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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 a patient who has been previously diagnosed with VTE and has completed a 3-6 month course of anticoagulation, a DASH score of ≤1 is associated with an annual risk of recurrence of 3.1%, which may be low enough to suggest discontinuing anticoagulation therapy. Conversely, a patient with a DASH score of ≥2 is 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” VTEs.
    • There is controversy regarding the length of time a patient should be anticoagulated after their first VTE.
    • The d-dimer test is measured ~1 month after stopping anticoagulation.
    • The cited 5-year recurrence rate of VTE is 25-30%.
    • The risk recurrence of VTE decreases with time.
    • The risk of bleeding complications due to anticoagulation increases with time of use.
    • The DASH score has yet to be externally validated.
    • Anticoagulation in this study was limited to vitamin K antagonists, and its use with other drug classes has yet to be established.
    • The DASH score was developed using meta-analysis of previously performed studies. Further prospective studies are required to confirm its utility.

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

    Result:

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    Next Steps
    Evidence
    Creator Insights

    Advice

    The DASH score has yet to be externally validated and will require further analysis before it can be used routinely. However, in a patient who is low risk for recurrent VTE and high risk for complications of anticoagulation, the DASH score has the potential to aid and support the decision to discontinue anticoagulation.

    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; points assigned below:

    Facts & Figures

    See formula table below:

    Criteria Weighted Score
    D-dimer Abnormal +2
    Age <50 yrs +1
    Sex - Male +1
    Hormone use at time of initial VTE -2

    Evidence Appraisal

    • The authors 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 with known VTE risk factors such as surgery, trauma, active cancer, immobility and pregnancy. Oral contraception use and Hormone therapy or a thrombophilic blood abnormality were included.
    • The 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 <e;50 years, 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.
    • 2554 patients were initially included with 727 excluded. 1818 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.
    DASH Score Annualized 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.

    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

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