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Blood Adv. 2018 Nov 27;2(22):3226-3256. doi: 10.1182/bloodadvances.2018024828.

American Society of Hematology 2018 guidelines for management of venous thromboembolism: diagnosis of venous thromboembolism.

Author information

1
Department of Medicine and.
2
Department of Pathology & Molecular Medicine, McMaster University, Hamilton, ON, Canada.
3
Department of Medicine, University of Ottawa/Ottawa Hospital Research Institute, Ottawa, ON, Canada.
4
Thrombosis and Atherosclerosis Research Institute (TaARI), McMaster University, Hamilton, ON, Canada.
5
Division of Angiology and Hemostasis, Department of Medical Specialties, Geneva University Hospitals, Geneva, Switzerland.
6
Faculty of Medicine, University of Geneva, Geneva, Switzerland.
7
Department of Radiology and.
8
Department of Medicine, Montefiore Medical Center/College of Medicine, Albert Einstein, Bronx, NY.
9
Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
10
Rockyview General Hospital, Calgary, AB, Canada.
11
Department of Emergency Medicine, School of Medicine, Indiana University, Indianapolis, IN.
12
Fort Myers, FL.
13
Wheaton, IL.
14
Department of Emergency Medicine, University of Illinois at Chicago, Chicago, IL.
15
Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
16
Department of Internal Medicine, School of Medicine, University of Missouri-Kansas City, Kansas City, MO.
17
Department of Medicine, Loyola University Medical Center, Maywood, IL; and.
18
Division of Nephrology and Hypertension, Department of Medicine, University of Kansas Medical Center, Kansas City, KS.

Abstract

BACKGROUND:

Modern diagnostic strategies for venous thromboembolism (VTE) incorporate pretest probability (PTP; prevalence) assessment. The ability of diagnostic tests to correctly identify or exclude VTE is influenced by VTE prevalence and test accuracy characteristics.

OBJECTIVE:

These evidence-based guidelines are intended to support patients, clinicians, and health care professionals in VTE diagnosis. Diagnostic strategies were evaluated for pulmonary embolism (PE), deep vein thrombosis (DVT) of the lower and upper extremity, and recurrent VTE.

METHODS:

The American Society of Hematology (ASH) formed a multidisciplinary panel including patient representatives. The McMaster University GRADE Centre completed systematic reviews up to 1 October 2017. The panel prioritized questions and outcomes and used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess evidence and make recommendations. Test accuracy estimates and VTE population prevalence were used to model expected outcomes in diagnostic pathways. Where modeling was not feasible, management and accuracy studies were used to formulate recommendations.

RESULTS:

Ten recommendations are presented, by PTP for patients with suspected PE and lower extremity DVT, and for recurrent VTE and upper extremity DVT.

CONCLUSIONS:

For patients at low (unlikely) VTE risk, using D-dimer as the initial test reduces the need for diagnostic imaging. For patients at high (likely) VTE risk, imaging is warranted. For PE diagnosis, ventilation-perfusion scanning and computed tomography pulmonary angiography are the most validated tests, whereas lower or upper extremity DVT diagnosis uses ultrasonography. Research is needed on new diagnostic modalities and to validate clinical decision rules for patients with suspected recurrent VTE.

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