What are the ASH guidelines for the diagnosis of venous thromboembolism (VTE)?

Updated: Nov 05, 2020
  • Author: Vera A De Palo, MD, MBA, FCCP; Chief Editor: Vinod K Panchbhavi, MD, FACS  more...
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Answer

In November 2018, the American Society of Hematology (ASH) released guidelines for the diagnosis of venous thromboembolism (VTE). [20] The American Academy of Family Physicians (AAFP) endorsed these guidelines in March 2019 and provided the following key recommendations from the guidelines. [90]

D-dimer testing alone should not be used to rule in or diagnose pulmonary embolism (PE), and a positive D-dimer alone should not be used to diagnose deep vein thrombosis (DVT).

Pulmonary embolism

In individuals with a low or intermediate pretest probability or prevalence, clinicians should use a D-dimer strategy to rule out PE, followed by a ventilation-perfusion (VQ) scan or computed tomography pulmonary angiography (CTPA) in patients requiring additional testing. D-dimer testing alone should not be used to rule in a PE.

In individuals with a high pretest probability or prevalence (≥50%), clinicians should start with CTPA to diagnose PE. If CTPA is not available, a VQ scan should be used with appropriate follow-up testing.

In individuals with a high pretest probability or prevalence, D-dimer testing alone should not be used to diagnose PE and should not be used as a subsequent test after CT.

In individuals with a positive D-dimer or likely pretest probability, CTPA should be performed. D-dimer testing can be used to exclude recurrent PE in individuals with an unlikely pretest probability.

In outpatients older than 50 years, use of an age-adjusted D-dimer cutoff is safe and improves the diagnostic yield. Age-adjusted cutoff = Age (years) × 10 µg/L (using D-dimer assays with a cutoff of 500 µg/L).

Lower-extremity deep vein thrombosis

In individuals with a low pretest probability or prevalence of lower-extremity (LE) DVT, clinicians should use a D-dimer strategy to rule out DVT, followed by proximal LE or whole-leg ultrasonography (US) in patients requiring additional testing.

In individuals with a low pretest probability or prevalence (≤ 10%), a positive D-dimer alone should not be used to diagnose DVT, and additional testing following negative proximal or whole-leg US should not be conducted.

In individuals with an intermediate pretest probability or prevalence (~25%), whole-leg or proximal LE US should be used. Serial proximal US testing is needed after a negative proximal ultrasonogram. No serial testing is needed after a negative whole-leg ultrasonogram.

In individuals with suspected DVT and a high pretest probability or prevalence (≥50%), whole-leg or proximal LE US should be used. Serial US should be used if the initial ultrasonogram is negative and no alternative diagnosis is identified.

Upper-extremity deep vein thrombosis

In individuals with a low prevalence/unlikely pretest probability of upper-extremity (UE) DVT, D-dimer testing should be used to exclude UE DVT, followed by duplex US if findings are positive.

In individuals with a high prevalence/likely pretest probability, either (a) D-dimer testing followed by duplex US/serial duplex US or (b) duplex US/serial duplex US alone can be used for assessing patients suspected of having a UE DVT.

A positive D-dimer alone should not be used to diagnose UE DVT.


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