Diagnosis of Venous Thromboembolism

Publication Date: November 27, 2018

Recommendations

Diagnosis of PE

The American Society of Hematology (ASH) guideline panel recommends using a strategy starting with D-dimer for excluding PE in a population with low prevalence/PTP (≤5%), followed by ventilation-perfusion (VQ) scan or computed tomography pulmonary angiography (CTPA) for patients requiring additional testing. If D-dimer is not readily available, alternate acceptable strategies include performing VQ scan or CTPA alone.

Low PTP/prevalence (≤5%).

  • for D-dimer effects on clinical outcomes.
(1⊕⊕⊕⊕)
312101
  • for D-dimer diagnostic accuracy studies.
(1⊕⊕⊕o)
312101
  • for VQ scan or CTPA effects on clinical outcomes.
(2⊕ooo)
312101
  • for VQ scan or CTPA diagnostic accuracy studies.
(2⊕⊕⊕o)
312101
The ASH guideline panel recommends against using a positive D-dimer alone to diagnose PE, and against additional testing following negative CTPA or normal VQ scan in a population with low prevalence/PTP (≤5%). (, )
(See grading for recommendation 1a.)
312101
The ASH guideline panel suggests using a strategy starting with D-dimer for excluding PE in a population with intermediate prevalence/PTP (∼20%), followed by VQ scan or CTPA for patients requiring additional testing. If D-dimer is not readily available, alternate acceptable strategies include performing VQ scan or CTPA alone. Patients who are likely to have a nondiagnostic VQ scan should undergo CTPA.

Intermediate PTP/prevalence (∼20%)

  • for D-dimer effects on clinical outcomes.
(1⊕⊕⊕⊕)
312101
  • for D-dimer diagnostic accuracy studies.
(2⊕⊕⊕o)
312101
  • for VQ scan or CTPA effects on clinical outcomes.
(2⊕ooo)
312101
  • for VQ scan or CTPA diagnostic accuracy studies.
(2⊕⊕⊕o)
312101
The ASH guideline panel recommends against using a positive D-dimer alone to diagnose PE, and against additional testing following negative CTPA or normal VQ scan in a population with intermediate prevalence/PTP (∼20%). (, )
(See grading for recommendation 2a.)
312101

High PTP/prevalence (≥50%)

The ASH guideline panel suggests using a strategy starting with CTPA for assessing patients suspected of having PE in a population with high prevalence/PTP (≥50%).
  • for CTPA effects on clinical outcomes.
(2⊕ooo)
312101
  • for CTPA diagnostic accuracy studies.
(2⊕⊕⊕o)
312101
The ASH guideline panel recommends against using a positive D-dimer alone to diagnose PE, and against using D-dimer as a subsequent test following a negative CT scan in a population with high prevalence/PTP (≥50%). (, )
(See grading for recommendation 3a.)
312101

Recurrent PE

The ASH guideline panel suggests using a strategy starting with D-dimer for excluding recurrent PE in a population with unlikely PTP. Patients with a positive D-dimer or those who have a likely PTP should undergo CTPA.
  • for D-dimer and CTPA effects on clinical outcomes.
(2, ⊕⊕oo)
312101
  • for D-dimer and CTPA diagnostic accuracy studies.
(2⊕⊕⊕o)
312101

Diagnosis of lower extremity DVT

The ASH guideline panel recommends using a strategy starting with D-dimer for excluding DVT in a population with low prevalence/PTP (≤10%), followed by proximal lower extremity ultrasound or whole-leg ultrasound for patients requiring additional testing. If D-dimer is not readily available, alternate acceptable strategies include performing proximal lower extremity or whole-leg ultrasound alone.

Low PTP/prevalence (≤10%)

  • for D-dimer effects on clinical outcomes.
(1⊕⊕⊕o)
312101
  • for D-dimer diagnostic accuracy studies.
(1⊕⊕⊕o)
312101
  • for proximal or whole-leg ultrasound effects on clinical outcomes.
(2⊕ooo)
312101
  • for proximal or whole-leg ultrasound diagnostic accuracy studies.
(2⊕⊕⊕o)
312101
The ASH guideline panel recommends against using a positive D-dimer alone to diagnose DVT, and against additional testing following negative proximal or whole-leg ultrasound in a population with low prevalence/PTP (≤10%). (, )
(See grading for recommendation 5a.)
312101
The ASH guideline panel suggests using a strategy using whole-leg ultrasound, or starting with proximal lower extremity ultrasound for evaluating patients suspected of having DVT in a population with intermediate prevalence/PTP (∼25%). No further testing is required if the whole-leg ultrasound is negative, but a negative initial proximal ultrasound should be followed by serial proximal ultrasound if no alternative diagnosis is identified. In an intermediate PTP population where the prevalence is lower, other potentially acceptable strategies include proximal lower extremity ultrasound alone with no additional follow-up testing for negative results, or a strategy starting with D-dimer for excluding DVT followed by proximal lower extremity ultrasound or whole-leg ultrasound for patients requiring additional testing.

Intermediate PTP/prevalence (∼25%)

  • for proximal or whole-leg ultrasound effects on clinical outcomes.
(2⊕ooo)
312101
  • for proximal or whole-leg ultrasound diagnostic accuracy studies.
(2⊕⊕⊕⊕)
312101
  • for D-dimer effects on clinical outcomes.
(2⊕⊕⊕o)
312101
  • for D-dimer and CTPA diagnostic accuracy studies.
(2⊕⊕⊕o)
312101
The ASH guideline panel recommends against using a positive D-dimer alone to diagnose DVT in a population with intermediate prevalence/PTP (∼25%). (, )
(See grading for recommendation 6a.)
312101

High PTP/prevalence (≥50%)

The ASH guideline panel suggests using a strategy starting with proximal lower extremity or whole-leg ultrasound for assessing patients suspected of having DVT in a population with high prevalence/PTP (≥50%). This should be followed by serial ultrasound if the initial ultrasound is negative and no alternative diagnosis is identified.
  • for proximal or whole-leg ultrasound effects on clinical outcomes.
(2⊕ooo)
312101
  • for proximal or whole-leg ultrasound diagnostic accuracy studies.
(2⊕⊕⊕⊕)
312101
The ASH guideline panel recommends against using a positive D-dimer alone to diagnose DVT in a population with high prevalence/PTP (≥50%). (, )
(See grading for recommendation 7a.)
312101

Recurrent DVT (lower extremity)

The ASH guideline panel suggests using a strategy starting with D-dimer for excluding recurrent DVT in a population with unlikely PTP. Patients with positive D-dimer or those who have likely PTP should undergo proximal lower extremity ultrasound.
  • for D-dimer and ultrasound effects on clinical outcomes.
(2⊕⊕oo)
312101
  • for D-dimer and ultrasound diagnostic accuracy studies.
(2⊕⊕oo)
312101

Diagnosis of upper extremity DVT

The ASH guideline panel suggests a strategy starting with D-dimer for excluding upper extremity DVT in a population with low prevalence/unlikely PTP (10%), followed by duplex ultrasound if D-dimer is positive. If D-dimer is not readily available, performing duplex ultrasound alone is acceptable.

Unlikely PTP/prevalence (10%)

  • for D-dimer effects on clinical outcomes.
(2⊕ooo)
312101
  • for D-dimer diagnostic accuracy studies.
(2⊕⊕⊕o)
312101
  • duplex ultrasound effects on clinical outcomes.
(2⊕ooo)
312101
  • duplex ultrasound diagnostic accuracy studies.
(2⊕⊕oo)
312101
The ASH guideline panel recommends against using a positive D-dimer alone to diagnose upper extremity DVT in a population with low prevalence/unlikely PTP (10%). (, )
(See grading for recommendation 9a.)
312101

Likely PTP/prevalence (40%)

The ASH guideline panel suggests a strategy of either D-dimer followed by duplex ultrasound/serial duplex ultrasound, or duplex ultrasound/serial duplex ultrasound alone for assessing patients suspected of having upper extremity DVT in a population with high prevalence/likely PTP (40%).
  • for D-dimer effects on clinical outcomes.
(2⊕ooo)
312101
  • for D-dimer diagnostic accuracy studies.
(2⊕⊕⊕o)
312101
  • duplex ultrasound effects on clinical outcomes.
(2⊕ooo)
312101
  • duplex ultrasound diagnostic accuracy studies.
(2⊕⊕oo)
312101
The ASH guideline panel recommends against using a positive D-dimer alone to diagnose upper extremity DVT in a population with high prevalence/likely PTP (40%). (, )
(See grading for recommendation 10a.)
312101

Recommendation Grading

Disclaimer

Overview

Title

Diagnosis of Venous Thromboembolism

Authoring Organization

Publication Month/Year

November 27, 2018

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

These evidence-based guidelines are intended to support patients, clinicians, and health care professionals in VTE diagnosis. Diagnostic strategies were evaluated for pulmonary embolism (PE), deep vein thrombosis (DVT) of the lower and upper extremity, and recurrent VTE.

Target Patient Population

Patients with suspected PE and lower extremity DVT, and for recurrent VTE and upper extremity DVT.

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Emergency care, Hospital, Long term care

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis

Diseases/Conditions (MeSH)

D054556 - Venous Thromboembolism, D020246 - Venous Thrombosis

Keywords

diagnosis, Venous Thromboembolism, ct

Source Citation

Blood Adv (2018) 2 (22): 3226–3256.
https://doi.org/10.1182/bloodadvances.2018024828