Managing and treating patients with VTE

Diagnosis of VTE

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While management of patients with signs or symptoms of VTE may be shaped by local protocols and formularies, the NICE guidelines for venous thromboembolic diseases recommend that all patients presenting with symptoms of DVT / PE should undergo an assessment of their general medical history and a physical examination to exclude other causes; those presenting with symptoms of PE should also be offered a chest X-ray to exclude other causes.¹

For those in whom VTE is suspected, the following diagnostic pathway should be followed.¹ Patients should undergo further diagnostic assessments to confirm their diagnosis and determine an appropriate management pathway. An interactive version of the full NICE pathway for diagnosing VTE – including PE – is available here.¹

Initial Diagnostic Assessment

As specified in NICE NG158, the initial diagnostic assessment of patients with suspected DVT should involve a 2-level DVT Wells score and the initial diagnostic assessment of patients with suspected PE, a 2-level PE Wells score.^1,2

The 2-level DVT Wells score and the 2-level PE Wells score are clinical scores that estimate the clinical probability of developing DVT or PE, respectively.² These scores are an important step in the diagnostic pathway.

Patients who score 2 points or more in the 2-level DVT Wells score are likely to have DVT and those with 1 point or less are unlikely. Similarly, patients who score more than 4 points in the 2-level PE Wells score are likely to have PE and those with 4 points or less are unlikely.²

The table below shows the 2-level DVT Wells score.

Two-level DVT Wells score²

Adapted from NICE NG158, 2020.²

If clinical suspicion of PE is low (the clinician estimates the likelihood of PE to be less than 15% based on the overall clinical impression and other diagnoses are feasible), consider using the PE rule-out criteria (PERC) to help determine whether any further investigations for PE are needed.^1,2 A link to determine the PERC rule for PE can be found here.

If PE is suspected, the 2-level PE Wells score should be used to estimate the clinical probability of PE.²

The table below shows the 2-level PE Wells score.

Two-level PE Wells score²

Adapted from NICE NG158, 2020.²

Patients with suspected PE should receive an immediate CTPA if they have a 2-level PE Wells score of more than 4 points, or proceed to a D-dimer test if they have a 2-level Wells score of 4 points or less.^1,2 The diagnosis and initial management for suspected PE is shown in the diagram below.

Suspected PE: diagnosis and initial management²

Image adapted from https://www.nice.org.uk/guidance/ng158/resources/visual-summary-pdf-8709091453.²

In the AMPLIFY trial, apixaban was given to patients with a confirmed VTE.⁴ The use of an appropriate anticoagulant for patients with a suspected VTE whilst awaiting confirmatory diagnostic tests is a clinical decision based on individual patient assessment.

* Laboratory or point-of-care test. Consider age-adjusted threshold for people over 50.²

† CT pulmonary angiogram. Assess suitability of V/Q SPECT or V/Q planar scan for allergy, severe renal impairment (CrCl <30 ml/min estimated using the Cockcroft and Gault formula) or high irradiation risk.²

‡ Measure baseline blood count, renal and hepatic function, PT and APTT but start anticoagulation before results are available and review within 24 hours.²

§ If possible, choose an anticoagulant that can be continued if PE is confirmed.²

¶ In March 2020, DOACs and some LMWHs were off label for use in suspected DVT.² For more information, see the GMC guidance on prescribing unlicensed medicines.

Interim therapeutic anticoagulation

NICE recommends that patients with suspected DVT should be offered interim therapeutic anticoagulation therapy if diagnostic investigations are expected to take longer than 4 hours from the time of first clinical suspicion, and that patients with suspected PE should be offered interim therapeutic anticoagulation if CTPA cannot be done immediately.^1,2 Clinicians should always take individual clinical circumstances into account when choosing an interim anticoagulant for patients with a suspected DVT or PE.²

When using interim therapeutic anticoagulation for suspected proximal DVT or PE:^1,2

• carry out baseline blood tests including full blood count, renal and hepatic function, prothrombin time (PT) and activated partial thromboplastin time (APTT)
• do not wait for the results of baseline blood tests before starting anticoagulation treatment
• review, and if necessary, act on the results of baseline blood tests within 24 hours of starting interim therapeutic anticoagulation

In the AMPLIFY trial, apixaban was given to patients with a confirmed DVT or PE.⁴ The use of an appropriate anticoagulant for patients with a suspected DVT or PE whilst awaiting confirmatory diagnostic tests is a clinical decision based on individual patient assessment.

In Managing VTE: Managing VTE | Signs and symptoms of VTE | Diagnosis of VTE |