1. Confirmed VTE Treatment Pathway
(excludes VTE in pregnancy – see obstetric guidelines)
Pulmonary Embolism
Deep Vein Thrombosis
High risk: systolic BP <90mmHg, syncope.
Intermediate/high risk: RV strain & +ve trop and deteriorating.
Intermediate/low risk: admit.
Low risk: sPESI=0: ?ambulatory Rx.
Poplitealor Femoral DVT
Iliac DVT
Below knee (calf) DVT
Thrombolysis candidate? No
Yes
Dalteparin s/c stat, then every 24 hours, as per body weight.
If CKD GFR <30mL/min: IV heparin infusion, instead of LMWH.
Consider for directed thrombolysis: if appropriate = liaise with RSCH vascular surgeons.
HASBLED score and assess risk vs benefit of Rx. If Rxing: DOAC x 6/52. If not Rxing: rpt leg uss in 1/52.
Stat dose IV Heparin* 5000 units while confirming diagnosis with stat CTPA or Echo.
VTE Risk Factors
Peri-arrest: 50mg tPA bolus, followed by a further 50mg after 15 mins if in cardiac arrest, continue CPR for 60 mins. If have ROSC, give 50mg infusion over 2 hrs instead of 2nd bolus dose.
Not peri-arrest: 10mg tPA bolus, followed by 90mg infusion over 2 hrs.
Surgically provoked.
<3% risk of recurrence.
Cancer related.
15% risk of recurrence.
Other transient provoking factor.
3-9% risk of recurrence.
Unprovoked or previous VTE. >9% risk of recurrence.
Consider DOAC*** for 3/12 (stop LMWH), unless PE with RV strain = 6/12.
Continue LMWH for minimum 6/12**, then continue an anticoagulant for as long as cancer considered active.
Consider DOAC*** for 6/12 (stop LMWH).
Advise life-long anticoagulation (minimum 6/12).
If warfarin loading, continue LMWH (minimum 5/7) till INR >2.0 for 24 hrs.
Commence IV heparin* infusion for 24 hrs once APTT <2.0 (check 3 hrs post end of tPA). Change to Dalteparin after 24 hrs if not bleeding.
*** DOAC C/Ix (see BNF) e.g. breast feeding, GFR <15mL/min.
* no IV heparin if already had full dose LMWH.
Malignancy screening: Thorough history for ‘red flag’ symptoms (weight loss / abdo pain / change in bowels / haemoptysis/ pv/pr/pu bleeding); palpate abdomen / breasts; FBC, U+E, LFT, Ca2+, PSA in ♂ ≥50 yrs, CXR, dipstick. Further investigations only in response to abnormalities in the screen above.
** Dalteparin 200 units/kg s/c daily for 1st month, then 150 units/kg (see SPC/BNF).
VTE risk factors:
Surgery: e.g. NOF #, TKR, THR, other major surgery (op + anaesthetic time >90 mins) in past 3/12.
Other provoking factor: Hospitalisation in past 3/12, severe dehydration, active cancer (dx in past 6/12, on chemo, mets), pregnancy or post-partum <6/52, HRT/OCP immobility ≥3 days, long haul journey >8 hrs, lower limb paralysis or immobilisation in past 3/12.
Other risk factors: age >60 yrs, obesity, family hx VTE, previous VTE.
DASH score:
D-dimer +ve once off Rx = +2
Age <50 yrs = +1
Sex: Male gender = +1
HRT/OCP provoked = -2
Score = annual risk of recurrence:
-2 = 1.8%
-1 = 1.9%
0 = 2.4%
+1 = 3.9%
+2 = 6.3%
+3 = 10.8%
+4 = 19.9%
Thrombophilia screen only if coming off anticoagulation (refer to haematology; tests done 1/12 after end of Rx):
1. Acquired thrombophilia screen in all patients with unprovoked VTE + debate over long term anticoag Rx.
2. Heritable thrombophilia screen in patients <45 years with unprovoked VTE + 1st degree family hx of unprovoked VTE age <45.
3. Oestrogen-provoked VTE age <45 yrs: acquired screen (+ antithrombin if +ve family hx unprovoked VTE <45).
Heritable screen = Factor V Leiden mutation, Protein C + S def, Prothrombin mutation, Antithrombin.
Acquired screen = Lupus Anticoagulant, Anticardiolipin.
Patients who wish to stop Anticoagulation: GP to consider DASH risk score. See
thrombophilia advice.
Authors: Simon Murphy, Nick Adams. Dec 2015 v2.2
Approved by Thrombosis Committee Dec 2015.
Based on BTS PE 2003, BCSH 4th Ed. Anticoag 2011, NICE CG