proximal DVT receive the appropriate follow up to assess continuation of LMWH, VKA and replacement of below-knee graduated compressions stockings?What referral systems do we have in place to facilitate the onward investigation for cancer and thrombophilia for patients with unprovoked DVT? How do they need to be modified to meet the NICE recommendations?NOTES FOR PRESENTERS:These questions are suggestions that have been developed to help provide a prompt for a discussion at the end of your presentation – please edit and adapt these to suit your local situation.Additional questionsHow can we ensure clinicians have easy access to the two-level DVT Wells score?How can we ensure that we provide the recommended patient information?
23NICE quality standard for diagnosis and management of venous thromboembolic diseases Published March 2013Defines clinical best practice within this topic area.Provides specific, concise quality statements, measures and audience descriptors to provide the public, health and social care professionals, commissioners and service providers with definitions of high-quality care.Covers the diagnosis and treatment of venous thromboembolic diseases in adults, excluding pregnant women.NOTES FOR PRESENTERS:NICE quality standard for diagnosis and management of venous thromboembolic diseasesPublished in March This quality standard defines clinical best practice within this topic area. It provides specific, concise quality statements, measures and audience descriptors to provide the public, health and social care professionals, commissioners and service providers with definitions of high-quality care. This quality standard covers the diagnosis and treatment of venous thromboembolic diseases in adults, excluding pregnant women.If you are showing this presentation when connected to the internet, click on the orange button to go straight to the NICE quality standard for management of venous thromboembolic diseases or go toClick here to go to the NICE quality standard for management of venous thromboembolic diseases
24NICE Evidence Services Visit NICE Evidence Services for the best available evidence on all aspects of VTE diseasesClick here to go to the NICE Evidence Services websiteNOTES FOR PRESENTERS:If you are showing this presentation when connected to the internet, click on the blue button to go straight to the NICE Evidence Services website topic page for VTE diseases.For the home page go to
25Click here to go to NICE Pathways website The NICE VTE Pathway shows all the recommendations in the VTE diseases and VTE: reducing the risk guidelinesClick here to go to NICE Pathways websiteNOTES FOR PRESENTERS:Key points to raiseThe recommendations from this guideline have been incorporated into a NICE VTE pathway, which is available fromIf you are showing this presentation when connected to the internet, click on the orange button to go straight to the NICE Pathways website. The front page includes a 2-minute video giving an overview of the features and content within the site, as well as the list of topics covered.NICE Pathways: guidance at your fingertipsOur new online tool provides quick and easy access, topic by topic, to the range of guidance from NICE, including quality standards, technology appraisals, clinical and public health guidance and NICE implementation tools. NICE pathways are simple to navigate and allow you to explore in increasing detail NICE recommendations and advice, giving you confidence that you are up to date with everything we have recommended.
26Find out more Visit http://guidance.nice.org.uk/CG144 for: the guidelineinformation for the publiccosting reportaudit supportbaseline assessment toolPE educational resource (training plan, slide set and clinical case scenarios)DVT educational resource (training plan, slide set and clinical case scenarios)podcasttwo-level wells score templatesNOTES FOR PRESENTERS:You can download the guidance documents from the NICE website.The NICE guideline – all the recommendations.‘Information for the public’ – information for patients and carers.The full guideline – all the recommendations, details of how they were developed, and reviews of the evidence they were based on.NICE has developed tools to help organisations implement this guideline, which can be found on the NICE website.Costing report – estimates the likely costs and savings anticipated when implementing the guideline.Clinical audit support with electronic data tools – for monitoring local practice.Baseline assessment tool – for assessing compliance against the guideline.PE educational resource – comprising of a training plan, slide set and clinical case scenarios – to support group and individual education and learning.DVT educational resource – comprising of a training plan, slide set and clinical case scenarios - to support group and individual education and learning.Podcast - Dr Roshan Agarwal, a member of the Guideline Development Group, discusses the venous thromboembolic diseases guidance and the link between VTE and cancerTwo-level wells score templates – templates for local adaptation to allow the two-level Wells score for DVT or PE to be calculated and recorded in a format suitable for filing in the patient record.
27What do you think?Did the implementation tool you accessed today meet your requirements, and will it help you to put the NICE guidance into practice? We value your opinion and are looking for ways to improve our tools. Please complete this short evaluation form. If you are experiencing problems accessing or using this tool, pleaseNOTES FOR PRESENTERS:Additional information:This final slide is not intended to be part of the presentation. It asks for feedback on whether this implementation tool meets your requirements and whether it will help you to put this NICE guidance into practice: your opinion would be appreciated.To open the links in this slide set, right click over the link and choose ‘open link’.To open the links in this slide, set right click over the link and choose ‘open link’
28Additional slidesThis additional slide contains the two-level DVT Wells score.If you used the hyperlinks to the Wells score in the presentation, you have already visited this slide.
29Two-level DVT Wells score Clinical featurePointsActive cancer (treatment ongoing, within 6 months, or palliative)1Paralysis, paresis or recent plaster immobilisation of the lower extremitiesRecently bedridden for 3 days or more or major surgery within 12 weeks requiring general or regional anaesthesiaLocalised tenderness along the distribution of the deep venous systemEntire leg swollenCalf swelling at least 3 cm larger than asymptomatic sidePitting oedema confined to the symptomatic legCollateral superficial veins (non-varicose)Previously documented DVTAn alternative diagnosis is at least as likely as DVT−2Clinical probability simplified scoreDVT likely2 points or moreDVT unlikely1 point or lessa Adapted with permission from Wells PS et al. (2003) Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. New England Journal of Medicine 349: 1227–35A template patient record Two-level DVT Wells score, which you can print, complete and then add to patient records can be downloaded from the NICE website http://guidance.nice.org.uk/CG144/TemplateWellsScore/doc/English.Return to slide 8‘Diagnostic investigations (1)’