Deep Vein thrombosis

Question 1

How does a DVT classically present?

Answer 1

• Red swollen calf
• Tenderness/pain over calf
• Pitting oedema confined to symptomatic leg
• Entire swollen leg

Question 2

What scoring system is used for DVT risk?

Answer 2

Two level DVT wells score

Question 3

What do patients score for on the DVT well score?

Answer 3

• Active cancer
• Paralysis/paresis/recent plaster immobilisation of lower leg
• Recently bedridden for 3 days/major surgery within 12 weeks
• Localised tenderness of deep veins
• Entire leg swollen
• Calf swelling at least 3cm larger than asymptomatic side
• Pitting oedema confined to symptomatic leg
• Collateral superficial veins
• Previously documented DVT

Question 4

What score is needed to make a DVT likely?

Answer 4

2 points or more

Question 5

What score makes DVT unlikely?

Answer 5

1 point o less

Question 6

If a DVT is likely what needs to be done?

Answer 6

1. a proximal leg vein ultrasound scan should be carried out within 4 hours
   
   • if the result is positive then a diagnosis of DVT is made and anticoagulant treatment should start
   • if the result is negative a D-dimer test should be arranged. A negative scan and negative D-dimer makes the diagnosis unlikely and alternative diagnoses should be considered
2. if a proximal leg vein ultrasound scan cannot be carried out within 4 hours a D-dimer test should be performed and interim therapeutic anticoagulation administered whilst waiting for the proximal leg vein ultrasound scan (which should be performed within 24 hours)
   
   • interim therapeutic anticoagulation used to mean giving low-molecular weight heparin update now give a DOAC such as apixaban or rivaroxaban
3. if the scan is negative but the D-dimer is positive:
   
   • stop interim therapeutic anticoagulation
   • offer a repeat proximal leg vein ultrasound scan 6 to 8 days later

Question 7

If a DVT is unlikely from the wells score what needs to be done?

Answer 7

Perform a D-Dimer

• Done within 4hours
• if not offer interim theraeutic anticoagulation
• If negative then unlikely
• if positive do USS in 4 hours

Question 8

What is the management of a DVT?

Answer 8

• Apixaban or rivaroxaban (DOACs) offered first line (instead of LMWH)
• If not suitable offer LMWH followed by dabigatran or edoxaban or LMWG folowed with warfarin
• All patient anticoagulated for at least 3 months
• Continuing anticoagulation considers whether VTE provoke or unprovoked
• Unprovoked VTE treatment continue for up to 6 months
• Consider testing for antiphospholipid antibdies if unprovoked DVT or PE