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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.

    No
    0
    Yes
    +2
    No
    0
    Yes
    +1
    No
    0
    Yes
    +1
    No
    0
    Yes
    -2

    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.

    Formula

    Addition of the selected points:See formula table below:

    Criteria Weighted Score
    D-dimer abnormal +2
    Age ≤50 years +1
    Sex - Male +1
    Hormone use at time of initial VTE (if female) -2

    Facts & Figures

    DASH Score Annual Recurrence Rate
    -2 1.8%*
    -1 1.0%
    0 2.4%
    1 3.9%
    2 6.3%
    3 10.8%
    4 19.9%

    *A very small sample had DASH Score of -2 in the derivation study.

    Evidence Appraisal

    • The authors of the original study performed a meta-analysis of available individual patient data derived from prospective studies of patients with first VTE who received anticoagulation and followed up over 5 years.
    • Patients were excluded if they had known VTE risk factors such as surgery, trauma, active cancer, immobility, or pregnancy. Oral contraception use and hormone therapy, or a thrombophilic blood abnormality, were included.
    • Patients were followed up after anticoagulation was stopped, and documentation was kept for recurrence, death or restarting of anticoagulation.
    • A Cox regression was performed for variables to develop a prognostic score.
    • Low risk was defined as a recurrence risk below 5%, based on prior recommendations (Kearon 2010).
    • The final variables included: D-dimer, age ≤50, patient sex, and hormone use at the time of initial VTE. After correction for optimism each was given a score: +2 for abnormal dimer, +1 for age ≤50, +1 for male sex, -2 for hormone use (in females).
    • An internal validation using random subjects from the cohort was performed 500 times to predict recurrence rate.
    • 2,554 patients were initially included, with 727 excluded. 1,818 final patients were included in the analysis. Median follow up was 22.4 months.
    • In the study cohort the annualized recurrence of VTE was 3.1% for patients with a DASH ≤1 and 9.3% for a DASH >1.
    • The authors concluded that in their cohort up to 51.6% of patients had a DASH ≤1 and could have avoided life-long anticoagulation.
    • The authors externally validated the score in a separate cohort in 2017.

    Literature

    Dr. Alberto Tosetto

    About the Creator

    Alberto Tosetto, MD, is a hematologist at the University of Bologne in Italy. He conducts research on coagulation disorders and the use of anticoagulants in treatment.

    To view Dr. Alberto Tosetto's publications, visit PubMed

    Content Contributors
    About the Creator
    Dr. Alberto Tosetto
    Content Contributors