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from Heartwire — a professional news service of WebMD
February 2, 2007 — The American College of Physicians and American Academy of Family Physicians announced clinical practice guidelines for the diagnosis and management of venous thromboembolism (VTE), which claims more than 200,000 lives each year in the United States.
The guidelines, which are the first ever to be developed by the 2 physician groups, were released on January 29, and are published jointly in the Annals of Internal Medicine and Annals of Family Medicine.
"The purpose of the guidelines is to present recommendations, based on the current evidence, to clinicians to aid in the diagnosis and management of lower extremity deep vein thrombosis (DVT) and pulmonary embolism (PE)," according to lead author Amir Qaseem, MD, of the American College of Physicians in Philadelphia, Pennsylvania.
The guidelines are also meant to bring attention to an expanding population at risk, Dr. Qaseem said in an interview with heartwire .
DVT occurs when clots form in the legs. If pieces of these leg clots break off and travel to the lungs, a serious condition called PE can occur.
"The annual incidence of VTE in the U.S. is 600,000 cases, and it is increasing with the aging population. Undiagnosed and untreated PE can result in up to 25% mortality. Early diagnosis and treatment is very crucial to prevent mortality and morbidity associated with it," stressed Dr. Qaseem.
He said the new guidelines are meant to help clinicians understand the value and use of various diagnostic tools, such as D-dimer and ultrasound, and the significance of the clinical characteristics that are useful in identifying high-risk patients.
"Strong evidence supports the use prediction rules," he said. "Use of high-sensitivity D-dimer assay in patients who have a low-pretest probability of VTE has a high negative predictive value, and is highest in younger patients with a low-pretest probability and no associated co-morbidities."
There is strong evidence supporting the use of ultrasonongraphy for diagnosing proximal DVT in patients with intermediate-to-high risk of pretest probability; however, he noted that sensitivity is much lower in asymptomatic patients for detecting calf vein DVT.
"The clinical prediction rules will help physicians determine risk categories. If patients are in low-to-intermediate risk, they should get the D-dimer test. If the test is positive, ultrasound may be indicated," Dr. Qaseem said in his interview with heartwire .
For management, Dr. Qaseem said low-molecular-weight heparin (LMWH) is indicated for DVT, as it is as effective as unfractionated heparin, especially for reducing morbidity and mortality during initial therapy. Outpatient therapy is safe and cost-effective to treat DVT (but is good only for the highly selected population and if good support services are in place).
The recommendations call for the use of compression stockings to prevent postphlebitic syndrome, and anticoagulation is important.
"Duration is dependent on risk factors: Three to six months for VTE secondary to transient risk factors, and for more than 12 months for recurrent VTE," Dr. Qaseem said.
The management guideline recommends
Ann Fam Med. 2007;5:57-62.
Ann Intern Med. 2007;146:204-240.
The complete contents of Heartwire , a professional news service of WebMD, can be found at www.theheart.org, a Web site for cardiovascular healthcare professionals.
VTE affects an estimated 71 per 100,000 persons each year. Thrombosis of veins proximal to the knee increases the risk for PE, which can occur at rates of up to 70% in such patients. Patients with undiagnosed, untreated PE have a rate of a subsequent fatal embolic event of 26%, and another 26% may experience a recurrent nonfatal embolic event. Thrombosis confined to the veins inferior to the knee carries a lower risk for PE, but these thrombi are associated with high rates of postthrombotic syndrome.
The use of D-dimer testing and clinical prediction rules has altered the ways that clinicians diagnose VTE since the last report from the Evidence-Based Practice Center and American College of Physicians in 2003. The current guidelines offer the best practice in diagnosing VTE among ambulatory patients.