Venous thromboembolism: Difference between revisions

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{{Venous thromboembolism}}
{{Venous thromboembolism}}
{{CMG}}; {{AE}} {{HK}}, {{IQ}}, {{Anmol}}, {{ARK}}
{{CMG}}; {{AE}} {{HK}}, {{IQ}}, {{Anmol}}, {{ARK}}
<br>
'''''To review the risk of VTE according to IMPROVEDD score, click [[IMPROVEDD risk score calculator|here]]'''.''
'''''To review the risk of VTE according to IMPROVE score, click [[IMPROVE VTE risk score|here]]'''.''
'''''To review the risk of VTE according to Caprini scores click [[Caprini score|here]]'''.''
'''''To predict the clinical risk of [[Pulmonary thromboembolism]] according to Wells score, click [[Wells score calculator|here]]'''.''


==Overiew==
==Overiew==
Venous thromboembolism (VTE) may be classified into [[deep vein thrombosis]] (DVT) and [[pulmonary embolism]] (PE). [[Pulmonary embolism]] may arise as a consequence of [[deep vein thrombosis]] as a result of [[embolization]] of the [[clot]] from deep [[veins]] of the legs. [[Pulmonary embolism]] (PE) is an [[acute]] obstruction of the [[pulmonary artery]] (or one of its branches). The obstruction in the [[pulmonary artery]] that causes a [[PE]] can be due to [[thrombus]], air, [[tumor]], or [[fat]]. Most often, this is due to a [[venous thrombosis]] (blood [[clot]] from a [[vein]]), which has been dislodged from its site of formation in the [[lower extremities]]. It has then [[Embolism|embolized]] to the [[Pulmonary artery|arterial]] blood supply of one of the [[lungs]]. [[Deep vein thrombosis]] (also known as [[deep venous thrombosis]] or [[DVT]] and colloquially referred to as "[[economy class syndrome]]") is the formation of a [[blood clot]] ("[[thrombus]]") in a [[deep vein]].
Venous thromboembolism (VTE) may be classified into [[deep vein thrombosis]] ([[DVT]]) and [[pulmonary embolism]] ([[Pulmonary embolism|PE]]). [[Pulmonary embolism]] may arise as a consequence of [[deep vein thrombosis]] as a result of [[embolization]] of the [[clot]] from deep [[veins]] of the legs. [[Pulmonary embolism]] (PE) is an [[acute]] obstruction of the [[pulmonary artery]] (or one of its branches). The obstruction in the [[pulmonary artery]] that causes a [[PE]] can be due to [[thrombus]], air, [[tumor]], or [[fat]]. Most often, [[pulmonary embolism]] is due to a [[venous thrombosis]] ([[blood clot]] from a [[vein]]), which has been dislodged from its site of formation in the [[lower extremities]]. It has then [[Embolism|embolized]] to the [[Pulmonary artery|arterial]] blood supply of one of the [[lungs]]. [[Deep vein thrombosis]] (also known as [[deep venous thrombosis]] or [[DVT]] and colloquially referred to as "[[economy class syndrome]]") is the formation of a [[blood clot]] ("[[thrombus]]") in a [[deep vein]].


==Classification==
==Classification==
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==Epidemiology==
==Epidemiology==
=== Prevalence ===
* The precise number of people affected by [[Deep vein thrombosis|DVT]]/[[Pulmonary embolism|PE]] is unknown,although as many as 900,000 people could be affected (100 to 200 per 100,000) each year in the United States.<ref name="urlData and Statistics | DVT/PE | NCBDDD | CDC">{{cite web |url=https://www.cdc.gov/ncbddd/dvt/data.html |title=Data and Statistics &#124; DVT/PE &#124; NCBDDD &#124; CDC |format= |work= |accessdate=}}</ref>
===Incidence===
===Incidence===
*The [[incidence]] of VTE increases with [[age]], ranging from less than 5 cases per 100,000 people in childhood to 500 cases per 100,000 people in the elderly.<ref name="pmid12814979">{{cite journal| author=White RH| title=The epidemiology of venous thromboembolism. | journal=Circulation | year= 2003 | volume= 107 | issue= 23 Suppl 1 | pages= I4-8 | pmid=12814979 | doi=10.1161/01.CIR.0000078468.11849.66 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12814979  }} </ref>
*The [[incidence]] of VTE increases with [[age]], ranging from less than 5 cases per 100,000 people in childhood to 500 cases per 100,000 people in the elderly.<ref name="pmid12814979">{{cite journal| author=White RH| title=The epidemiology of venous thromboembolism. | journal=Circulation | year= 2003 | volume= 107 | issue= 23 Suppl 1 | pages= I4-8 | pmid=12814979 | doi=10.1161/01.CIR.0000078468.11849.66 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12814979  }} </ref>
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===Recurrence of VTE===
===Recurrence of VTE===
*Approximately 33% of people with VTE will have a recurrence within 10 years.<ref name="pmid20331949">{{cite journal| author=Beckman MG, Hooper WC, Critchley SE, Ortel TL| title=Venous thromboembolism: a public health concern. | journal=Am J Prev Med | year= 2010 | volume= 38 | issue= 4 Suppl | pages= S495-501 | pmid=20331949 | doi=10.1016/j.amepre.2009.12.017 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20331949  }} </ref><ref name="CDC3">[http://www.cdc.gov/ncbddd/dvt/data.html CDC- Deep Vein Thrombosis (DVT) / Pulmonary Embolism (PE) — Blood Clot Forming in a Vein]</ref>
*Approximately 33% (1 in 3) of people with VTE will have a recurrence within 10 years.<ref name="pmid20331949">{{cite journal| author=Beckman MG, Hooper WC, Critchley SE, Ortel TL| title=Venous thromboembolism: a public health concern. | journal=Am J Prev Med | year= 2010 | volume= 38 | issue= 4 Suppl | pages= S495-501 | pmid=20331949 | doi=10.1016/j.amepre.2009.12.017 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20331949  }} </ref><ref name="CDC3">[http://www.cdc.gov/ncbddd/dvt/data.html CDC- Deep Vein Thrombosis (DVT) / Pulmonary Embolism (PE) — Blood Clot Forming in a Vein]</ref>


*The risk of recurrence of [[VTE]] in patients diagnosed with first-time [[VTE]] is estimated to be approximately 7-8% per year during an average follow up period of 2.2 years of subsequent observation.<ref name="pmid15210384">{{cite journal |author=Cushman M, Tsai AW, White RH, ''et al.''|title=Deep vein thrombosis and pulmonary embolism in two cohorts: the longitudinal investigation of thromboembolism etiology |journal=Am. J. Med.|volume=117 |issue=1 |pages=19–25 |year=2004 |month=July |pmid=15210384 |doi=10.1016/j.amjmed.2004.01.018 |url=}}</ref>
*The risk of recurrence of [[VTE]] in patients diagnosed with first-time [[VTE]] is estimated to be approximately 7-8% per year during an average follow up period of 2.2 years of subsequent observation.<ref name="pmid15210384">{{cite journal |author=Cushman M, Tsai AW, White RH, ''et al.''|title=Deep vein thrombosis and pulmonary embolism in two cohorts: the longitudinal investigation of thromboembolism etiology |journal=Am. J. Med.|volume=117 |issue=1 |pages=19–25 |year=2004 |month=July |pmid=15210384 |doi=10.1016/j.amjmed.2004.01.018 |url=}}</ref>
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==Risk Factors==
==Risk Factors==
Shown below is a list of predisposing factors for [[VTE]].<ref name="pmid12814980">{{cite journal| author=Anderson FA, Spencer FA| title=Risk factors for venous thromboembolism. | journal=Circulation | year= 2003 | volume= 107 | issue= 23 Suppl 1 | pages= I9-16 | pmid=12814980 | doi=10.1161/01.CIR.0000078469.07362.E6 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12814980  }} </ref><ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref> The risk factors are classified as moderate or weak depending on how strongly they predispose for a VTE.
Shown below is a list of predisposing factors for [[VTE]]. The risk factors are classified as moderate or weak depending on how strongly they are associated with a VTE.<ref name="pmid9842042">{{cite journal |vauthors=Massicotte MP, Dix D, Monagle P, Adams M, Andrew M |title=Central venous catheter related thrombosis in children: analysis of the Canadian Registry of Venous Thromboembolic Complications |journal=J. Pediatr. |volume=133 |issue=6 |pages=770–6 |year=1998 |pmid=9842042 |doi= |url=}}</ref><ref name="pmid14702496">{{cite journal |vauthors=Worly JM, Fortenberry JD, Hansen I, Chambliss CR, Stockwell J |title=Deep venous thrombosis in children with diabetic ketoacidosis and femoral central venous catheters |journal=Pediatrics |volume=113 |issue=1 Pt 1 |pages=e57–60 |year=2004 |pmid=14702496 |doi= |url=}}</ref><ref name="pmid12814980">{{cite journal| author=Anderson FA, Spencer FA| title=Risk factors for venous thromboembolism. | journal=Circulation | year= 2003 | volume= 107 | issue= 23 Suppl 1 | pages= I9-16 | pmid=12814980 | doi=10.1161/01.CIR.0000078469.07362.E6 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12814980  }} </ref><ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref>


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'''Risk factors of VTE may be categorized in to modifiable, non-modifiable, temporary and other risk factors.'''
'''Risk factors of VTE may be categorized into modifiable, non-modifiable, temporary, and other risk factors.'''


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❑ Modifiable risk factors are reversible based upon lifestyle/behavior modification. <br>
❑ Modifiable risk factors are reversible based upon lifestyle/behavior modification. <br>
❑ [[Obesity]] is defined as a body-mass index (BMI) above 30 kg/m2.<ref name="pmid20404252">{{cite journal| author=Holst AG, Jensen G, Prescott E| title=Risk factors for venous thromboembolism: results from the Copenhagen City Heart Study. | journal=Circulation | year= 2010 | volume= 121 | issue= 17 | pages= 1896-903 | pmid=20404252 | doi=10.1161/CIRCULATIONAHA.109.921460 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20404252  }} </ref> <ref name="pmid21352080">{{cite journal| author=Vayá A, Martínez-Triguero ML, España F, Todolí JA, Bonet E, Corella D| title=The metabolic syndrome and its individual components: its association with venous thromboembolism in a Mediterranean population. | journal=Metab Syndr Relat Disord | year= 2011 | volume= 9 | issue= 3 | pages= 197-201 | pmid=21352080 | doi=10.1089/met.2010.0117 | pmc= | url= }} </ref> <ref name="pmid18695082">{{cite journal| author=Eichinger S, Hron G, Bialonczyk C, Hirschl M, Minar E, Wagner O et al.| title=Overweight, obesity, and the risk of recurrent venous thromboembolism. | journal=Arch Intern Med | year= 2008 | volume= 168 | issue= 15 | pages= 1678-83 | pmid=18695082 | doi=10.1001/archinte.168.15.1678 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18695082  }} </ref> <br>
❑ [[Obesity]] is defined as a [[Body mass index|body-mass index]] ([[Body mass index|BMI]]) above 30 kg/m2.<ref name="pmid20404252">{{cite journal| author=Holst AG, Jensen G, Prescott E| title=Risk factors for venous thromboembolism: results from the Copenhagen City Heart Study. | journal=Circulation | year= 2010 | volume= 121 | issue= 17 | pages= 1896-903 | pmid=20404252 | doi=10.1161/CIRCULATIONAHA.109.921460 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20404252  }} </ref> <ref name="pmid21352080">{{cite journal| author=Vayá A, Martínez-Triguero ML, España F, Todolí JA, Bonet E, Corella D| title=The metabolic syndrome and its individual components: its association with venous thromboembolism in a Mediterranean population. | journal=Metab Syndr Relat Disord | year= 2011 | volume= 9 | issue= 3 | pages= 197-201 | pmid=21352080 | doi=10.1089/met.2010.0117 | pmc= | url= }} </ref> <ref name="pmid18695082">{{cite journal| author=Eichinger S, Hron G, Bialonczyk C, Hirschl M, Minar E, Wagner O et al.| title=Overweight, obesity, and the risk of recurrent venous thromboembolism. | journal=Arch Intern Med | year= 2008 | volume= 168 | issue= 15 | pages= 1678-83 | pmid=18695082 | doi=10.1001/archinte.168.15.1678 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18695082  }} </ref> <br>
❑ [[Smoking]]:<ref name="pmid20404252">{{cite journal| author=Holst AG, Jensen G, Prescott E| title=Risk factors for venous thromboembolism: results from the Copenhagen City Heart Study. | journal=Circulation | year= 2010 | volume= 121 | issue= 17 | pages= 1896-903 | pmid=20404252 | doi=10.1161/CIRCULATIONAHA.109.921460 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20404252  }} </ref> Smoking significantly increases the risk of [[DVT]], particularly among women who are taking [[oral contraceptive pills]] as well as among obese people. <br>
❑ [[Smoking]]:<ref name="pmid20404252">{{cite journal| author=Holst AG, Jensen G, Prescott E| title=Risk factors for venous thromboembolism: results from the Copenhagen City Heart Study. | journal=Circulation | year= 2010 | volume= 121 | issue= 17 | pages= 1896-903 | pmid=20404252 | doi=10.1161/CIRCULATIONAHA.109.921460 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20404252  }} </ref> Smoking significantly increases the risk of [[DVT]], particularly among women who are taking [[oral contraceptive pills]] as well as among obese people. <br>
❑ Use of [[oral contraceptives]]<ref name="pmid17726684">{{cite journal| author=Pomp ER, Rosendaal FR, Doggen CJ| title=Smoking increases the risk of venous thrombosis and acts synergistically with oral contraceptive use. | journal=Am J Hematol | year= 2008 | volume= 83 | issue= 2 | pages= 97-102 | pmid=17726684 | doi=10.1002/ajh.21059 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17726684  }} </ref> <br>
❑ Use of [[oral contraceptives]]<ref name="pmid17726684">{{cite journal| author=Pomp ER, Rosendaal FR, Doggen CJ| title=Smoking increases the risk of venous thrombosis and acts synergistically with oral contraceptive use. | journal=Am J Hematol | year= 2008 | volume= 83 | issue= 2 | pages= 97-102 | pmid=17726684 | doi=10.1002/ajh.21059 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17726684  }} </ref> <br>
❑ [[Hyperhomocysteinemia]]:<ref name="pmid8592549">{{cite journal| author=den Heijer M, Koster T, Blom HJ, Bos GM, Briet E, Reitsma PH et al.| title=Hyperhomocysteinemia as a risk factor for deep-vein thrombosis. | journal=N Engl J Med | year= 1996 | volume= 334 | issue= 12 | pages= 759-62 | pmid=8592549 | doi=10.1056/NEJM199603213341203 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8592549  }} </ref> [[Hyperhomocysteinemia]] can be reduced with vitamin B supplementation.<br>
❑ [[Hyperhomocysteinemia]]:<ref name="pmid8592549">{{cite journal| author=den Heijer M, Koster T, Blom HJ, Bos GM, Briet E, Reitsma PH et al.| title=Hyperhomocysteinemia as a risk factor for deep-vein thrombosis. | journal=N Engl J Med | year= 1996 | volume= 334 | issue= 12 | pages= 759-62 | pmid=8592549 | doi=10.1056/NEJM199603213341203 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8592549  }} </ref> [[Hyperhomocysteinemia]] can be reduced with [[vitamin B]] supplementation.<br>
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❑ Advanced age <br>
❑ Advanced age <br>
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❑ Other possible factors associated with VTE include:<ref name="pmid20620109">{{cite journal| author=Konofal E, Lecendreux M, Cortese S| title=Sleep and ADHD. | journal=Sleep Med | year= 2010 | volume= 11 | issue= 7 | pages= 652-8 | pmid=20620109 | doi=10.1016/j.sleep.2010.02.012 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20620109  }} </ref> <br>
❑ Other possible factors associated with VTE include:<ref name="pmid20620109">{{cite journal| author=Konofal E, Lecendreux M, Cortese S| title=Sleep and ADHD. | journal=Sleep Med | year= 2010 | volume= 11 | issue= 7 | pages= 652-8 | pmid=20620109 | doi=10.1016/j.sleep.2010.02.012 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20620109  }} </ref> <br>
:❑ Nutrition low in fish <br>
:❑ [[Nutrition]] low in fish <br>
:❑ [[Psychological stress]] <br>
:❑ [[Psychological stress]] <br>
:❑ Cardiovascular risk factors such as [[diabetes]] and [[hypercholesterolemia]] <br>
:❑ Cardiovascular risk factors such as [[diabetes]] and [[hypercholesterolemia]] <br>
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==Diagnosis==
==Diagnosis==
The diagnostic guidelines for venous thromboembolism are as follows:<ref name="pmid24319219">{{cite journal |vauthors=Wells P, Anderson D |title=The diagnosis and treatment of venous thromboembolism |journal=Hematology Am Soc Hematol Educ Program |volume=2013 |issue= |pages=457–63 |year=2013 |pmid=24319219 |doi=10.1182/asheducation-2013.1.457 |url=}}</ref>
The diagnostic guidelines for venous thromboembolism are as follows:<ref name="pmid24319219">{{cite journal |vauthors=Wells P, Anderson D |title=The diagnosis and treatment of venous thromboembolism |journal=Hematology Am Soc Hematol Educ Program |volume=2013 |issue= |pages=457–63 |year=2013 |pmid=24319219 |doi=10.1182/asheducation-2013.1.457 |url=}}</ref><ref name="urlDoes This Patient Have Deep Vein Thrombosis? | Venous Thromboembolism | JAMA | The JAMA Network">{{cite web |url=https://jamanetwork.com/journals/jama/fullarticle/202182 |title=Does This Patient Have Deep Vein Thrombosis? &#124; Venous Thromboembolism &#124; JAMA &#124; The JAMA Network |format= |work= |accessdate=}}</ref><ref name="urlDiagnostic accuracy of D-dimer test for exclusion of venous thromboembolism: a systematic review - DI NISIO - 2007 - Journal of Thrombosis and Haemostasis - Wiley Online Library">{{cite web |url=http://onlinelibrary.wiley.com/doi/10.1111/j.1538-7836.2007.02328.x/abstract |title=Diagnostic accuracy of D-dimer test for exclusion of venous thromboembolism: a systematic review - DI NISIO - 2007 - Journal of Thrombosis and Haemostasis - Wiley Online Library |format= |work= |accessdate=}}</ref><ref name="urlComputed Tomographic Pulmonary Angiography vs Ventilation-Perfusion Lung Scanning in Patients With Suspected Pulmonary Embolism | Cardiology | JAMA | The JAMA Network">{{cite web |url=https://jamanetwork.com/journals/jama/fullarticle/1108374 |title=Computed Tomographic Pulmonary Angiography vs Ventilation-Perfusion Lung Scanning in Patients With Suspected Pulmonary Embolism &#124; Cardiology &#124; JAMA &#124; The JAMA Network |format= |work= |accessdate=}}</ref>
 
===Deep Vein Thrombosis===
 
{{familytree/start |summary=Sample 1}}
{{familytree/start |summary=Sample 1}}
{{familytree | | | | | | | | | A01 |A01=Suspected [[DVT]]}}  
{{familytree | | | | | | | | | A01 |A01=Suspected [[DVT]]}}  
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{{familytree/end}}
{{familytree/end}}


<br>
===Pulmonary Embolism===


{{familytree/start}}
{{familytree/start}}
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{{familytree | | |!| | | | | | | | | | | | | |!| }}
{{familytree | | |!| | | | | | | | | | | | | |!| }}
{{familytree | | D01 | | | | | | | | |,|-|-|-|^|-|-|-|-|.| | D01=Stop}}
{{familytree | | D01 | | | | | | | | |,|-|-|-|^|-|-|-|-|.| | D01=Stop}}
{{familytree | | | | | | | | | | | | E01 | | | | | | | E02 |E01=CXR|E02=Ultrasound<br>If signs of [[DVT]] present}}
{{familytree | | | | | | | | | | | | E01 | | | | | | | E02 |E01=CXR|E02=[[Ultrasound]]<br>If signs of [[DVT]] present}}
{{familytree | | | | | | | | | | | | |!| | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | |!| | | | | | | | | | |}}
{{familytree | | | | | | | | | F01 |-|^|-|-|-|-|-| F02 | | | | | |F01=Normal<br> [[PE]] unlikely with positive D-dimer or [[PE]] likely|F02= Abnormal<br> [[PE]] unlikely with positive [[D-dimer]] or [[PE]] likely}}
{{familytree | | | | | | | | | F01 |-|^|-|-|-|-|-| F02 | | | | | |F01=Normal<br> [[PE]] unlikely with positive [[D-dimer]] or [[PE]] likely|F02= Abnormal<br> [[PE]] unlikely with positive [[D-dimer]] or [[PE]] likely}}
{{familytree | | | | | | | | | |!| | | | | | | | | |!| | | | |}}
{{familytree | | | | | | | | | |!| | | | | | | | | |!| | | | |}}
{{familytree | | | | | | | | | G01 | | | | | | | | G02 | | | | | |G01=[[V/Q scan]]|G02=[[CTPA]]}}
{{familytree | | | | | | | | | G01 | | | | | | | | G02 | | | | | |G01=[[V/Q scan]]|G02=[[CTPA]]}}
{{familytree | | | | | |,|-|-|-|+|-|-|-|.| | | |,|-|^|-|.| | | | | |}}
{{familytree | | | | | |,|-|-|-|+|-|-|-|.| | | |,|-|^|-|.| | | | | |}}
{{familytree | | | | | J01 | | J02 | | J03 | | j04 | | j05 | |J01=Nnormal|J02=Non diagnostic|J03=High probability|j04=PE present|j05=[[PE]] absent}}
{{familytree | | | | | J01 | | J02 | | J03 | | j04 | | j05 | |J01=Normal|J02=Non diagnostic|J03=High probability|j04=PE present|j05=[[PE]] absent}}
{{familytree | | | | | |!| | | |!| | | |!| | | |!| | | |!| |}}
{{familytree | | | | | |!| | | |!| | | |!| | | |!| | | |!| |}}
{{familytree | | | | | I01 | | |!| | | I02 | | I03 | | I04 | | |I01=Stop|I02=Treat|I03=Treat|I04=Stop}}
{{familytree | | | | | I01 | | |!| | | I02 | | I03 | | I04 | | |I01=Stop|I02=Treat|I03=Treat|I04=Stop}}
Line 214: Line 233:
{{familytree | | | | | | J01 | | | | J02 | | | J01=PE unlikely|J02= [[PE]] likely}}
{{familytree | | | | | | J01 | | | | J02 | | | J01=PE unlikely|J02= [[PE]] likely}}
{{familytree | | | | | | |!| | | | | |!| | | | | | | | | | | | |}}
{{familytree | | | | | | |!| | | | | |!| | | | | | | | | | | | |}}
{{familytree | | | | | | F01 | | | | F02 | | | |F01=Serial ultrasound|F02=[[CTPA]] or serial ultrasound}}
{{familytree | | | | | | F01 | | | | F02 | | | |F01=Serial [[ultrasound]]|F02=[[CTPA]] or serial [[ultrasound]]}}
{{familytree/end}}
{{familytree/end}}
'''Pulmonary embolism Wells Score Calculator'''
<small>
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF; width: 70%" align="center" | '''Variable'''|| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align="center" | '''Wells Score'''<ref name="pmid10744147">{{cite journal |author=Wells PS, Anderson DR, Rodger M, Ginsberg JS, Kearon C, Gent M, Turpie AG, Bormanis J, Weitz J, Chamberlain M, Bowie D, Barnes D, Hirsh J |title=Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer |journal=Thromb. Haemost. |volume=83 |issue=3 |pages=416–20 |year=2000 |pmid=10744147 |doi=|url=http://www.schattauer.de/index.php?id=1268&L=1&pii=th00030416&no_cache=1 |accessdate=2012-05-01}}</ref>
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align="left" | Clinically suspected [[DVT]] (leg swelling, pain with palpation)|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align="left" | 3.0
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align="left" | Alternative diagnosis is less likely than PE|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align="left" | 3.0
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align="left" | Immobilization/[[surgery]] in previous four weeks|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align="left" | 1.5
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align="left" | Previous history of [[DVT]] or [[PE]]|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align="left" | 1.5
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align="left" | [[Tachycardia]] (heart rate more than 100 bpm)|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align="left" | 1.5
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align="left" | [[Malignancy]] (treatment for within 6 months, palliative)|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align="left" | 1.0
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align="left" | [[Hemoptysis]]|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align="left" | 1.0
|-
|}</small>


==Prevention==
==Prevention==
The follwoing table summarizes the major scoring criterias used for risk assessment of VTE and their prophylaxis options:<ref name="CohenHarrington2016">{{cite journal|last1=Cohen|first1=Alexander T.|last2=Harrington|first2=Robert A.|last3=Goldhaber|first3=Samuel Z.|last4=Hull|first4=Russell D.|last5=Wiens|first5=Brian L.|last6=Gold|first6=Alex|last7=Hernandez|first7=Adrian F.|last8=Gibson|first8=C. Michael|title=Extended Thromboprophylaxis with Betrixaban in Acutely Ill Medical Patients|journal=New England Journal of Medicine|volume=375|issue=6|year=2016|pages=534–544|issn=0028-4793|doi=10.1056/NEJMoa1601747}}</ref><ref name="pmid22315261">{{cite journal |vauthors=Kahn SR, Lim W, Dunn AS, Cushman M, Dentali F, Akl EA, Cook DJ, Balekian AA, Klein RC, Le H, Schulman S, Murad MH |title=Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines |journal=Chest |volume=141 |issue=2 Suppl |pages=e195S–e226S |year=2012 |pmid=22315261 |pmc=3278052 |doi=10.1378/chest.11-2296 |url=}}</ref><ref name="pmid22315263">{{cite journal |vauthors=Gould MK, Garcia DA, Wren SM, Karanicolas PJ, Arcelus JI, Heit JA, Samama CM |title=Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines |journal=Chest |volume=141 |issue=2 Suppl |pages=e227S–e277S |year=2012 |pmid=22315263 |pmc=3278061 |doi=10.1378/chest.11-2297 |url=}}</ref><ref name="CohenSpiro2013">{{cite journal|last1=Cohen|first1=Alexander T.|last2=Spiro|first2=Theodore E.|last3=Büller|first3=Harry R.|last4=Haskell|first4=Lloyd|last5=Hu|first5=Dayi|last6=Hull|first6=Russell|last7=Mebazaa|first7=Alexandre|last8=Merli|first8=Geno|last9=Schellong|first9=Sebastian|last10=Spyropoulos|first10=Alex C.|last11=Tapson|first11=Victor|title=Rivaroxaban for Thromboprophylaxis in Acutely Ill Medical Patients|journal=New England Journal of Medicine|volume=368|issue=6|year=2013|pages=513–523|issn=0028-4793|doi=10.1056/NEJMoa1111096}}</ref><ref name="urlFDA approved betrixaban (BEVYXXA, Portola) for the prophylaxis of venous thromboembolism (VTE) in adult patients">{{cite web |url=https://www.fda.gov/drugs/informationondrugs/approveddrugs/ucm564422.htm |title=FDA approved betrixaban (BEVYXXA, Portola) for the prophylaxis of venous thromboembolism (VTE) in adult patients |format= |work= |accessdate=}}</ref>
The following table summarizes major scoring criteria for risk assessment of VTE:<ref>{{cite journal|title=The IMPROVEDD VTE Risk Score: Incorporation of D-Dimer into the IMPROVE Score to Improve Venous Thromboembolism Risk Stratification|doi=10.1055/s-0037-160392910.1055/s-0037-1603929}}</ref><ref name="pmid21436241">{{cite journal| author=Spyropoulos AC, Anderson FA, FitzGerald G, Decousus H, Pini M, Chong BH et al.| title=Predictive and associative models to identify hospitalized medical patients at risk for VTE. | journal=Chest | year= 2011 | volume= 140 | issue= 3 | pages= 706-714 | pmid=21436241 | doi=10.1378/chest.10-1944 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21436241  }} </ref><ref name="pmid20738765">{{cite journal| author=Barbar S, Noventa F, Rossetto V, Ferrari A, Brandolin B, Perlati M et al.| title=A risk assessment model for the identification of hospitalized medical patients at risk for venous thromboembolism: the Padua Prediction Score. | journal=J Thromb Haemost | year= 2010 | volume= 8 | issue= 11 | pages= 2450-7 | pmid=20738765 | doi=10.1111/j.1538-7836.2010.04044.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20738765  }} </ref><ref name="pmid1754886">{{cite journal| author=Caprini JA, Arcelus JI, Hasty JH, Tamhane AC, Fabrega F| title=Clinical assessment of venous thromboembolic risk in surgical patients. | journal=Semin Thromb Hemost | year= 1991 | volume= 17 Suppl 3 | issue= | pages= 304-12 | pmid=1754886 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1754886  }} </ref>


<small>
{|
! colspan="4" style="background:#4479BA; color: #FFFFFF;" align="center" + |Scoring criteria for risk assessment*
|-
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Type of patient
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Scoring system
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Score
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Risk
|-
| rowspan="23" style="background:#DCDCDC;" align="center" + |Non-surgical patient
| rowspan="14" style="background:#DCDCDC;" align="center" + |'''[[IMPROVE and IMPROVEDD scores for venous thromboembolism|IMPROVEDD Score]]'''
| style="background:#DCDCDC;" align="center" + |
| style="background:#DCDCDC;" align="center" + |Predicted % VTE risk through 42 days
|-
| style="background:#F5F5F5;" align="center" + |0
| style="background:#F5F5F5;" + |0.4%
|-
| style="background:#F5F5F5;" align="center" + |1
| style="background:#F5F5F5;" + |0.6%
|-
| style="background:#F5F5F5;" align="center" + |2
| style="background:#F5F5F5;" + |0.8%
|-
| style="background:#F5F5F5;" align="center" + |3
| style="background:#F5F5F5;" + |1.2%
|-
| style="background:#F5F5F5;" align="center" + |4
| style="background:#F5F5F5;" + |1.6%
|-
| style="background:#F5F5F5;" align="center" + |5-10
| style="background:#F5F5F5;" + |2.2%
|-
| style="background:#DCDCDC;" align="center" + |
| style="background:#DCDCDC;" align="center" + |Predicted % VTE risk through 77 days
|-
| style="background:#F5F5F5;" align="center" + |0
| style="background:#F5F5F5;" + |0.5%
|-
| style="background:#F5F5F5;" align="center" + |1
| style="background:#F5F5F5;" + |0.7%
|-
| style="background:#F5F5F5;" align="center" + |2
| style="background:#F5F5F5;" + |1.0%
|-
| style="background:#F5F5F5;" align="center" + |3
| style="background:#F5F5F5;" + |1.4%
|-
| style="background:#F5F5F5;" align="center" + |4
| style="background:#F5F5F5;" + |1.9%
|-
| style="background:#F5F5F5;" align="center" + |5-10
| style="background:#F5F5F5;" + |2.75
|-
| rowspan="7" style="background:#DCDCDC;" align="center" + |'''[[IMPROVE and IMPROVEDD scores for venous thromboembolism|IMPROVE score]]'''
| style="background:#DCDCDC;" align="center" + |
| style="background:#DCDCDC;" align="center" + |Predicted % VTE risk through 3 months
|-
| style="background:#F5F5F5;" align="center" + |0
| style="background:#F5F5F5;" + |0.5%
|-
| style="background:#F5F5F5;" align="center" + |1
| style="background:#F5F5F5;" + |1.0%
|-
| style="background:#F5F5F5;" align="center" + |2
| style="background:#F5F5F5;" + |1.7%
|-
| style="background:#F5F5F5;" align="center" + |3
| style="background:#F5F5F5;" + |3.1%
|-
| style="background:#F5F5F5;" align="center" + |4
| style="background:#F5F5F5;" + |4%
|-
| style="background:#F5F5F5;" align="center" + |5-8
| style="background:#F5F5F5;" + |11%
|-
| rowspan="2" style="background:#DCDCDC;" align="center" + | '''Padua Score'''
| style="background:#F5F5F5;" align="center" + |< 4
| style="background:#F5F5F5;" + |Low risk for VTE
|-
| style="background:#F5F5F5;" align="center" + |≥ 4
| style="background:#F5F5F5;" + |High risk for VTE
|-
| rowspan="4" style="background:#DCDCDC;" align="center" + | Surgical patient
| rowspan="4" style="background:#DCDCDC;" align="center" + |'''Caprini score'''
| style="background:#F5F5F5;" align="center" + |0-1
| style="background:#F5F5F5;" + |Low risk of VTE
|-
| style="background:#F5F5F5;" align="center" + |2
| style="background:#F5F5F5;" + |Moderate of VTE
|-
| style="background:#F5F5F5;" align="center" + |3-4
| style="background:#F5F5F5;" + |High risk of VTE
|-
| style="background:#F5F5F5;" align="center" + |≥ 5
| style="background:#F5F5F5;" + |Highest risk for VTE
|}
</small>
The following table summarizes the major scoring criteria used for risk assessment of VTE and their prophylaxis options:<ref name="CohenHarrington2016">{{cite journal|last1=Cohen|first1=Alexander T.|last2=Harrington|first2=Robert A.|last3=Goldhaber|first3=Samuel Z.|last4=Hull|first4=Russell D.|last5=Wiens|first5=Brian L.|last6=Gold|first6=Alex|last7=Hernandez|first7=Adrian F.|last8=Gibson|first8=C. Michael|title=Extended Thromboprophylaxis with Betrixaban in Acutely Ill Medical Patients|journal=New England Journal of Medicine|volume=375|issue=6|year=2016|pages=534–544|issn=0028-4793|doi=10.1056/NEJMoa1601747}}</ref><ref name="pmid22315261">{{cite journal |vauthors=Kahn SR, Lim W, Dunn AS, Cushman M, Dentali F, Akl EA, Cook DJ, Balekian AA, Klein RC, Le H, Schulman S, Murad MH |title=Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines |journal=Chest |volume=141 |issue=2 Suppl |pages=e195S–e226S |year=2012 |pmid=22315261 |pmc=3278052 |doi=10.1378/chest.11-2296 |url=}}</ref><ref name="pmid22315263">{{cite journal |vauthors=Gould MK, Garcia DA, Wren SM, Karanicolas PJ, Arcelus JI, Heit JA, Samama CM |title=Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines |journal=Chest |volume=141 |issue=2 Suppl |pages=e227S–e277S |year=2012 |pmid=22315263 |pmc=3278061 |doi=10.1378/chest.11-2297 |url=}}</ref><ref name="CohenSpiro2013">{{cite journal|last1=Cohen|first1=Alexander T.|last2=Spiro|first2=Theodore E.|last3=Büller|first3=Harry R.|last4=Haskell|first4=Lloyd|last5=Hu|first5=Dayi|last6=Hull|first6=Russell|last7=Mebazaa|first7=Alexandre|last8=Merli|first8=Geno|last9=Schellong|first9=Sebastian|last10=Spyropoulos|first10=Alex C.|last11=Tapson|first11=Victor|title=Rivaroxaban for Thromboprophylaxis in Acutely Ill Medical Patients|journal=New England Journal of Medicine|volume=368|issue=6|year=2013|pages=513–523|issn=0028-4793|doi=10.1056/NEJMoa1111096}}</ref><ref name="urlFDA approved betrixaban (BEVYXXA, Portola) for the prophylaxis of venous thromboembolism (VTE) in adult patients">{{cite web |url=https://www.fda.gov/drugs/informationondrugs/approveddrugs/ucm564422.htm |title=FDA approved betrixaban (BEVYXXA, Portola) for the prophylaxis of venous thromboembolism (VTE) in adult patients |format= |work= |accessdate=}}</ref><ref name="pmid20738765">{{cite journal |vauthors=Barbar S, Noventa F, Rossetto V, Ferrari A, Brandolin B, Perlati M, De Bon E, Tormene D, Pagnan A, Prandoni P |title=A risk assessment model for the identification of hospitalized medical patients at risk for venous thromboembolism: the Padua Prediction Score |journal=J. Thromb. Haemost. |volume=8 |issue=11 |pages=2450–7 |year=2010 |pmid=20738765 |doi=10.1111/j.1538-7836.2010.04044.x |url=}}</ref><ref name="pmid2503127">{{cite journal |vauthors=Steel K |title=Bathing problems in the over 70s |journal=BMJ |volume=298 |issue=6687 |pages=1578–9 |year=1989 |pmid=2503127 |pmc=1836788 |doi= |url=}}</ref><ref name="pmid21436241">{{cite journal| author=Spyropoulos AC, Anderson FA, FitzGerald G, Decousus H, Pini M, Chong BH et al.| title=Predictive and associative models to identify hospitalized medical patients at risk for VTE. | journal=Chest | year= 2011 | volume= 140 | issue= 3 | pages= 706-714 | pmid=21436241 | doi=10.1378/chest.10-1944 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21436241  }} </ref><ref name="urlDeep vein thrombosis assessment of probability of subsequent VTE and risk scores - wikidoc">{{cite web |url=http://www.wikidoc.org/index.php/Deep_vein_thrombosis_assessment_of_probability_of_subsequent_VTE_and_risk_scores |title=Deep vein thrombosis assessment of probability of subsequent VTE and risk scores - wikidoc |format= |work= |accessdate=}}</ref><ref name="urlVenous Thromboembolism Prophylaxis and Treatment in Patients With Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update: Journal of Clinical Oncology: Vol 31, No 17">{{cite web |url=http://ascopubs.org/doi/full/10.1200/jco.2013.49.1118 |title=Venous Thromboembolism Prophylaxis and Treatment in Patients With Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update: Journal of Clinical Oncology: Vol 31, No 17 |format= |work= |accessdate=}}</ref><ref name="urlAbstract 19875: IMPROVEDD Score: Addition of D-Dimer to the IMPROVE Score Improves Venous Thromboembolism Risk Stratification. An APEX Trial Substudy | Circulation">{{cite web |url=http://circ.ahajournals.org/content/134/Suppl_1/A19875 |title=Abstract 19875: IMPROVEDD Score: Addition of D-Dimer to the IMPROVE Score Improves Venous Thromboembolism Risk Stratification. An APEX Trial Substudy &#124; Circulation |format= |work= |accessdate=}}</ref>
<small>
{|
{|
! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" + |Patient population
! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" + |Patient population
! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" + |Sub-population
! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" + |Sub-population
! colspan="5" style="background:#4479BA; color: #FFFFFF;" align="center" + |Scoring criteria for risk assessment
! colspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" + |Scoring criteria for risk assessment
! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" + |Major predisposing risk factors and their score
! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" + |Major predisposing risk factors and their score
! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" + |Prophylaxis recommendations
! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" + |Prophylaxis recommendations
|-
|-
| style="background:#4479BA; color: #FFFFFF;" align="center" + |'''Padua score'''  
| style="background:#4479BA; color: #FFFFFF;" align="center" + |'''Padua score'''  
| style="background:#4479BA; color: #FFFFFF;" align="center" + |'''IMPROVE score'''
| style="background:#4479BA; color: #FFFFFF;" align="center" + |'''IMPROVE score'''  
| style="background:#4479BA; color: #FFFFFF;" align="center" + |'''IMPROVE bleeding risk score''' 
| style="background:#4479BA; color: #FFFFFF;" align="center" + |'''IMPROVE Associative score'''  
| style="background:#4479BA; color: #FFFFFF;" align="center" + |'''Caprini score'''
| style="background:#4479BA; color: #FFFFFF;" align="center" + |'''Caprini score'''
|-
|-
| rowspan="4" style="background:#DCDCDC;" align="center" + |Non-surgical patients
| rowspan="4" style="background:#DCDCDC;" align="center" + |Non-surgical patients
| rowspan="2" style="background:#DCDCDC;" align="center" + |Acutely ill  patients
| rowspan="2" style="background:#DCDCDC;" align="center" + |Acutely ill  patients
| rowspan="2" |✔
| rowspan="2" style="background:#F5F5F5;" align="center" + |✔
| rowspan="2" |✔
| rowspan="2" style="background:#F5F5F5;" align="center" + |✔
| rowspan="2" |✔
| rowspan="2" style="background:#F5F5F5;" align="center" + |<nowiki>-</nowiki>
| rowspan="2" |✔
| style="background:#F5F5F5;" + |'''IMPROVE:'''
| rowspan="2" |<nowiki>-</nowiki>
|'''IMPROVE:'''
* Active [[cancer]]: 3
* Active [[cancer]]: 3
* Previous VTE: 3
* Previous VTE: 3
* Decreased mobility: 3
* Decreased mobility: 3
* [[Thrombophilia]]: 3
* [[Thrombophilia]]: 3
Line 253: Line 389:
* Acute [[Rheumatologic disease|rheumatologic]] disorder and/or acute infection: 1
* Acute [[Rheumatologic disease|rheumatologic]] disorder and/or acute infection: 1
* [[Obesity]]: 1
* [[Obesity]]: 1
* [[Hormonal]] therapy
* [[Hormonal]] therapy
| rowspan="2" |
| rowspan="2" style="background:#F5F5F5;" + |
* Hospitalized medical patients:
* Hospitalized medical patients:
** Increased risk of [[thrombosis]]
** Increased risk of [[thrombosis]]
Line 272: Line 407:
*** Extending the duration of thromboprophylaxis beyond the period of patient immobilization or acute hospital stay is not recommended
*** Extending the duration of thromboprophylaxis beyond the period of patient immobilization or acute hospital stay is not recommended
|-
|-
|'''IMPROVE bleeding risk:'''
| style="background:#F5F5F5;" + |'''IMPROVE bleeding risk:'''
* Active [[gastric]] or [[duodenal]] ulcer: 4.5
* Active [[gastric]] or [[duodenal]] ulcer: 4.5
* Prior [[bleeding]] within the last 3 months: 4
* Prior [[bleeding]] within the last 3 months: 4
Line 288: Line 423:
|-
|-
| style="background:#DCDCDC;" align="center" + |Cancer in outpatient
| style="background:#DCDCDC;" align="center" + |Cancer in outpatient
|<nowiki>-</nowiki>
| style="background:#F5F5F5;" align="center" + |<nowiki>-</nowiki>
|<nowiki>-</nowiki>
| style="background:#F5F5F5;" align="center" + |<nowiki>-</nowiki>
|<nowiki>-</nowiki>
| style="background:#F5F5F5;" align="center" + |<nowiki>-</nowiki>
|<nowiki>-</nowiki>
| style="background:#F5F5F5;" + |
|<nowiki>-</nowiki>
|
* Does the patient have a solid tumor 
* Does the patient have a solid tumor 
AND 
AND 
* Additional risk factors for VTE?
* Additional risk factors for VTE?
* Previous VTE
* Previous VTE
* Hormonal therapy
* Hormonal therapy
Line 304: Line 436:
* Thalidomide
* Thalidomide
* Lenalidomide
* Lenalidomide
|
| style="background:#F5F5F5;" + |
* If major predisposing risk factors present:
* If major predisposing risk factors present:
** [[LMWH]]
** [[LMWH]]
Line 312: Line 444:
|-
|-
| style="background:#DCDCDC;" align="center" + |Long travel
| style="background:#DCDCDC;" align="center" + |Long travel
|
| style="background:#F5F5F5;" align="center" + | -
|
| style="background:#F5F5F5;" align="center" + | -
|
| style="background:#F5F5F5;" align="center" + | -
|
| style="background:#F5F5F5;" + |
|
|
* Prior VTE episode 
* Prior VTE episode 
* Recent [[trauma]] 
* Recent [[trauma]] 
Line 327: Line 457:
* [[Estrogen]] intake
* [[Estrogen]] intake
* [[Thrombophilia]]
* [[Thrombophilia]]
|
| style="background:#F5F5F5;" + |
* Frequent ambulation
* Frequent ambulation
* Calf [[muscle]] excercise
* Calf [[muscle]] excercise
Line 335: Line 465:
| rowspan="7" style="background:#DCDCDC;" align="center" + |Surgical patients
| rowspan="7" style="background:#DCDCDC;" align="center" + |Surgical patients
| style="background:#DCDCDC;" align="center" + |[[Orthopedic surgery|Orthopedic]] surgery patients
| style="background:#DCDCDC;" align="center" + |[[Orthopedic surgery|Orthopedic]] surgery patients
|<nowiki>-</nowiki>
| style="background:#F5F5F5;" align="center" + |<nowiki>-</nowiki>
|<nowiki>-</nowiki>
| style="background:#F5F5F5;" align="center" + |<nowiki>-</nowiki>
|<nowiki>-</nowiki>
| style="background:#F5F5F5;" align="center" + |<nowiki></nowiki>
|<nowiki>-</nowiki>
| style="background:#F5F5F5;" align="center" + |<nowiki>-</nowiki>
|<nowiki>-</nowiki>
| style="background:#F5F5F5;" + |
|<nowiki>-</nowiki>
|
* Total hip or knee [[arthroplasty]]:
* Total hip or knee [[arthroplasty]]:
** Pharmacological VTE [[prophylaxis]]
** Pharmacological VTE [[prophylaxis]]
Line 367: Line 495:
|-
|-
| style="background:#DCDCDC;" align="center" + |General and abdominal pelvic surgeries
| style="background:#DCDCDC;" align="center" + |General and abdominal pelvic surgeries
|<nowiki>-</nowiki>
| style="background:#F5F5F5;" align="center" + |<nowiki>-</nowiki>
|<nowiki>-</nowiki>
| style="background:#F5F5F5;" align="center" + |<nowiki>-</nowiki>
|<nowiki>-</nowiki>
| style="background:#F5F5F5;" align="center" + |✔
|<nowiki>-</nowiki>
| rowspan="6" style="background:#F5F5F5;" + |'''Caprini''':
|✔
| rowspan="6" |'''Caprini''':
* 5 points:
* 5 points:
** [[Stroke]] (in the previous month) 
** [[Stroke]] (in the previous month) 
Line 415: Line 541:
** Bed rest 
** Bed rest 
** [[Inflammatory bowel disease]]
** [[Inflammatory bowel disease]]
|
| style="background:#F5F5F5;" + |
* Low risk of VTE:
* Low risk of VTE:
** Early ambulation
** Early ambulation
Line 438: Line 564:
|-
|-
| style="background:#DCDCDC;" align="center" + |[[Cardiac]] surgery
| style="background:#DCDCDC;" align="center" + |[[Cardiac]] surgery
|<nowiki>-</nowiki>
| style="background:#F5F5F5;" align="center" + |<nowiki>-</nowiki>
|<nowiki>-</nowiki>
| style="background:#F5F5F5;" align="center" + |<nowiki>-</nowiki>
|<nowiki>-</nowiki>
| style="background:#F5F5F5;" align="center" + |✔
|<nowiki>-</nowiki>
| style="background:#F5F5F5;" + |
|✔
|
* Non-hemorrhagic post-op complications:
* Non-hemorrhagic post-op complications:
** [[LDUH]]   OR 
** [[LDUH]]   OR 
Line 452: Line 576:
|-
|-
| style="background:#DCDCDC;" align="center" + |Thoracic surgery
| style="background:#DCDCDC;" align="center" + |Thoracic surgery
|<nowiki>-</nowiki>
| style="background:#F5F5F5;" align="center" + |<nowiki>-</nowiki>
| -
| style="background:#F5F5F5;" align="center" + | -
| -
| style="background:#F5F5F5;" align="center" + |✔
|<nowiki>-</nowiki>
| style="background:#F5F5F5;" + |
|✔
|
* In case of [[pulmonary]] resection, [[pneumonectomy]], extrapleural [[pneumonectomy]], [[esophagectomy]]:
* In case of [[pulmonary]] resection, [[pneumonectomy]], extrapleural [[pneumonectomy]], [[esophagectomy]]:
** No bleeding risk:
** No bleeding risk:
Line 469: Line 591:
|-
|-
| style="background:#DCDCDC;" align="center" + |[[Craniotomy]]
| style="background:#DCDCDC;" align="center" + |[[Craniotomy]]
|<nowiki>-</nowiki>
| style="background:#F5F5F5;" align="center" + |<nowiki>-</nowiki>
|<nowiki>-</nowiki>
| style="background:#F5F5F5;" align="center" + |<nowiki>-</nowiki>
|<nowiki>-</nowiki>
| style="background:#F5F5F5;" align="center" + |✔
|<nowiki>-</nowiki>
| style="background:#F5F5F5;" + |
|✔
|
* In case of craniotomy for malignancy: (Very high risk for VTE)
* In case of craniotomy for malignancy: (Very high risk for VTE)
** Mechanical VTE [[prophylaxis]] ([[Intermittent pneumatic compression]] is preferred)  PLUS 
** Mechanical VTE [[prophylaxis]] ([[Intermittent pneumatic compression]] is preferred)  PLUS 
Line 482: Line 602:
|-
|-
| style="background:#DCDCDC;" align="center" + |Spinal surgery
| style="background:#DCDCDC;" align="center" + |Spinal surgery
|<nowiki>-</nowiki>
| style="background:#F5F5F5;" align="center" + |<nowiki>-</nowiki>
|<nowiki>-</nowiki>
| style="background:#F5F5F5;" align="center" + |<nowiki>-</nowiki>
|<nowiki>-</nowiki>
| style="background:#F5F5F5;" align="center" + |✔
|<nowiki>-</nowiki>
| style="background:#F5F5F5;" + |
|✔
|
* In case of spinal surgery for [[malignancy]] OR antero-posterior approach: (High risk for VTE)
* In case of spinal surgery for [[malignancy]] OR antero-posterior approach: (High risk for VTE)
** Mechanical VTE [[prophylaxis]] ([[intermittent pneumatic compression]] is preferred) PLUS 
** Mechanical VTE [[prophylaxis]] ([[intermittent pneumatic compression]] is preferred) PLUS 
Line 495: Line 613:
|-
|-
| style="background:#DCDCDC;" align="center" + |Trauma
| style="background:#DCDCDC;" align="center" + |Trauma
|<nowiki>-</nowiki>
| style="background:#F5F5F5;" align="center" + |<nowiki>-</nowiki>
|<nowiki>-</nowiki>
| style="background:#F5F5F5;" align="center" + |<nowiki>-</nowiki>
|<nowiki>-</nowiki>
| style="background:#F5F5F5;" align="center" + |✔
|<nowiki>-</nowiki>
| style="background:#F5F5F5;" + |
|✔
|
* No contraindiction to [[LDUH]] or [[Low molecular weight heparin|LMWH]]:
* No contraindiction to [[LDUH]] or [[Low molecular weight heparin|LMWH]]:
** [[LDUH]]   OR 
** [[LDUH]]   OR 
Line 510: Line 626:
|}<span style="font-size:85%"> '''Abbreviations:''' '''LDUH:''' low dose [[unfractionated heparin]]; '''LMWH:''' low molecular weight heparin; '''VTE:''' Venous thromboembolism </span>
|}<span style="font-size:85%"> '''Abbreviations:''' '''LDUH:''' low dose [[unfractionated heparin]]; '''LMWH:''' low molecular weight heparin; '''VTE:''' Venous thromboembolism </span>


<small>
==References==
{|
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Padua Score
! style="background:#4479BA; color: #FFFFFF;" align="center" + |IMPROVE score
! style="background:#4479BA; color: #FFFFFF;" align="center" + |IMPROVE bleeding risk score
! style="background:#4479BA; color: #FFFFFF;" align="center" + |IMPROVE Associative score
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Caprini score
|- style="background:#F5F5F5;" align="center" + |
|
(Score≥ 4: High risk for VTE
 
Score< 4: Low risk for VTE)
|
0 0.5%
1 1.0%


2 1.7%
3 3.1%
4 5.4%
5-8 11%
|
(Score ≥7: Elevated risk of bleeding
Score <7: Not elevated risk of bleeding)
|
(Score 0-1: Low risk for VTE
Score 2-3: Intermediate risk for VTE
Score 4-10: Hight risk for VTE)
|
(Score 0-1: Low risk of VTE
Score 2: Moderate of VTE
Score 3-4: High risk of VTE
Score ≥ 5: Highest risk for VTE)
|}
</small>
==References==
<references />
<references />

Latest revision as of 05:48, 10 February 2019

Venous thromboembolism Microchapters

Patient Information

Deep vein thrombosis
Pulmonary embolism

Overview

Classification

Epidemiology

Risk Factors

Diagnosis

Treatment

Deep Vein Thrombosis
Pulmonary Embolism

Prevention

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2]; Associate Editor(s)-in-Chief: Syed Hassan A. Kazmi BSc, MD [3], Iqra Qamar M.D.[4], Anmol Pitliya, M.B.B.S. M.D.[5], Aravind Reddy Kothagadi M.B.B.S[6]


To review the risk of VTE according to IMPROVEDD score, click here.

To review the risk of VTE according to IMPROVE score, click here.

To review the risk of VTE according to Caprini scores click here.

To predict the clinical risk of Pulmonary thromboembolism according to Wells score, click here.

Overiew

Venous thromboembolism (VTE) may be classified into deep vein thrombosis (DVT) and pulmonary embolism (PE). Pulmonary embolism may arise as a consequence of deep vein thrombosis as a result of embolization of the clot from deep veins of the legs. Pulmonary embolism (PE) is an acute obstruction of the pulmonary artery (or one of its branches). The obstruction in the pulmonary artery that causes a PE can be due to thrombus, air, tumor, or fat. Most often, pulmonary embolism is due to a venous thrombosis (blood clot from a vein), which has been dislodged from its site of formation in the lower extremities. It has then embolized to the arterial blood supply of one of the lungs. Deep vein thrombosis (also known as deep venous thrombosis or DVT and colloquially referred to as "economy class syndrome") is the formation of a blood clot ("thrombus") in a deep vein.

Classification

Venous thromboembolism (VTE) may be classified into:[1][2]

The following table further classifies DVT and PE:[3][4][5][6][5][7][8][9]

Classification of Venous Thromboembolism
Clinical diagnosis Sub-classification Comments
Deep vein thrombosis Upper extremity
Lower extremity
Pulmonary embolism (PE) Massive PE (High risk)

OR

OR

Sub-massive PE (Intermediate risk PE)

AND

Low risk PE

Epidemiology

Prevalence

  • The precise number of people affected by DVT/PE is unknown,although as many as 900,000 people could be affected (100 to 200 per 100,000) each year in the United States.[10]

Incidence

  • The incidence of VTE increases with age, ranging from less than 5 cases per 100,000 people in childhood to 500 cases per 100,000 people in the elderly.[11]
  • Those who are more than 65 years of age are at three times higher risk for VTE compared to those who are 45-54 years old.[12]
  • In the United States, the annual incidence of VTE is estimated to be approximately 100 per 100,000 persons.[11]

Age

  • The incidence of VTE increases with age, ranging from less than 5 cases per 100,000 people in childhood to 500 cases per 100,000 people in the elderly.[11]
  • Those who are more than 65 years of age are at three times higher risk for VTE compared to those who are 45-54 years old.[12]

Gender

  • Studies about differences in the incidence of VTE by gender have yielded mixed results:
  • In addition, the risk for DVT was reported to consistently increase with age across both genders.[12]

Race

Hospitalization for VTE

  • During 2007–2009, an estimated annual average of 547,596 hospitalizations culminated in a diagnosis of VTE for adults aged ≥18 years. Estimates for DVT and PE diagnoses were not mutually exclusive. An estimated annual average of 348,558 adult hospitalizations resulted in a diagnosis of DVT, and 277,549 adult hospitalizations resulted in a diagnosis of PE. An estimated annual average of 78,511 adult hospitalizations (14% of overall VTE hospitalizations) had diagnoses of both DVT and PE.[18]
  • The estimated average annual number of hospitalizations with VTE was successively greater among older age groups: 54,034 for persons aged 18–39 years; 143,354 for persons aged 40–59 years; and 350,208 for persons aged ≥60 years. The estimated average annual number of hospitalizations with VTE was comparable for men (250,973) and women (296,623).[18]
  • Shown below is an image depicting the estimated average annual number of hospitalization with a diagnosis of DVT, PE, or VTE by age and sex.
Estimated average annual number of hospitalizations with a diagnosis of deep thrombosis (DVT), pulmonary embolism (PE), or venous thromboembolism (VTE), by patient sex and age group — National Hospital Discharge Survey, United States, 2007–2009 - Source:CDC
  • The average annual rates of hospitalizations with a discharge diagnosis of DVT, PE, or VTE among adults were 152, 121, and 239 per 100,000 population, respectively. For VTE, the average annual rates were 60 per 100,000 population aged 18–39 years, 143 for persons aged 40–49 years, 200 for persons aged 50–59 years, 391 for persons aged 60–69 years, 727 for persons aged 70–79 years, and 1,134 for persons aged ≥80 years. The rates of hospitalization were similar for men and women, and the point estimates increased for both sexes by age.[18]
  • On average, 28,726 hospitalized adults with a VTE diagnosis died each year. Of these patients, an average of 13,164 had a DVT diagnosis and 19,297 had a PE diagnosis; 3,735 had both DVT and PE diagnoses.[18]

Recurrence of VTE

  • Approximately 33% (1 in 3) of people with VTE will have a recurrence within 10 years.[19][20]
  • The risk of recurrence of VTE in patients diagnosed with first-time VTE is estimated to be approximately 7-8% per year during an average follow up period of 2.2 years of subsequent observation.[12]
  • Among patients with a first episode of VTE, the risk of recurrence of VTE is particularly elevated in the first 6 to 12 months following the first episode of VTE. The risk of recurrent VTE remains up to 10 years, with a estimated cumulative incidence of first overall VTE recurrence of 30%. Predictors for recurrence of VTE include malignancy, neurological diseases, and paresis.[21]
  • The recent increase in thrombosis incidence may be related to improved diagnostic modalities and increased awareness by clinicians.[11]

Complications of VTE

  • Estimates suggest that 60,000-100,000 Americans die of VTE, 10 to 30% of which will die within one month of diagnosis.[19][20]

Risk Factors

Shown below is a list of predisposing factors for VTE. The risk factors are classified as moderate or weak depending on how strongly they are associated with a VTE.[22][23][24][25]

Moderate risk factors Weak risk factors
Chemotherapy
Obesity

Chronic heart failure
Respiratory failure
Hormone replacement therapy
Cancer
Oral contraceptive pills
Stroke
Pregnancy
Postpartum
❑ Prior history of VTE
Thrombophilia

Hospitalization

❑ Advanced age

Laparoscopic surgery
❑ Prepartum
Varicose veins

Risk factors of VTE may be categorized into modifiable, non-modifiable, temporary, and other risk factors.

Modifiable Risk Factors Non-Modifiable Risk Factors Temporary Risk Factors Other Risk Factors

❑ Modifiable risk factors are reversible based upon lifestyle/behavior modification.
Obesity is defined as a body-mass index (BMI) above 30 kg/m2.[26] [27] [28]
Smoking:[26] Smoking significantly increases the risk of DVT, particularly among women who are taking oral contraceptive pills as well as among obese people.
❑ Use of oral contraceptives[29]
Hyperhomocysteinemia:[30] Hyperhomocysteinemia can be reduced with vitamin B supplementation.

❑ Advanced age
Heart failure
Thrombophilia or hypercoagulable state
Polycythemia vera

Factor V Leiden
Prothrombin G20210A mutation
Protein C deficiency
Protein S deficiency
Activated protein C resistance
Antithrombin III deficiency
Factor VIII mutation
Antiphospholipid syndrome
Heparin induced thrombocytopenia
Nephrotic syndrome
Paroxysmal nocturnal hemoglobinuria

Pregnancy and the peri-partum period
❑ Active cancer
Central venous catheterization

❑ Other possible factors associated with VTE include:[31]

Nutrition low in fish
Psychological stress
❑ Cardiovascular risk factors such as diabetes and hypercholesterolemia

Diagnosis

The diagnostic guidelines for venous thromboembolism are as follows:[32][33][34][35]

Deep Vein Thrombosis

 
 
 
 
 
 
 
 
Suspected DVT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Clinical probability
likely
 
 
 
 
 
 
 
Clinical probability
unlikely
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ultrasound
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Normal
 
Abnormal
 
 
 
 
 
D-dimer
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
D-dimer
 
Treat
 
 
 
 
 
 
 
 
 
Positive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
Positive
 
 
 
 
Negative
 
 
 
Ultrasound
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stop
 
Repeat ultrasound in 1 week
 
 
 
 
Stop
 
Abnormal
 
Normal
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treat
 
Stop
 


Pulmonary Embolism

 
 
 
 
 
 
 
 
Suspected pulmonary embolism
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
D-dimer
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
 
 
 
 
 
 
 
 
 
 
Positive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stop
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CXR
 
 
 
 
 
 
Ultrasound
If signs of DVT present
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Normal
PE unlikely with positive D-dimer or PE likely
 
 
 
 
 
 
 
 
Abnormal
PE unlikely with positive D-dimer or PE likely
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
V/Q scan
 
 
 
 
 
 
 
CTPA
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Normal
 
Non diagnostic
 
High probability
 
PE present
 
PE absent
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stop
 
 
 
 
 
 
Treat
 
Treat
 
Stop
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
PE unlikely
 
 
 
PE likely
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Serial ultrasound
 
 
 
CTPA or serial ultrasound
 
 
 


Pulmonary embolism Wells Score Calculator

Variable Wells Score[36]
Clinically suspected DVT (leg swelling, pain with palpation) 3.0
Alternative diagnosis is less likely than PE 3.0
Immobilization/surgery in previous four weeks 1.5
Previous history of DVT or PE 1.5
Tachycardia (heart rate more than 100 bpm) 1.5
Malignancy (treatment for within 6 months, palliative) 1.0
Hemoptysis 1.0

Prevention

The following table summarizes major scoring criteria for risk assessment of VTE:[37][38][39][40]

Scoring criteria for risk assessment*
Type of patient Scoring system Score Risk
Non-surgical patient IMPROVEDD Score Predicted % VTE risk through 42 days
0 0.4%
1 0.6%
2 0.8%
3 1.2%
4 1.6%
5-10 2.2%
Predicted % VTE risk through 77 days
0 0.5%
1 0.7%
2 1.0%
3 1.4%
4 1.9%
5-10 2.75
IMPROVE score Predicted % VTE risk through 3 months
0 0.5%
1 1.0%
2 1.7%
3 3.1%
4 4%
5-8 11%
Padua Score < 4 Low risk for VTE
≥ 4 High risk for VTE
Surgical patient Caprini score 0-1 Low risk of VTE
2 Moderate of VTE
3-4 High risk of VTE
≥ 5 Highest risk for VTE

The following table summarizes the major scoring criteria used for risk assessment of VTE and their prophylaxis options:[41][42][43][44][45][39][46][38][47][48][49]

Patient population Sub-population Scoring criteria for risk assessment Major predisposing risk factors and their score Prophylaxis recommendations
Padua score IMPROVE score Caprini score
Non-surgical patients Acutely ill patients - IMPROVE:
IMPROVE bleeding risk:
Cancer in outpatient - - -
  •  Does the patient have a solid tumor 

AND 

  • Additional risk factors for VTE?
  • Previous VTE
  • Hormonal therapy
  • Immobilization
  • Angiogenesis inhibitors
  • Thalidomide
  • Lenalidomide
  • If major predisposing risk factors present:
  • If no major predisposing risk factors present:
    • No VTE prophylaxis
Long travel - - -
  • Frequent ambulation
  • Calf muscle excercise
  • Sitting in an isle seat
  • Below knee compression stockings (15-30 mm Hg pressure at ankle)
Surgical patients Orthopedic surgery patients - - -
General and abdominal pelvic surgeries - - Caprini:
Cardiac surgery - -
Thoracic surgery - -
Craniotomy - -
Spinal surgery - -
Trauma - -

Abbreviations: LDUH: low dose unfractionated heparin; LMWH: low molecular weight heparin; VTE: Venous thromboembolism

References

  1. Moheimani F, Jackson DE (2011). "Venous thromboembolism: classification, risk factors, diagnosis, and management". ISRN Hematol. 2011: 124610. doi:10.5402/2011/124610. PMC 3196154. PMID 22084692.
  2. Kasper, Dennis (2015). Harrison's principles of internal medicine. New York: McGraw Hill Education. ISBN 978-0071802154.
  3. Anand SS, Wells PS, Hunt D, Brill-Edwards P, Cook D, Ginsberg JS (1998). "Does this patient have deep vein thrombosis?". JAMA. 279 (14): 1094–9. PMID 9546569.
  4. Wells PS, Hirsh J, Anderson DR, Lensing AW, Foster G, Kearon C; et al. (1995). "Accuracy of clinical assessment of deep-vein thrombosis". Lancet. 345 (8961): 1326–30. PMID 7752753.
  5. 5.0 5.1 Cogo A, Lensing AW, Prandoni P, Hirsh J (1993). "Distribution of thrombosis in patients with symptomatic deep vein thrombosis. Implications for simplifying the diagnostic process with compression ultrasound". Arch Intern Med. 153 (24): 2777–80. PMID 8257253.
  6. Galanaud JP, Sevestre-Pietri MA, Bosson JL, Laroche JP, Righini M, Brisot D; et al. (2009). "Comparative study on risk factors and early outcome of symptomatic distal versus proximal deep vein thrombosis: results from the OPTIMEV study". Thromb Haemost. 102 (3): 493–500. doi:10.1160/TH09-01-0053. PMID 19718469.
  7. Joffe HV, Kucher N, Tapson VF, Goldhaber SZ, Deep Vein Thrombosis (DVT) FREE Steering Committee (2004). "Upper-extremity deep vein thrombosis: a prospective registry of 592 patients". Circulation. 110 (12): 1605–11. doi:10.1161/01.CIR.0000142289.94369.D7. PMID 15353493.
  8. Isma N, Svensson PJ, Gottsäter A, Lindblad B (2010). "Upper extremity deep venous thrombosis in the population-based Malmö thrombophilia study (MATS). Epidemiology, risk factors, recurrence risk, and mortality". Thromb Res. 125 (6): e335–8. doi:10.1016/j.thromres.2010.03.005. PMID 20406709.
  9. Muñoz FJ, Mismetti P, Poggio R, Valle R, Barrón M, Guil M; et al. (2008). "Clinical outcome of patients with upper-extremity deep vein thrombosis: results from the RIETE Registry". Chest. 133 (1): 143–8. doi:10.1378/chest.07-1432. PMID 17925416.
  10. "Data and Statistics | DVT/PE | NCBDDD | CDC".
  11. 11.0 11.1 11.2 11.3 11.4 11.5 White RH (2003). "The epidemiology of venous thromboembolism". Circulation. 107 (23 Suppl 1): I4–8. doi:10.1161/01.CIR.0000078468.11849.66. PMID 12814979.
  12. 12.0 12.1 12.2 12.3 12.4 Cushman M, Tsai AW, White RH, Heckbert SR, Rosamond WD, Enright P; et al. (2004). "Deep vein thrombosis and pulmonary embolism in two cohorts: the longitudinal investigation of thromboembolism etiology". Am J Med. 117 (1): 19–25. doi:10.1016/j.amjmed.2004.01.018. PMID 15210384.
  13. Silverstein MD, Heit JA, Mohr DN, Petterson TM, O'Fallon WM, Melton LJ (1998). "Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based study". Arch Intern Med. 158 (6): 585–93. PMID 9521222.
  14. Kniffin WD, Baron JA, Barrett J, Birkmeyer JD, Anderson FA (1994). "The epidemiology of diagnosed pulmonary embolism and deep venous thrombosis in the elderly". Arch Intern Med. 154 (8): 861–6. PMID 8154949.
  15. "Venous Thromboembolism in Adult Hospitalizations — United States, 2007–2009". Retrieved 2012-10-06.
  16. Ridker PM, Miletich JP, Hennekens CH, Buring JE (1997). "Ethnic distribution of factor V Leiden in 4047 men and women. Implications for venous thromboembolism screening". JAMA. 277 (16): 1305–7. PMID 9109469.
  17. Gregg JP, Yamane AJ, Grody WW (1997). "Prevalence of the factor V-Leiden mutation in four distinct American ethnic populations". Am J Med Genet. 73 (3): 334–6. PMID 9415695.
  18. 18.0 18.1 18.2 18.3 [1] Hussain R. Yusuf, MD, James Tsai, MD, Hani K. Atrash, MD, Sheree Boulet, DrPH, Scott D. Grosse, PhD, Div of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, CDC. Venous Thromboembolism in Adult Hospitalizations — United States, 2007–2009
  19. 19.0 19.1 19.2 Beckman MG, Hooper WC, Critchley SE, Ortel TL (2010). "Venous thromboembolism: a public health concern". Am J Prev Med. 38 (4 Suppl): S495–501. doi:10.1016/j.amepre.2009.12.017. PMID 20331949.
  20. 20.0 20.1 20.2 CDC- Deep Vein Thrombosis (DVT) / Pulmonary Embolism (PE) — Blood Clot Forming in a Vein
  21. Heit JA, Mohr DN, Silverstein MD, Petterson TM, O'Fallon WM, Melton LJ (2000). "Predictors of recurrence after deep vein thrombosis and pulmonary embolism: a population-based cohort study". Arch Intern Med. 160 (6): 761–8. PMID 10737275.
  22. Massicotte MP, Dix D, Monagle P, Adams M, Andrew M (1998). "Central venous catheter related thrombosis in children: analysis of the Canadian Registry of Venous Thromboembolic Complications". J. Pediatr. 133 (6): 770–6. PMID 9842042.
  23. Worly JM, Fortenberry JD, Hansen I, Chambliss CR, Stockwell J (2004). "Deep venous thrombosis in children with diabetic ketoacidosis and femoral central venous catheters". Pediatrics. 113 (1 Pt 1): e57–60. PMID 14702496.
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