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Information ⬇

Author(s): Charlotte Masterton-Smith and Kevin O'Kane

Consider the diagnosis in any patient presenting with new-onset leg pain or swelling, especially if it is unilateral and if there are risk factors for venous thrombosis (Table 56.1). The assessment and management of suspected deep vein thrombosis is summarized in Figure 56.1.

Priorities ⬆ ⬇

Outline

Assess the probability of deep vein thrombosis (DVT), using clinical judgement combined with the Wells score (Table 56.2).

If the Clinical Probability of DVT is Low!!navigator!!

Check plasma D-dimer.

  • If plasma D-dimer is negative, DVT is effectively excluded. Pursue other diagnoses (Table 56.3).
  • If plasma D-dimer is positive, request a duplex scan of proximal leg veins (to be performed within four hours; if this is not possible, give an interim 24-h treatment dose of low-molecular-weight heparin, pending the result of the scan).

If the Clinical Probability of DVT is Intermediate or High!!navigator!!

Request a duplex scan of proximal leg veins (to be performed within four hours; if this is not possible, give an interim 24-h treatment dose of low-molecular-weight heparin, pending the result of the scan).

  • If the scan is positive for DVT, start anticoagulation.
  • If the scan is negative for DVT, check plasma D-dimer. Pursue other diagnoses (Table 56.3). Repeat the duplex scan 6–8 days later in patients with a positive D-dimer test to confirm no DVT.

Further Management ⬆ ⬇

Outline

Anticoagulation!!navigator!!

Anticoagulation is discussed in detail in Chapter 103. Anticoagulation for deep vein thrombosis can be with rivaroxaban, low-molecular-weight heparin or warfarin (preceded by and overlapping with heparin).

Rivaroxaban

Start rivaroxaban 15 mg twice daily PO, unless contraindicated or if creatinine clearance is <15 mL/min. Continue rivaroxaban for 21 days then change to 20 mg daily.

Rivaroxaban is contraindicated in pregnancy, breastfeeding, renal failure, significant liver disease, concomitant use of cytochrome P-450 inhibitors, and is not currently recommended in patients with active cancer.

Low-molecular-weight heparin

Low-molecular-weight heparin (LMWH) is indicated in patients with active cancer (particularly if undergoing chemotherapy) or who are pregnant.

Warfarin

Warfarin should be used if rivaroxaban is contraindicated and in the absence of active cancer or pregnancy.

  • Warfarin loading is given in Table 103.11.
  • It is initially pro-thrombotic, so is co-administered with LMWH or unfractionated heparin. During this period, check both the activated partial thromboplastin time (APTT) and International Normalized Ratio (INR) daily.
  • Heparin can be stopped after five days provided the INR is >2.0.
  • The target INR is usually 2.0–3.0.

Duration of anticoagulation

The duration and dosing of treatment will be monitored by the anticoagulation clinic, which should follow up all patients with a new diagnosis of DVT within a week of diagnosis.

Supportive Care!!navigator!!

For patients with extensive DVT, bed rest with elevation of the leg for 24–48h or until swelling is resolving.

Why Has the Patient Had a DVT?!!navigator!!

Consider the presence of risk factors (Table 56.1). In many patients, the cause of DVT is obvious. Further tests for patients with unprovoked DVT are given in Table 56.4. Patients aged under 50 with unprovoked DVT or with a strong family history of venous thromboembolism should be screened for a thrombophilic disorder: seek advice from a haematologist.

Further Reading ⬆

Di Nisio M, vanEs N, Büller HR. (2016) Deep vein thrombosis and pulmonary embolism. Lancet .

Kearon C, Akl EA, Ornelas J, et al. (2016) Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest 149, 315–352.

National Institute for Health and Care Excellence (2015) Venous thromboembolic diseases: diagnosis, management and thrombophilia testing Clinical guideline (CG144). https://www.nice.org.uk/guidance/cg144