DASH Prediction Score for Recurrent VTE
Do NOT use in patients with active hemorrhage or signs/symptoms of VTE.
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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From the Creator
Why did you develop the DASH Score? Was there a particular clinical experience or patient encounter that inspired you to create this tool for clinicians?
I have a deep interest in improving clinical practice by developing quantitative methods in medicine. Medicine is primarily an art, and clinical gestalt in many cases is equivalent or superior to clinical epidemiology. Nonetheless, quantitative methods are important for a first glance assessment of patients, and also to teach the basis for common patient evaluation to young colleagues. I mostly perceive the DASH Score as a good teaching instrument.
What pearls, pitfalls and/or tips do you have for users of the DASH Score? Do you know of cases when it has been applied, interpreted, or used inappropriately?
The DASH Score is straightforward to use - sex and age plus hormone use at the time of index event are readily collected during the patient's visit. But the evaluation of D-dimer is critical: it should be measured after at least three weeks (21 days) after VKA discontinuation, maybe a little earlier in patients taking DOACs. We always advise using a sensitive D-dimer assay because some point of care or qualitative tests may not be sensitive enough to rule out a positive D-dimer. When using a quantitative assay, the prognostic cut-off is lower than the diagnostic one, preferably being at 350 ng/mL FEU. Using an insensitive method or an inappropriate timing or D-dimer cut-off should be considered as a hazardous practice with the DASH Score.
How do you use the DASH Score in your own clinical practice? Can you give an example of a scenario in which you use it?
We must face reality: there are excellent reasons to advise a prolonged anticoagulant treatment in patients with the first episode of unprovoked VTE. Prolonged treatment with low-dose DOACs has really changed the scenario in these years, and probably nowadays there are fewer patients that may benefit from DASH than in the warfarin era. Still, there may be some patients that are willing to discontinue treatment because of their preferences or lifestyle, or simply because they suffered from a thrombotic episode that was deemed to be minor or not life-threatening. These are exactly the patients that I consider to be perfect to apply DASH.
What recommendations do you have for doctors once they have applied the DASH Score? Are there any adjustments or updates you would make to the score based on new data or practice changes?
Data from the DULCIS management study (Palareti 2014) suggest that the use of repeated D-dimer with the resumption of the anticoagulant therapy may be a safer approach for patients, further reducing the recurrence risk. Whether repeating D-dimer measurement and DASH Score is worthwhile is however unknown, but could be perhaps considered after one month if the DASH Score was negative in the first evaluation.
Any other research in the pipeline that you're particularly excited about?
We are running a very ambitious study here in Italy named APIDULCIS, that it is aimed at evaluating if patients having a normal D-dimer (and hence with a presumably low DASH Score) compare in terms of VTE recurrence with patients having increased D-dimer at resuming an anticoagulant therapy with low-dose apixaban. This study will offer an interesting insight into the usefulness of D-dimer and of the DASH Score in the management of patients with unprovoked VTE.
About the Creator
Alberto Tosetto, MD, is the director of the Hemophilia and Thrombosis Center at the San Bortolo Hospital, Vicenza, Italy. He is a hematologist with a long-lasting interest in benign hematology, hemostasis, and clinical epidemiology.
To view Dr. Alberto Tosetto's publications, visit PubMed