Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Suspected Acute Venous Thromboembolic Disease
Official 2018 guideline from the American College of Emergency Physicians.
summary by Eric Steinberg, DO, MEHP
Recommendations
Risk Stratification
For patients who are at low risk for acute pulmonary embolism (PE), use the Pulmonary Embolism Rule-out Criteria (PERC) to exclude the diagnosis without further diagnostic testing.
Level B
In patients older than 50 years deemed to be low or intermediate risk for acute pulmonary embolism (PE), clinicians may use a negative age-adjusted D-dimer* result to exclude the diagnosis of pulmonary embolism.
*For highly sensitive D-dimer assays using fibrin equivalent units (FEU) use a cutoff of age × 10 μg/L; for highly sensitive D-dimer assays using D-dimer units (DDU), use a cutoff of age × 5 μg/L.
*For highly sensitive D-dimer assays using fibrin equivalent units (FEU) use a cutoff of age × 10 μg/L; for highly sensitive D-dimer assays using D-dimer units (DDU), use a cutoff of age × 5 μg/L.
Level B
Selected patients with acute pulmonary embolism (PE) who are at low risk for adverse outcomes as determined by Pulmonary Embolism Severity Index (PESI), simplified PESI (sPESI), or the Hestia Criteria may be safely discharged from the emergency department (ED) on anticoagulation, with close outpatient follow-up.
Level C
Intervention
Given the lack of evidence, anticoagulation treatment decisions for patients with subsegmental pulmonary embolism (PE) without associated deep venous thrombosis (DVT) should be guided by individual patient risk profiles and preferences. [Consensus recommendation]
Level C
In selected patients diagnosed with acute deep venous thrombosis (DVT) , a non-vitamin K antagonist oral anticoagulant (NOAC) may be used as a safe and effective treatment alternative to low-molecular-weight heparin (LMWH)/vitamin K antagonist (VKA).
Level B
Selected patients with acute deep venous thrombosis (DVT) may be safely treated with a non-vitamin K antagonist oral anticoagulant (NOAC) and directly discharged from the emergency department (ED).
Level C
What do the icons mean?
Level A
Generally accepted principles for patient care that reflect a high degree of clinical certainty (eg, based on evidence from 1 or more Class of Evidence I or multiple Class of Evidence II studies).Level B
Recommendations for patient care that may identify a particular strategy or range of strategies that reflect moderate clinical certainty (eg, based on evidence from 1 or more Class of Evidence II studies or strong consensus of Class of Evidence III studies).Level C
Recommendations for patient care that are based on evidence from Class of Evidence III studies or, in the absence of any adequate published literature, based on expert consensus. In instances where consensus recommendations are made, “consensus” is placed in parentheses at the end of the recommendation.
