Acute Venous Thromboembolic Disease

Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Suspected Acute Venous Thromboembolic Disease

  • Scope of Application. This guideline is intended for physicians working in emergency departments (EDs).
  • Inclusion Criteria. This guideline is intended for adult patients presenting to the ED with suspected or known acute venous thromboembolism (ie, PE or DVT).
  • Exclusion Criteria. This guideline is not intended to address the care of pediatric patients, or those with venous thromboembolism in the setting of cardiac arrest or pregnancy.

Critical Questions

  • In adult patients with suspected acute pulmonary embolism (PE), can a clinical prediction rule be used to identify a group of patients at very low risk for the diagnosis of PE for whom no additional diagnostic workup is required?

    Recommendations
    Level A Recommendations

    None specified.

    Level B Recommendations

    For patients who are at low risk for acute PE, use the Pulmonary Embolism Rule-out Criteria (PERC) to exclude the diagnosis without further diagnostic testing.

    Level C Recommendations

    None specified.

    Level A Recommendations

    None specified.

    Level B Recommendations

    For patients who are at low risk for acute PE, use the Pulmonary Embolism Rule-out Criteria (PERC) to exclude the diagnosis without further diagnostic testing.

    Level C Recommendations

    None specified.

  • In adult patients with low to intermediate pretest probability for acute pulmonary embolism (PE), does a negative age-adjusted D-dimer result identify a group of patients at very low risk for the diagnosis of PE for whom no additional diagnostic workup is required?

    Recommendations
    Level A Recommendations

    None specified.

    Level B Recommendations

    In patients older than 50 years deemed to be low or intermediate risk for acute PE, clinicians may use a negative age-adjusted D-dimer* result to exclude the diagnosis of PE. *For highly sensitive D-dimer assays using fibrin equivalent units (FEU) use a cutoff of age×10 μg/L; for highly sensitive D-dimer assays using D-dimer units (DDU), use a cutoff of age×5 μg/L.

    Level C Recommendations

    None specified.

    Level A Recommendations

    None specified.

    Level B Recommendations

    In patients older than 50 years deemed to be low or intermediate risk for acute PE, clinicians may use a negative age-adjusted D-dimer* result to exclude the diagnosis of PE. *For highly sensitive D-dimer assays using fibrin equivalent units (FEU) use a cutoff of age×10 μg/L; for highly sensitive D-dimer assays using D-dimer units (DDU), use a cutoff of age×5 μg/L.

    Level C Recommendations

    None specified.

  • In adult patients with subsegmental pulmonary embolism (PE), is it safe to withhold anticoagulation?

    Recommendations
    Level A Recommendations

    None specified.

    Level B Recommendations

    None specified.

    Level C Recommendations

    Given the lack of evidence, anticoagulation treatment decisions for patients with subsegmental PE without associated deep venous thrombosis (DVT) should be guided by individual patient risk profiles and preferences. [Consensus recommendation]

    Level A Recommendations

    None specified.

    Level B Recommendations

    None specified.

    Level C Recommendations

    Given the lack of evidence, anticoagulation treatment decisions for patients with subsegmental PE without associated deep venous thrombosis (DVT) should be guided by individual patient risk profiles and preferences. [Consensus recommendation]

  • In adult patients diagnosed with acute pulmonary embolism (PE), is initiation of anticoagulation and discharge from the emergency department (ED) safe?

    Recommendations
    Level A Recommendations

    None specified.

    Level B Recommendations

    None specified.

    Level C Recommendations

    Selected patients with acute PE who are at low risk for adverse outcomes as determined by Pulmonary Embolism Severity Index (PESI), simplified PESI (sPESI), or the Hestia criteria may be safely discharged from the ED on anticoagulation, with close outpatient follow-up.

    Level A Recommendations

    None specified.

    Level B Recommendations

    None specified.

    Level C Recommendations

    Selected patients with acute PE who are at low risk for adverse outcomes as determined by Pulmonary Embolism Severity Index (PESI), simplified PESI (sPESI), or the Hestia criteria may be safely discharged from the ED on anticoagulation, with close outpatient follow-up.

  • In adult patients diagnosed with acute lower-extremity deep venous thrombosis (DVT) who are discharged from the emergency department (ED), is treatment with a Non–Vitamin K Antagonist Oral Anticoagulant (NOAC) safe and effective compared with treatment with low-molecular-weight heparin (LMWH) and vitamin K antagonist (VKA)?

    Recommendations
    Level A Recommendations

    None specified.

    Level B Recommendations

    In selected patients diagnosed with acute DVT, a NOAC may be used as a safe and effective treatment alternative to LMWH/VKA.

    Level C Recommendations

    Selected patients with acute DVT may be safely treated with a NOAC and directly discharged from the ED.

    Level A Recommendations

    None specified.

    Level B Recommendations

    In selected patients diagnosed with acute DVT, a NOAC may be used as a safe and effective treatment alternative to LMWH/VKA.

    Level C Recommendations

    Selected patients with acute DVT may be safely treated with a NOAC and directly discharged from the ED.

Findings and Strength of Recommendations

Clinical findings and strength of recommendations regarding patient management were made according to the following criteria:
Level A recommendations
Generally accepted principles for patient care that reflect a high degree of clinical certainty (eg, based on evidence from 1 or more Class of Evidence I or multiple Class of Evidence II studies).
Level B recommendations
Recommendations for patient care that may identify a particular strategy or range of strategies that reflect moderate clinical certainty (eg, based on evidence from 1 or more Class of Evidence II studies or strong consensus of Class of Evidence III studies).
Level C recommendations
Recommendations for patient care that are based on evidence from Class of Evidence III studies or, in the absence of adequate published literature, based on expert consensus. In instances in which consensus recommendations are made, “consensus” is placed in parentheses at the end of the recommendation.
There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. Factors such as heterogeneity of results, uncertainty about effect magnitude, and publication bias, among others, might lead to a downgrading of recommendations.
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