Practice
Guidelines
Management of venous thromboembolic diseases and the role of thrombophilia testing: summary of NICE guidance
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BMJ
2012;344:e3979
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30 July 2012
Many valid comments already posted about the utility (or lack thereof) of chasing undiscovered cancer in patients with VTE, so I won't add much except to say that if one is to undertake a CT scan (abdo+pelvis) then given the low sensitiviy of CXR a CT chest should be seriously considered instead in this older-age patient group.
My greater concern about the way these guidelines were presented in the BMJ both in this summary and in the News section the week before s that they ignore statements about the imaging: Namely that isotope perfusion scan, VQ or VQ SPECT study is an entirely acceptable alternative to CTPA. BMJ we can argue is primarily read by primary care doctors, doctors who now commissioner services. Let's not feed them incomplete info about services that they can commission. In our hospital, due to pressures on CT scanners from cancer/trial imaging, it is easier to get VQ (SPECT) within 4 hours than CTPA and I am sure we are not alone.
Competing interests: None declared
Royal Wolverhampton Hospital, Wednsefield Rd, Wolverhampton WV10 0QP
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16 July 2012
Editor,
The recent summary of the updated NICE guidelines [1] into the management of venous thromboembolic diseases is welcomed with the particular positive strength of the guidelines in providing a timeframe and therefore momentum to the acute diagnostic investigations. Focusing purely on an evidence based approach sometimes limits the advice offered, however, and the new guidelines fail to capture important changing practice, in both the UK and elsewhere, and to give clarity to the clinicians adopting more to ambulatory and an outpatient based approach in managing both lower limb deep venous thrombosis and pulmonary embolic disease.
In the case of the latter, the proposed pathways are now supported by additional measures of severity and calculated risk of related mortality adopting chemical biomarkers such as troponin, cardiac echo to assess associated pulmonary hypertension, and clinical severity scores such as the Pulmonary Embolism Severity Index (PESI). Although some patients with low risk may then be considered for ambulatory regimens, these risk-based protocols also better inform clinicians enabling them to discuss risk with patients and potentially consent more to systemic thrombolytic therapies particularly where, despite no recorded haemodynamic instability, CT pulmonary angiography shows a proximal thrombus load suggesting sub-massive pulmonary embolism.
References
[1] Management of venous thromboembolic diseases and the role of thrombophilia testing: summary of NICE guidance. BMJ 2012;344:e3979
Competing interests: None declared
Shrewsbury & Telford Hospital NHS and University of Keele Medical School, Princess Royal Hospital, Apley, Telford TF1 6TA
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12 July 2012
NICE have enthusiastically publicised their recommendation to consider further investigations for cancer in all patients aged over 40 years with a first unprovoked deep venous thrombosis (DVT) or pulmonary embolism (PE). Actually, this comprises a very small part of the whole guideline on the investigation and management of venous thromboembolism (VTE) [1], which otherwise adds little to existing evidence-based guidelines. Both the British Thoracic Society [2] and the European Society for Cardiology [3] concluded that screening for cancer in a patient presenting with an unprovoked DVT or PE is not warranted, since the presence of an occult cancer will become apparent on taking a detailed history and performing a thorough physical examination, along with initial investigations including chest radiograph. How the NICE guideline development group (GDG) came to the opposite conclusion, namely that screening by abdominal-pelvic CT scanning (and mammography for women) should be performed in patients who do not have symptoms or signs of cancer, requires further scrutiny.
Their recommendation is based on a single non-blinded trial that did not achieve its primary outcome measure [4]. When comparing the intensively screened group versus the usual investigation group, the 95% confidence intervals for the relative risk of 2 year cancer-related mortality were wide and encompassed unity (0.1-2.75), indicating that there was no statistically significant effect. Inexplicably, the GDG interpreted this study as demonstrating “there may be a decrease which is potentially clinically important in cancer related mortality”. Presumably realising they were on shaky ground, the GDG have tried to justify their recommendation on the grounds that VTE treatment regimes differ between patients with and without known cancer, although this evidence is derived from a completely different population of patients [5]. The psychological and physical harm caused to patients by the discovery of incidental lesions on CT scans and their subsequent follow-up is not considered. The GDG advocate screening because they say patients would want it, but the arguments for and against screening are complex so patients and the public deserve unbiased advice from NICE. Instead, it appears that the GDG have misinterpreted the evidence so that NICE can demonstrate that their new document is different from existing guidelines.
There are parallels with the NICE guideline on VTE prophylaxis in hospitalized patients, which has been criticised [6] for making recommendations based on a weak surrogate outcome (asymptomatic DVT), which clearly contradicts NICE’s own stated principles of focusing on outcomes that are clinically meaningful and important to patients.
References
1. National Institute for Health and Clinical Excellence. Venous thromboembolic diseases: the management of venous thromboembolic diseases and the role of thrombophilia testing (CG144). London: National Institute for Health and Clinical Excellence, 2012
2. The British Thoracic Society Standards of Care Committee, PEGDG. British Thoracic Society guidelines for the management of suspected acute pulmonary embolism. Thorax 2003;58:470-483.
3. Torbicki A, Perrier A, Konstantinides S, et al. Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur.Heart J. 2008;29:2276-2315.
4. Piccioli A, Lensing AWA, Prins AH, et al. Extensive screening for occult malignant disease in idiopathic venous thromboembolism: a prospective randomized clinical trial. Journal of Thrombosis and Haemostasis 2004;2:884-889.
5. Lee AY, Levine MN, Baker RI, et al. Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in patients with cancer. N.Engl.J.Med. 2003;349:146-153.
6. Welfare M. NICE's recommendations for thromboembolism are not evidence based. British Medical Journal 2011;343:d6452
Competing interests: None declared
Hull York Medical School, Castle Hill Hospital, Cottingham HU16 5JQ
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11 July 2012
Health warning - not all EBM
NICE guidance CG144 has been very helpfully summarised by the authors - but i would caution readers and clinicians to review the detailed guidance before blindly following the summary advice for the following reasons:
a)thrombolytic therapy is recommended for certain dvt patients- but the original guidance rates the studies as "low quality with serious imprecision" and recommends further research
b)thrombophilia testing is also recommended - although the detailed guidance acknowledges that this may not be clinically or cost effective -again further research is helpfully recommended in the guidance
c)screening for cancer - apart from sensible physical examination and baseline bloods and CXR which are usually done, the group recommend considering a CT scan (and mammography for women) - but in the detailed guidance, acknowledge that the quality of studies are low and that it may increase radiation from ct and may increase distress to patients from false positives - and very helpfully recommend further research.
Thus, the majority of readers who may rely solely on the summary guidance need to be aware that perhaps due to space limitations these reservations were not articulated in the summary in the bmj. We should accordingly be mindful that we do not blindly follow NICE guidance, as the evidence base may not be robust enough - which is acknowledged in the detailed guidance. It would have been more helpful if these reservations or caveats were included in the summary or better still, the grade of evidence supporting the recommendation was mentioned - perhaps deliberately omitted because it was level C, ie expert opinion, and not grade A?
Competing interests: None declared
royal wolverhampton hospital, wolverhampton,wv10 0qp
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11 July 2012
Guideline Development Group members must be privileged to work in a fantastically well resourced environment where an ultrasound scan to diagnose leg DVT is freely available, as they based their recommendation for the scan to be provided within 4 hours of having been requested on personal opinion. I cannot imagine many radiology departments being able to consistently match this ambition 7 days a week, or even the alternative of scan within 24 hours whilst patients are started on anticoagulation. I do wonder why the Guideline Development Group members stopped short of recommending an equally precise and stringent time frame for the provision of CT pulmonary angiogram in patients with suspected PE? Perhaps they have realized by this stage of guidance development the utopia of these time frames.
Competing interests: None declared
Aintree University Hospitals NHS Foundation Trust, Longmoor Lane, Liverpool L9 7AL
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