Deep vein thrombosis

Question 1

What did NICE update in 2020 regarding venous thromboembolism (VTE)?

Answer 1

NICE updated guidelines on the investigation and management of VTE, recommending direct oral anticoagulants (DOACs) as first-line treatment for most people with VTE.

Question 2

What is the recommended treatment for patients with active cancer and VTE according to the 2020 guidelines?

Answer 2

DOACs are recommended for patients with active cancer, replacing the previous recommendation of low-molecular weight heparin (LMWH).

Question 3

Is routine cancer screening recommended after a VTE diagnosis?

Answer 3

No, routine cancer screening is no longer recommended following a VTE diagnosis.

Question 4

What should be performed if a DVT is suspected?

Answer 4

A two-level DVT Wells score should be performed.

Question 5

What is the score for active cancer in the two-level DVT Wells score?

Answer 5

Active cancer (treatment ongoing, within 6 months, or palliative) scores 1 point.

Question 6

What does a score of 2 points or more indicate in the DVT Wells score?

Answer 6

DVT is likely.

Question 7

What should be done if DVT is likely?

Answer 7

A proximal leg vein ultrasound scan should be carried out within 4 hours.

Question 8

What is the next step if the ultrasound scan for DVT is positive?

Answer 8

A diagnosis of DVT is made and anticoagulant treatment should start.

Question 9

What should be done if the ultrasound scan is negative but the D-dimer is positive?

Answer 9

Stop interim therapeutic anticoagulation and offer a repeat proximal leg vein ultrasound scan 6 to 8 days later.

Question 10

What should be done if DVT is unlikely (1 point or less)?

Answer 10

Perform a D-dimer test within 4 hours.

Question 11

What type of D-dimer tests does NICE recommend?

Answer 11

NICE recommends either a point-of-care (finger prick) or laboratory-based test.

Question 12

What is the cornerstone of VTE management?

Answer 12

The cornerstone of VTE management is anticoagulant therapy.

Question 13

What anticoagulants are recommended as first-line treatment after a DVT diagnosis?

Answer 13

Apixaban or rivaroxaban (both DOACs) should be offered first-line.

Question 14

What should be done if neither apixaban nor rivaroxaban are suitable?

Answer 14

Use LMWH followed by dabigatran or edoxaban, or LMWH followed by a vitamin K antagonist (VKA, i.e. warfarin).

Question 15

What is the recommended length of anticoagulation for all patients?

Answer 15

All patients should have anticoagulation for at least 3 months.

Question 16

How is the continuation of anticoagulation determined?

Answer 16

It is determined by whether the VTE was provoked or unprovoked.

Question 17

What is the typical treatment duration for a provoked VTE?

Answer 17

Typically stopped after the initial 3 months (3 to 6 months for people with active cancer).

Question 18

What is the typical treatment duration for an unprovoked VTE?

Answer 18

Treatment is typically continued for up to 3 further months (i.e. 6 months in total).

Question 19

What tool can be used to assess the risk of bleeding?

Answer 19

The ORBIT score can be used to help assess the risk of bleeding.

Question 20

What does NICE state regarding continuing anticoagulation for patients with unprovoked DVT or PE?

Answer 20

Explain that the benefits of continuing anticoagulation treatment are likely to outweigh the risks.

Question 21

What are the features of deep vein thrombosis?

Answer 21

Lower limb pain (often calf pain) and tenderness along the line of the deep veins.

This includes swelling, erythema, pitting oedema, and distension of superficial veins.

Question 22

What type of pain is commonly associated with deep vein thrombosis?

Answer 22

Calf pain and tenderness along the line of the deep veins.

Question 23

What are the signs of swelling in deep vein thrombosis?

Answer 23

Swelling, erythema, pitting oedema, and distension of superficial veins.

Question 24

Answer 24

flow chart for investigating 2-level Wells test

Question 25

2-level Wells test criteria and points

Answer 25