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

• Published in: Blood advances 2018-11, Vol.2 (22), p.3226-3256
• Main Authors: Lim, Wendy, Le Gal, Grégoire, Bates, Shannon M., Righini, Marc, Haramati, Linda B., Lang, Eddy, Kline, Jeffrey A., Chasteen, Sonja, Snyder, Marcia, Patel, Payal, Bhatt, Meha, Patel, Parth, Braun, Cody, Begum, Housne, Wiercioch, Wojtek, Schünemann, Holger J., Mustafa, Reem A.
• Format: Article
• Language: English
• Subjects: Cardiology and cardiovascular system; Clinical Guidelines; Human health and pathology; Life Sciences
• ISSN: 2473-9529; 2473-9537
• DOI: 10.1182/bloodadvances.2018024828

In February 2022, these guidelines were reviewed by an expert work group convened by ASH. Review included limited searches for new evidence and discussion of the search results. Following this review, the ASH Committee on Quality agreed to continue monitoring the supporting evidence rather than revise or retire these guidelines at this time. Limited searches and expert review will be repeated annually going forward until these guidelines are revised or retired. 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.