American Society of Hematology 2018 guidelines for management of venous thromboembolism: diagnosis of venous thromboembolism

Abstract

Background: Modern diagnostic strategies for venous thromboembolism (VTE) incorporate pretest probability (PTP; prevalence) assessment. The ability of diagnostic tests to correctly identify or exclude VTE is influenced by VTE prevalence and test accuracy characteristics.

Objective: 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.

Methods: The American Society of Hematology (ASH) formed a multidisciplinary panel including patient representatives. The McMaster University GRADE Centre completed systematic reviews up to 1 October 2017. The panel prioritized questions and outcomes and used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess evidence and make recommendations. Test accuracy estimates and VTE population prevalence were used to model expected outcomes in diagnostic pathways. Where modeling was not feasible, management and accuracy studies were used to formulate recommendations.

Results: Ten recommendations are presented, by PTP for patients with suspected PE and lower extremity DVT, and for recurrent VTE and upper extremity DVT.

Conclusions: For patients at low (unlikely) VTE risk, using D-dimer as the initial test reduces the need for diagnostic imaging. For patients at high (likely) VTE risk, imaging is warranted. For PE diagnosis, ventilation-perfusion scanning and computed tomography pulmonary angiography are the most validated tests, whereas lower or upper extremity DVT diagnosis uses ultrasonography. Research is needed on new diagnostic modalities and to validate clinical decision rules for patients with suspected recurrent VTE.

Conflict of interest statement

Conflict-of-interest disclosure: All authors were members of the guideline panel or members of the systematic review team or both. As such, they completed a disclosure of interest form, which was reviewed by ASH and is available as supplements 2 and 3.

© 2018 by The American Society of Hematology.

Figures

Figure 1.

Flowchart for recommendations 1a and b (diagnosis of PE for patients with low PTP/prevalence [≤5%]). *Hemodynamically stable, nonpregnant patient. **See other algorithms. ***Highly sensitive D-dimer. ****If feasible. CDR, clinical decision rule; US, ultrasound.

Figure 2.

Flowchart for recommendations 2a and b (diagnosis of PE for patients with intermediate PTP/prevalence [∼20%]). *Hemodynamically stable, nonpregnant patient. **See other algorithms. ***Highly sensitive D-dimer. ****If feasible.

Figure 3.

Flowchart for recommendations 3a and b (diagnosis of PE for patients with high PTP/prevalence [≥50%]). *Hemodynamically stable, nonpregnant patient. **See other algorithms. ***In selected situations, negative CTPA may be sufficient to rule out PE. ****Serial proximal US if clinical PTP >50%.

Figure 4.

Flowchart for recommendation 4 (diagnosis of recurrent PE). *Hemodynamically stable, nonpregnant patient. **Highly sensitive D-dimer.

Figure 5.

Flowchart for recommendations 5a and b (diagnosis of DVT for patients with low PTP/prevalence [≤10%]). *Hemodynamically stable, nonpregnant patient. **See other algorithms. ***Highly sensitive D-dimer. LE DVT, lower extremity deep vein thrombosis.

Figure 6.

Flowchart for recommendations 6a and b (diagnosis of DVT for patients with intermediate PTP/prevalence [∼25%]). *Hemodynamically stable, nonpregnant patient. **See other algorithms. ***Highly sensitive D-dimer.

Figure 7.

Flowchart for recommendations 7a and b (diagnosis of DVT for patients with high PTP/prevalence [≥50%]). *Hemodynamically stable, nonpregnant patient. **See other algorithms.

Figure 8.

Flowchart for recommendation 8 (diagnosis of recurrent lower extremity DVT). *Hemodynamically stable, nonpregnant patient. **Highly sensitive D-dimer.

Figure 9.

Flowchart for recommendations 9a and b (diagnosis of upper extremity DVT for patients with unlikely PTP/low prevalence [10%]). *Hemodynamically stable, nonpregnant patient. **See other algorithms. ***Highly sensitive D-dimer. UE DVT, upper extremity deep vein thrombosis.

Figure 10.

Flowchart for recommendations 10a and b (diagnosis of upper extremity DVT for patients with likely PTP/high prevalence [40%]). *Hemodynamically stable, nonpregnant patient. **See other algorithms. ***Highly sensitive D-dimer.