Diagnosis of Venous Thromboembolism
Publication Date: November 27, 2018
Last Updated: March 14, 2022
Recommendations
Diagnosis of PE
Low PTP/prevalence (≤5%).
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.
- for D-dimer effects on clinical outcomes.
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- for D-dimer diagnostic accuracy studies.
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- for VQ scan or CTPA effects on clinical outcomes.
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- for VQ scan or CTPA diagnostic accuracy studies.
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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%). (, )
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Intermediate PTP/prevalence (∼20%)
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.
- for D-dimer effects on clinical outcomes.
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- for D-dimer diagnostic accuracy studies.
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- for VQ scan or CTPA effects on clinical outcomes.
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- 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%). (, )
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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.
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- for CTPA diagnostic accuracy studies.
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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%). (, )
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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.
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- for D-dimer and CTPA diagnostic accuracy studies.
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Diagnosis of lower extremity DVT
Low PTP/prevalence (≤10%)
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.
- for D-dimer effects on clinical outcomes.
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- for D-dimer diagnostic accuracy studies.
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- for proximal or whole-leg ultrasound effects on clinical outcomes.
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- for proximal or whole-leg ultrasound diagnostic accuracy studies.
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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%). (, )
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Intermediate PTP/prevalence (∼25%)
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.
- for proximal or whole-leg ultrasound effects on clinical outcomes.
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- for proximal or whole-leg ultrasound diagnostic accuracy studies.
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- for D-dimer effects on clinical outcomes.
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- for D-dimer and CTPA diagnostic accuracy studies.
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The ASH guideline panel recommends against using a positive D-dimer alone to diagnose DVT in a population with intermediate prevalence/PTP (∼25%). (, )
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.
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- for proximal or whole-leg ultrasound diagnostic accuracy studies.
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The ASH guideline panel recommends against using a positive D-dimer alone to diagnose DVT in a population with high prevalence/PTP (≥50%). (, )
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.
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- for D-dimer and ultrasound diagnostic accuracy studies.
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Diagnosis of upper extremity DVT
Unlikely PTP/prevalence (10%)
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.
- for D-dimer effects on clinical outcomes.
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- for D-dimer diagnostic accuracy studies.
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- duplex ultrasound effects on clinical outcomes.
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- duplex ultrasound diagnostic accuracy studies.
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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%). (, )
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.
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- for D-dimer diagnostic accuracy studies.
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- duplex ultrasound effects on clinical outcomes.
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- duplex ultrasound diagnostic accuracy studies.
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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%). (, )
312101
Title
Diagnosis of Venous Thromboembolism
Authoring Organization
American Society of Hematology
Publication Month/Year
November 27, 2018
Last Updated Month/Year
June 12, 2023
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
Diseases/Conditions (MeSH)
D054556 - Venous Thromboembolism, D020246 - Venous Thrombosis
Keywords
diagnosis, Venous Thromboembolism, ct