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Practice Guidelines

Venous thromboembolism in adults: summary of updated NICE guidance on diagnosis, management, and thrombophilia testing

BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1565 (Published 19 May 2020) Cite this as: BMJ 2020;369:m1565
  1. Terry McCormack, general practitioner and, honorary professor of primary care cardiovascular medicine1,
  2. Marie C Harrisingh, senior technical analyst2,
  3. Daniel Horner, consultant emergency and intensive care medicine3 4,
  4. Susan Bewley, committee chair and professor emeritus (honorary) obstetrics and women’s health5
  5. on behalf of the Guideline Committee
  1. 1Institute of Clinical and Applied Health Research, Hull York Medical School, Hull, UK
  2. 2National Institute for Health and Care Excellence, London, UK
  3. 3Salford Royal NHS Foundation Trust, Stott Lane, Salford, UK
  4. 4Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK
  5. 5Division of Women and Children’s Health, School of Life Course Sciences, King’s College London, London, UK
  1. Correspondence to
    M C Harrisingh marie.harrisingh{at}nice.org.uk

What’s new in this guidance?

  • If clinical suspicion of pulmonary embolism is low, consider using the pulmonary embolism rule-out criteria (PERC) to help determine whether any further investigations for pulmonary embolism are needed

  • In people over 50, consider using an age-adjusted D-dimer

  • Consider outpatient treatment for low risk patients with pulmonary embolism

  • Offer apixaban or rivaroxaban as interim treatment for suspected venous thromboembolism (VTE) or substantive treatment for confirmed VTE unless special considerations apply. If neither is suitable (and special considerations do not apply) then offer low molecular weight heparin (LMWH) followed by dabigatran or edoxaban, or LMWH with a vitamin K antagonist

  • Consider using direct oral anticoagulants (DOACs) for people with active cancer

  • Do not offer further investigations for cancer to people with unprovoked deep vein thrombosis or pulmonary embolism unless they have relevant clinical symptoms or signs.

Venous thromboembolic (VTE) disease is a continuing global health burden with serious mortality, morbidity, and health economic consequences.1 The one year case fatality rate of definite or probable VTE has been estimated at 23%.2 Approximately 1 to 2 of every 1000 adults in the worldwide population will be diagnosed with VTE annually, with higher incidence rates in those over 70 (2 to 7/1000) and over 80 (3 to 12/1000).13

On 26 March 2020, the National Institute for Health and Care Excellence (NICE) published NG158,4 an updated version of its guideline on the diagnosis and management of VTE (original version 2012, minor update 2015: National Institute for Health and Care Excellence 2020 venous thromboembolism in adults: diagnosis, management and thrombophilia testing. https://www.nice.org.uk/guidance/ng158). This article summarises the new key recommendations, with a focus on those most relevant to primary care and secondary generalist physicians, and includes existing 2012 or 2015 recommendations that have not been updated where they are relevant to the topic …

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