VTE – ClinCaseQuest https://clincasequest.hospital Medical education in clinical cases Sat, 29 Apr 2023 17:24:41 +0000 en-US hourly 1 https://wordpress.org/?v=6.2.13 https://clincasequest.hospital/wp-content/uploads/sites/7/2020/02/logo-ru-project-90x90.png VTE – ClinCaseQuest https://clincasequest.hospital 32 32 SAVED VTE Score https://clincasequest.hospital/saved-vte-score/ Wed, 11 Jan 2023 14:09:11 +0000 https://clincasequest.hospital/?p=34420 SAVED score for venous thromboembolism risk stratification in patients with multiple myeloma receiving immunomodulators. Variable Points Surgery within 90 days +2 Mongoloid race -3 History…

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]]> SAVED score for venous thromboembolism risk stratification in patients with multiple myeloma receiving immunomodulators.

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* Required


VariablePoints
Surgery within 90 days+2
Mongoloid race-3
History of VTE+3
Age ≥ 80 years+1
Dexamethasone (dosage regimen):
• Standard dose (120-160 mg/cycle)
• High dose (>160 g/cycle)
+1
+2


Calculation

High risk (≥ 2 points). Recommended:

  • Enoxaparin 40 mg subcutaneously 1 time/day
  • Dalteparin 5000 units subcutaneously 1 time/day (category 2B)
  • Warfarin (INR 2-3)

Low risk (< 2 points). Recommended:

  • Do not prescribe medications
  • Aspirin 81-325 mg/day


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Multiple Myeloma Diagnostic Criteria – Online Calculator

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≥1 of the following (A or B)

≥1 myeloma defining event (C1 or C2)

* Required
For Multiple Myeloma Diagnostic Criteria assessment necessary to provide selection of the…
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IMPEDE VTE Score

IMPEDE score for venous thromboembolism risk stratification in patients with multiple myeloma receiving immunomodulators. [ezfc…

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]]> IMPEDE VTE Score https://clincasequest.hospital/impede-vte-score/ Wed, 11 Jan 2023 14:06:45 +0000 https://clincasequest.hospital/?p=34419 IMPEDE score for venous thromboembolism risk stratification in patients with multiple myeloma receiving immunomodulators. Individual Risk Factors Points Myeloma risk scores Points Positive Factors  …

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]]> IMPEDE score for venous thromboembolism risk stratification in patients with multiple myeloma receiving immunomodulators.

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Individual Risk Factors

Positive Factors

Negative Factors

Myeloma risk scores

* Required



Individual Risk FactorsPointsMyeloma risk scoresPoints
Positive Factors   
Central venous catheter/tunneled central catheter+2Immunomodulator (IM)+4
Fracture of the pelvis, hip joint, or femur+4A drug that stimulates erythropoiesis+1
Obesity (body mass index ≥ 25)+1Dexamethasone < 160 mg per month+2
Previous VTE+5Dexamethasone > 160 mg per month+4
  Doxorubicin or multicomponent chemotherapy+3
Negative Factors   
Ethnicity/Race – Mongoloid/Pacific Islander-3  
Current thromboprophylaxis: low molecular weight heparin (LMWH) at prophylactic doses or aspirin-3  
Current thromboprophylaxis: LMWH at prophylactic doses or warfarin-4  

Calculation

High risk (>3 points). An anticoagulant is recommended if it has not been prescribed before:

  • Enoxaparin 40 mg subcutaneously 1 time/day
  • Dalteparin 5000 units 1 time/day (category 2B)
  • Warfarin (INR 2-3)

Low risk (≤3 points). Recommended:

  • Do not prescribe medications
  • Aspirin 81-325 mg/day


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Multiple Myeloma Diagnostic Criteria – Online Calculator

≥1 of the following (A or B)

≥1 myeloma defining event (C1 or C2)

For Multiple Myeloma Diagnostic Criteria assessment necessary to provide selection of the…
Read More

SAVED VTE Score

SAVED score for venous thromboembolism risk stratification in patients with multiple myeloma receiving immunomodulators. [ezfc…

Read More

Сообщение IMPEDE VTE Score появились сначала на ClinCaseQuest.

]]> Wells’ Deep Vein Thrombosis Criteria – online calculator https://clincasequest.hospital/wells-dvt-criteria/ Sat, 12 Feb 2022 09:34:00 +0000 https://clincasequest.hospital/?p=33466 The Wells’ DVT Criteria can be used in the outpatient and emergency department. By risk stratifying to low risk (Wells’ Score <2) and a negative…

Сообщение Wells’ Deep Vein Thrombosis Criteria – online calculator появились сначала на ClinCaseQuest.

]]> The Wells’ DVT Criteria can be used in the outpatient and emergency department. By risk stratifying to low risk (Wells’ Score <2) and a negative D-dimer the clinician can exclude the further ultrasound (US) diagnostic test to rule out DVT.

The Wells’ Score is less useful in hospitalized patients.

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Treatment or palliation within 6 months

Measured 10 cm below tibial tuberosity

* Required


The physician may not prescribe an ultrasound (ultrasound) to rule out DVT if the patient has low-risk DVT (<2 points) based on risk stratification on Wells` score and negative D-dimer.

The Wells’ scale should only be used after a detailed patient’s history taking and a physical examination in patients who are at risk of DVT.

The Wells’ Deep Vein Thrombosis (DVT) Risk Criteria stratifies patients by risk of DVT. There is a low prevalence of DVT in patients with a low pretest probability of DVT (<25%). Complications of DVT include pulmonary embolism (PE) and pulmonary hypertension, the mortality rate of which is 1-8%, so the timely diagnosis of DVT is the best prevention of PE and pulmonary hypertension.

Traditional diagnosis of DVT involves ultrasonography of the lower extremities, which is associated with time and financial resources. Using Wells` DVT criteria physicians can identify those patients who are generally unlikely have DVT. Further testing of patients for D-dimer can also safely rule out DVT without the necessity for an ultrasound.

The predictive scale includes nine parameters and the clinician’s clinical judgment regarding the likelihood of an alternative diagnosis.Well’s assessment score based on addition of the selected points:

VariablePoints
Active cancer (treatment or palliation within 6 months)1
Bedridden recently >3 days or major surgery within 12 weeks1
Calf swelling >3 cm compared to the other leg (measured 10 cm below tibial tuberosity)1
Collateral (nonvaricose) superficial veins present1
Entire leg swollen1
Localized tenderness along the deep venous system1
Pitting edema, confined to symptomatic leg1
Paralysis, paresis, or recent plaster immobilization of the lower extremity1
Previously documented DVT1
Alternative diagnosis to DVT as likely or more likely-2

There are a few versions of the criteria with minor differences between them. This is the most widely validated scale, based on Wells 2003.

Interpretation:

Шкала Wells’Risk groupPrevalence of DVTRecommendations
≤0Low/unlikely5%These patients should proceed to D-dimer testing:
• A negative high or moderate sensitivity D-dimer results in a probability <1 % and no further imaging is required
• A positive D-dimer should proceed to US testing
• A negative US is sufficient for DVT rule out
• A positive US is concerning for DVT; strongly consider treatment with anticoagulation
1-2Moderate17%These patients should proceed to high-sensitivity D-dimer testing (moderate sensitivity D-dimer is not sufficient)
• A negative high-sensitivity D-dimer is sufficient for rule out of DVT in a moderate risk patient with a probability of <1%
• A positive high sensitivity D-dimer should proceed to US testing
• A negative US is sufficient for ruling out DVT
• A positive US is concerning for DVT, strongly consider treatment with anticoagulation
• Moderate risk group should only undergo D-dimer testing for rule out without ultrasonography if a high-sensitivity D-dimer is being used
≥3High/likely17-53%All DVT likely patients should receive a diagnostic US
• D-dimer testing should be utilized to help risk-stratify these DVT-likely patients
• In DVT likely patients with negative D-dimer: • A negative US is sufficient for ruling out DVT, consider discharge
• A positive US should be concerning for DVT, strongly consider treatment with anticoagulation
•In DVT likely patients with a positive D-dimer:
• A positive US should be concerning for DVT, strongly consider treatment with anticoagulation
• A negative US is still concerning for DVT. A repeat US should be performed within 1 week for re-evaluation

Sometimes patients with DVT and a negative D-dimer are revealed in clinical practice.

  • A negative ultrasound result is sufficient to rule out DVT and consider discharge.
  • A positive ultrasound result indicates the presence of DVT, with the necessity of anticoagulants treatment.

With DVT and positive D-dimer:

  • A positive ultrasound result is sufficient to make a diagnosis of DVT necessity of anticoagulants treatment.
  • Negative ultrasound may also occur with DVT. A follow-up ultrasound should be performed within 1 week for re-evaluation.

This predictive score was derived from a series of studies by Wells’ et al. (Wells 1995, Wells 1997, Wells 2003) in an attempt to stratify the risk of DVT in symptomatic outpatients in order to reduce clinical resource burden and avoid overuse of imaging.

This scale has been included in the American College of Pulmonology guidelines for DVT.

NB!

  • The clinician’s clinical assessment should take precedence over the score on this predictive scale. High suspicion for DVT should require imaging regardless of Wells’ score.
  • The presence of DVT is critical in assessing the presence of PE, and if PE is being differentiated, alternative decision-making tools such as the Wells’ PE score or the PERC rule should be used.

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Sources:

  1. Wells PS, Hirsh J, Anderson DR, et al. Accuracy of clinical assessment of deep-vein thrombosis. Lancet. 1995;345(8961):1326-30.https://pubmed.ncbi.nlm.nih.gov/7752753/
  2. Wells PS, Anderson DR, Bormanis J, et al. Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet. 1997;350(9094):1795-8. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(97)08140-3/fulltext
  3. Wells PS, Anderson DR, Rodger M, Forgie M, Kearon C, Dreyer J, Kovacs G, Mitchell M, Lewandowski B, Kovacs MJ. Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. N Engl J Med. 2003 Sep 25;349(13):1227-35. https://pubmed.ncbi.nlm.nih.gov/14507948/
  4. Scarvelis D, Wells PS. Diagnosis and treatment of deep-vein thrombosis. CMAJ. 2006 Oct 24;175(9):1087-92. Review. Erratum in: CMAJ. 2007 Nov 20;177(11):1392. https://pubmed.ncbi.nlm.nih.gov/17060659/
  5. Wells PS, Owen C, Doucette S, Fergusson D, Tran H. Does this patient have deep vein thrombosis? JAMA. 2006 Jan 11;295(2):199-207. Review. https://pubmed.ncbi.nlm.nih.gov/16403932/
  6. Bates SM, Jaeschke R, Stevens SM, Goodacre S, Wells PS, Stevenson M.D., Kearon C, Schunemann HJ, Crowther M, Pauker SG, Makdissi R, Guyatt GH. Diagnosis of DVT: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. https://pubmed.ncbi.nlm.nih.gov/22315267/
  7. Silveira PC, Ip IK, Goldhaber SZ, Piazza G, Benson CB, Khorasani R. Performance of Wells Score for Deep Vein Thrombosis in the Inpatient Setting. JAMA Intern Med. 2015 Jul;175(7):1112-7. doi: 10.1001/jamainternmed.2015.1687. https://pubmed.ncbi.nlm.nih.gov/25985219/

See also:

Well’s criteria for Pulmonary Embolism probability assessment
PERC Rule for Pulmonary Embolism- online calculator

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]]> DASH Prediction Score for Recurrent VTE https://clincasequest.hospital/dash-score-vte/ Sat, 21 Aug 2021 12:06:00 +0000 https://clincasequest.hospital/?p=29924 Predicts likelihood of recurrence of VTE. The DASH Score is meant to be applied to stable patients. It should not be applied to patients with…

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]]> Predicts likelihood of recurrence of VTE.

The DASH Score is meant to be applied to stable patients. It should not be applied to patients with active hemorrhage or those with signs and symptoms of VTE.

Many patients diagnosed with VTE are put on long-term or even life-long anticoagulation. The DASH Score predicts which individuals may be low-risk enough to stop anticoagulation after an appropriate 3-6 month period.

D-dimer abnormal
Measured ~1 month after stopping anticoagulation:
No
Yes

Age ≤50 years:
No
Yes

Male patient:
No
Yes

Hormone use at VTE onset (if female)
If male patient, select “No”:
No
Yes



Patient’s score Points Annual Recurrence Rate of VTE Management
0 0 0 0

Addition of the selected points:

CriteriaWeighted Score
D-dimer abnormal+2
Age ≤50 years+1
Sex – Male+1
Hormone use at time of initial VTE (if female)-2

Clinical interpretation:

In a patient with previously diagnosed VTE who has completed a 3-6 month course of anticoagulation if the DASH score is:

PointsAnnual Recurrence Rate of VTEManagement
   
≤1Low RiskConsider discontinuing anticoagulation, as this group has an annual recurrence risk of 3.1%.
 ≥2High riskConsider continuing anticoagulation, as this group has an annual recurrence risk of 9.3%.    

In patients previously diagnosed with VTE who have completed a 3-6 month course of anticoagulation, DASH Scores ≤1 are associated with 3.1% annual recurrence, which may be low enough to consider discontinuing anticoagulation. Conversely, patients with DASH Scores ≥2 are at high risk for recurrent VTE and may require long-term anticoagulation.

Statistical interpretation:

DASH ScoreAnnual Recurrence Rate
-21.8%*
-11.0%
02.4%
13.9%
26.3%
310.8%
419.9%

The DASH prediction rule is a risk stratification tool which aids physicians in deciding whether a patient with their first unprovoked venous thromboembolism (VTE) is at risk for recurrence and could aid in deciding how long a patient should be on anticoagulation. Patients were excluded from this study if they had:

  • antiphospholipid antibodies or antithrombin deficiency;
  • Surgery;
  • Trauma;
  • Active cancer;
  •  Immobility;
  •  Pregnancy/peripartum status,

as these were thought to be “provoked” or “secondary” VTE.

The authors of the original study performed a meta-analysis of available individual patient data derived from prospective studies of patients with first VTE who received anticoagulation and followed up over 5 years.

Patients were excluded if they had known VTE risk factors such as surgery, trauma, active cancer, immobility, or pregnancy. Oral contraception use and hormone therapy, or a thrombophilic blood abnormality, were included.

Patients were followed up after anticoagulation was stopped, and documentation was kept for recurrence, death or restarting of anticoagulation.

The final variables included: D-dimer, age ≤50, patient sex, and hormone use at the time of initial VTE. After correction for optimism each was given a score: +2 for abnormal dimer, +1 for age ≤50, +1 for male sex, -2 for hormone use (in females).

In the study cohort the annualized recurrence of VTE was 3.1% for patients with a DASH ≤1 and 9.3% for a DASH >1. The authors concluded that in their cohort up to 51.6% of patients had a DASH ≤1 and could have avoided life-long anticoagulation.

Controversy exists regarding the length of time a patient should be anticoagulated after their first VTE. D-dimer is measured ~1 month after stopping anticoagulation. The cited 5-year recurrence rate of VTE is 25-30%. The recurrence risk of VTE decreases with time. The risk of bleeding complications due to anticoagulation increases with time of use.

The DASH Score has been externally validated; however, recurrence risk in patients >65 years old is still >5% even in patients with low DASH Scores (Tosetto 2017).

Anticoagulation in the original study was limited to vitamin K antagonists, and its use with other drug classes has yet to be established.

No decision rule should trump clinical assessment. Consider the clinical scenario before continuing or discontinuing anticoagulation for VTE.

Literature:
Tosetto A, Iorio A, Marcucci M, Baglin T, Cushman M, Eichinger S, Palareti G, Poli D, Tait RC, Douketis J. Predicting disease recurrence in patients with previous unprovoked venous thromboembolism: a proposed prediction score (DASH).J Thromb Haemost. 2012 Jun;10(6):1019-25. doi: 10.1111/j.1538-7836.2012.04735.x. https://pubmed.ncbi.nlm.nih.gov/22489957/
Kearon C, Iorio A, Palareti G. Risk of recurrent venous thromboembolism after stopping treatment in cohort studies: recommendation for acceptable rates and standardized reporting. J Thromb Haemost 2010; 8: 2313–5. https://onlinelibrary.wiley.com/doi/full/10.1111/j.1538-7836.2010.03991.x
Tosetto A, Testa S, Martinelli I, et al. External validation of the DASH prediction rule: a retrospective cohort study. J Thromb Haemost. 2017;15(10):1963-1970. https://onlinelibrary.wiley.com/doi/full/10.1111/jth.13781
Kearon C, Kahn SR, Agnelli G, Goldhaber S, Raskob GE, Comerota AJ. Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133: 454S–545S.

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