Venous Thromboembolism (DVT and PE)
NICE guideline [NG158] Venous thromboembolic diseases: diagnosis, management and thrombophilia testing. Last updated: Aug 2023.
Deep Vein Thrombosis (DVT) Guidelines
If DVT is suspected, calculate the two-level DVT Wells score
Interpretation:
| Clinical feature | Points |
|---|---|
| Active cancer (or within 6 months) | 1 |
| Lower limb immobilisation (recent plaster use, paralysis, paresis) | 1 |
| Recently bedridden for ≥3 days or major surgery within 12 weeks requiring general or regional anaesthesia | 1 |
| Localised tenderness along the distribution of deep venous system | 1 |
| Entire leg swollen | 1 |
| Calf swelling >3 cm larger than the other leg | 1 |
| Pitting oedema confined to the affected leg | 1 |
| Collateral superficial veins (non-varicose) | 1 |
| Previously documented DVT | 1 |
| An alternative diagnosis is at least as likely as DVT | -2 |
Interpretation:
- Score 2 or more: DVT likely
- Score 1 or less: DVT unlikely
Perform a proximal leg vein ultrasound (with results available within 4 hours)
If the ultrasound cannot be done within 4 hours, perform the following:
- Perform D-dimer test, and
- Offer interim therapeutic anticoagulation, and
- Ensure ultrasound is done within 24 hours
Diagnose DVT and start treatment
Perform D-dimer test
- -ve D-dimer → DVT unlikely, consider alternative diagnosis (stop any interim anticoagulation)
- +ve D-dimer → repeat proximal leg vein ultrasound 6-8 days later
- Abnormal ultrasound → start treatment
- Normal ultrasound → consider alternative diagnosis
Perform D-dimer test (with results available within 4 hours):
- -ve D-dimer → DVT unlikely, consider alternative diagnosis (stop any interim anticoagulation)
- +ve D-dimer → perform a proximal leg vein ultrasound (with results available within 4 hours)
- If ultrasound not possible → offer interim therapeutic anticoagulation and ensure ultrasound is done within 24 hours
If D-dimer cannot be done within 4 hours → offer interim therapeutic anticoagulation while waiting
This section is identical for DVT and PE
The drug class of choice to treat DVT and PE are anticoagulants.
The drug class of choice to treat DVT and PE are anticoagulants.
1st line:
2nd line:
- Apixaban or rivaroxaban
2nd line:
- Warfarin with , or
- Dabigatran or edoxaban with
| Patient population | Recommended drug |
|---|---|
| Renal failure (creatinine clearance <15 mL/min) | Avoid Direct oral anticoagulant, use:
|
| Active cancer |
|
| Pregnancy | DOAC and warfarin are contraindicated, use:
|
| Anticoagulation contraindicated | Consider inferior vena cava filter |
| Antiphospholipid syndrome (triple positive) | Warfarin with LMWH lead in |
- Provoked: 3 months
- Unprovoked: 6 months
- Concurrent cancer: 3-6 months
Pulmonary Embolism (PE) Guidelines
If PE is suspected, calculate the two-level PE Wells score
Interpretation:
| Clinical feature | Points |
|---|---|
| Clinical features of DVT (minimum of leg swelling and pain with palpation of the deep veins) | 3 |
| An alternative diagnosis is less likely than PE | 3 |
| Heart rate >100 bpm | 1.5 |
| Immobilisation for >3 days or surgery in the previous 4 weeks | 1.5 |
| Previous DVT / PE | 1.5 |
| Haemoptysis | 1 |
| Active cancer (or within 6 months) | 1 |
Interpretation:
- Score 5 or more: PE likely
- Score 4 or less: PE unlikely
Perform a CT pulmonary angiogram (CTPA) immediately
- Abnormal CTPA → diagnose PE and start treatment
- Normal CTPA
- If DVT is suspected → consider a proximal leg vein ultrasound scan
- If DVT is not suspected → PE unlikely, consider alternative diagnosis (stop any interim anticoagulation)
If CTPA is not appropriate (allergic to contrast / severe renal impairment - creatinine clearance <30 mL/min / high risk from irradiation)
- Consider V/Q SPECT or planar scan as an alternative
If CTPA / V/Q scan cannot be done immediately → offer interim therapeutic anticoagulation while awaiting CTPA
Perform D-dimer test (with results available within 4 hours):
- -ve D-dimer → PE unlikely, consider alternative diagnosis (stop any interim anticoagulation)
- +ve D-dimer → perform CTPA (or V/Q scan) immediately (i.e. follow the above PE likely algorithm)
If D-dimer cannot be done within 4 hours → offer interim therapeutic anticoagulation while waiting
Offer:
- Continuous UFH infusion, and
- Consider thrombolytic therapy (e.g. alteplase)
This section is identical for DVT and PE
The drug class of choice to treat DVT and PE are anticoagulants.
The drug class of choice to treat DVT and PE are anticoagulants.
1st line:
2nd line:
- Apixaban or rivaroxaban
2nd line:
- Warfarin with , or
- Dabigatran or edoxaban with
| Patient population | Recommended drug |
|---|---|
| Renal failure (creatinine clearance <15 mL/min) | Avoid Direct oral anticoagulant, use:
|
| Active cancer |
|
| Pregnancy | DOAC and warfarin are contraindicated, use:
|
| Anticoagulation contraindicated, or PE happened while on anticoagulation | Consider inferior vena cava filter |
| Antiphospholipid syndrome (triple positive) | Warfarin with LMWH lead in |
- Provoked: 3 months
- Unprovoked: 6 months
- Concurrent cancer: 3-6 months
