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    DASH Prediction Score for Recurrent VTE

    Predicts likelihood of recurrence of first VTE.
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    INSTRUCTIONS

    Do NOT use in patients with active hemorrhage or signs/symptoms of VTE.

    When to Use
    Pearls/Pitfalls
    Why Use

    In patients previously diagnosed with VTE who have completed a 3-6 month course of anticoagulation, DASH Scores ≤1 are associated with 3.1% annual recurrence, which may be low enough to consider discontinuing anticoagulation. Conversely, patients with DASH Scores ≥2 are at high risk for recurrent VTE and may require long-term anticoagulation.

    The DASH prediction rule is a risk stratification tool which aids physicians in deciding whether a patient with their first unprovoked venous thromboembolism (VTE) is at risk for recurrence and could aid in deciding how long a patient should be on anticoagulation.

    • Patients were excluded from this study if they had antiphospholipid antibodies or antithrombin deficiency, or surgery, trauma, active cancer, immobility, or pregnancy/peripartum status, as these were thought to be “provoked” or “secondary” VTE.
    • Controversy exists regarding the length of time a patient should be anticoagulated after their first VTE.
    • D-dimer is measured ~1 month after stopping anticoagulation.
    • The cited 5-year recurrence rate of VTE is 25-30%.
    • The recurrence risk of VTE decreases with time.
    • The risk of bleeding complications due to anticoagulation increases with time of use.
    • The DASH Score has been externally validated; however, recurrence risk in patients >65 years old is still >5% even in patients with low DASH Scores (Tosetto 2017).
    • Anticoagulation in the original study was limited to vitamin K antagonists, and its use with other drug classes has yet to be established.

    Many patients diagnosed with VTE are put on long-term or even life-long anticoagulation. The DASH Score predicts which individuals may be low-risk enough to stop anticoagulation after an appropriate 3-6 month period.

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    Result:

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    Next Steps
    Evidence
    Creator Insights

    Management

    In a patient with previously diagnosed VTE who has completed a 3-6 month course of anticoagulation:

    • DASH ≤1:
      • Consider discontinuing anticoagulation, as this group has an annual recurrence risk of 3.1%.
    • DASH ≥2:
      • Consider continuing anticoagulation, as this group has an annual recurrence risk of 9.3%.

    Critical Actions

    • No decision rule should trump clinical gestalt. Consider the clinical scenario before continuing or discontinuing anticoagulation for VTE.
    • The DASH Score is meant to be applied to stable patients. It should not be applied to patients with active hemorrhage or those with signs and symptoms of VTE.
    Content Contributors
    About the Creator
    Dr. Alberto Tosetto
    Are you Dr. Alberto Tosetto?
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