1. Venous thromboembolic diseases: the management of venous thromboembolic diseases and the role of thrombophilia testing June 2012 NICE clinical guideline 144 Deep vein thrombosis Support for education and learning slide set

2. What this presentation covers Background Scope Recommendations Discussion NHS Evidence NICE Pathway Find out more

3. Glossary INR: International normalised ratio VTE: Venous thromboembolism PE: Pulmonary embolism DVT: Deep vein thrombosis CTPA: CT pulmonary angiogram V/Q SPECT: Ventilation perfusion scan PTS: Post-thrombotic syndrome VKA: Vitamin K antagonist UFH: Unfractionated heparin LMWH: Low molecular weight heparin

4. Definitions Provoked DVT or PE: DVT or PE in patients with recent occurrence of major clinical risk factor for VTE Proximal DVT: DVT in popliteal vein or above Renal impairment: eGFR of less than 90 ml/minute/1.73 m 2 (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 PE

5. Background Thrombus (blood clot) forms in a vein Deep vein thrombosis - in deep veins of leg or pelvis Pulmonary embolism - thrombus dislodges and travels to pulmonary arteries Term ‘venous thromboembolism’ includes DVT and PE Risk factors include: thrombophilia, history of DVT, surgery, obesity, acute illness, cancer and immobility 500,000 people in Europe die from preventable hospital-acquired VTE every year

6. Scope Guidance on management of VTE, investigations for cancer in patients with VTE and thrombophilia testing Covers adults with suspected or confirmed DVT or PE Includes advice on the Wells score, D-dimer measurement, ultrasound and radiological imaging Does not cover those younger than 18, or women who are pregnant

7. Recommendations for DVT Diagnostic investigations and diagnosis Treatments: –pharmacological interventions –thrombolytic therapy –mechanical interventions Patient information –verbal and written –self-management Investigations for cancer Thrombophilia testing

8. Diagnostic 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 and a physical examination If DVT suspected use the two-level DVT Wells scoretwo-level DVT Wells score

9. Diagnostic investigations (2) Wells score = DVT unlikely Offer a D-dimer test and if the result is positive offer either: proximal leg vein ultrasound scan (within 4 hours of request) or if 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

10. Diagnostic investigations (3) Wells score = DVT likely Offer proximal leg vein ultrasound scan (within 4 hours of request), if negative, a D-dimer test or if 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 request Repeat proximal leg vein ultrasound scan 6–8 days later for all patients with positive D-dimer test and negative proximal leg vein ultrasound scan

11. Diagnosis Diagnose DVT and treat patients with positive proximal leg vein ultrasound Take 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 scan. likely 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.

12. Pharmacological interventions (1) Confirmed PE or proximal DVT – offer low molecular weight heparin (LMWH) or fondaparinux as soon as possible, unless: severe renal impairment increased risk of bleeding haemodynamically unstable Confirmed PE or proximal DVT and active cancer: offer LMWH, continue for 6 months

13. Pharmacological treatment (2) Patients with confirmed PE or proximal DVT offer: Vitamin K antagonist within 24 hours of diagnosis. Continue for at least 3 months

14. Thrombolytic therapy Consider catheter-directed thrombolytic therapy for patients with symptomatic iliofemoral DVT who have: symptoms of less than 14 days’ duration and good functional status and a life expectancy of 1 year or more and a low risk of bleeding.

15. Mechanical interventions (1) Temporary inferior vena caval filters: offer to patients with proximal DVT or PE who cannot have anticoagulation treatment consider 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 placed

16. Mechanical interventions (2) Do not offer elastic graduated compression stockings to prevent post-thrombotic syndrome or VTE recurrence after a proximal DVT. This recommendation does not cover the use of elastic stockings for the management of leg symptoms after DVT.

17. Patient information: verbal and written How to use anticoagulants Duration of treatment Possible side effects and what to do Effects of other drugs, foods and alcohol Monitoring How anticoagulants may affect dental treatment Taking anticoagulants if they are planning pregnancy or become pregnant How activities may be affected When and how to seek medical help

18. Patient information: self management Information and advice Patients 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 stockings Self-monitoring of INR Do not routinely offer to PE or DVT patients

19. Investigations 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) and chest X-ray and blood tests (full blood count, serum calcium and liver function tests) and urinalysis

20. Investigations 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 scan mammogram for women

21. Thrombophilia testing X Do not offer to patients who are continuing anticoagulation treatment X Do not offer to patients who have had provoked DVT or PE X 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 treatment

22. Discussion How 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 in order 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 in order to meet the NICE recommendations

23. NHS Evidence Visit NHS Evidence for the best available evidence on all aspects of VTE diseases Click here to go to the NHS Evidence website

24. NICE Pathway The NICE VTE Pathway shows all the recommendations in the VTE diseases and VTE - reducing the risk guidelines Click here to go to NICE Pathways website

25. Find out more Visit www.nice.org.uk/guidance/CG144 for:www.nice.org.uk/guidance/CG144 the guideline ‘Understanding NICE guidance’ costing statement audit support baseline assessment tool PE training plan DVT training plan

26. What 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.short evaluation form If you are experiencing problems accessing or using this tool, please email implementation@nice.org.ukimplementation@nice.org.uk To open the links in this slide set right click over the link and choose ‘open link’

27. Additional slides This additional slide contains the two level DVT Wells score. If you used the hyperlinks to the Wells score during the presentation you have already visited this slide.

28. Two-level DVT Wells score Clinical featurePoints Active cancer (treatment ongoing, within 6 months, or palliative)1 Paralysis, paresis or recent plaster immobilisation of the lower extremities 1 Recently bedridden for 3 days or more or major surgery within 12 weeks requiring general or regional anaesthesia 1 Localised tenderness along the distribution of the deep venous system 1 Entire leg swollen1 Calf swelling at least 3 cm larger than asymptomatic side1 Pitting oedema confined to the symptomatic leg1 Collateral superficial veins (non-varicose)1 Previously documented DVT1 An alternative diagnosis is at least as likely as DVT−2 Clinical probability simplified score DVT likely2 points or more DVT unlikely1 point or less a 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: 1227–35 Return to slide 8 ‘Diagnostic investigations (1)’