Amir Qaseem, MD, PhD, MHA; Vincenza Snow, MD, MS; Patricia Barry, MD, MPH; E. Rodney Hornbake, MD; Jonathan E. Rodnick, MD; Timothy Tobolic, MD; Belinda Ireland, MD, MS; Jodi B. Segal, MD; Eric B. Bass, MD, MPH; Kevin B. Weiss, MD, MPH; Lee Green, MD, MPH; Douglas K. Owens, MD, MS; and the Joint American Academy of Family Physicians/American College of Physicians Panel on Deep Venous Thrombosis/Pulmonary Embolism†
Disclaimer: No statement in this article should be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
Note: Clinical guidelines are “guides” only and may not apply to all patients and all clinical situations. Thus, they are not intended to override clinicians' judgment. All American College of Physicians clinical practice guidelines are considered automatically withdrawn or invalid 5 years after publication or once an update has been issued.
Grant Support: The American College of Physicians and the American Academy of Family Physicians operating budgets.
Potential Financial Conflicts of Interest: None disclosed.
Request for Single Reprints: Amir Qaseem, MD, PhD, MHA, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.
This guideline summarizes the current approaches for the diagnosis of venous thromboembolism. The importance of early diagnosis to prevent mortality and morbidity associated with venous thromboembolism cannot be overstressed. This field is highly dynamic, however, and new evidence is emerging periodically that may change the recommendations. The purpose of this guideline is to present recommendations based on current evidence to clinicians to aid in the diagnosis of lower extremity deep venous thrombosis and pulmonary embolism.
*This guideline was originally published in the Annals of Family Medicine on 1 January 2007. Readers who wish to cite this article should use the following citation: Qaseem A, Snow V, Barry P, Hornbake ER, Rodnick JE, Tobolic T, et al. Current diagnosis of venous thromboembolism in primary care: A clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians. Ann Fam Med. 2007;5:57-62.
†Clinical Efficacy and Assessment Subcommittee of the American College of Physicians: Douglas K. Owens, MD, MS (Chair); Mark Aronson, MD; Donald E. Casey Jr., MD, MPH, MBA; J. Thomas Cross Jr., MD, MPH; Nancy C. Dolan, MD; Nick Fitterman, MD; E. Rodney Hornbake, MD; Paul Shekelle, MD, PhD; Katherine D. Sherif, MD; and Kevin Weiss, MD, MPH (Immediate Past Chair). Commission on Science of the American Academy of Family Physicians: Eric M. Wall, MD, MPH (Chair); Kevin A. Peterson, MD, MPH; James M. Gill, MD; Robert C. Marshall, MD, MPH; Jonathan E. Rodnick, MD; Kenneth G. Schellhase, MD, MPH; Steven W. Strode, MD, MEd, MPH; Kurtis S. Elward, MD, MPH; James W. Mold, MD, MPH; Jonathan L. Temte, MD, PhD; Frederick M. Chen, MD, MPH; Thomas F. Koinis, MD; Donya A. Powers, MD; Karl M. Kochendorfer, MD; Peter John Oppelt; Herbert F. Young, MD, MA; and Bellinda K. Schoof, MHA. Approved by the American College of Physicians Board of Regents on 4 April 2006. Approved by the American Academy of Family Physicians Board of Directors on 28 March 2006.
Table 1. Wells Prediction Rule for Diagnosing Deep Venous Thrombosis: Clinical Evaluation Table for Predicting Pretest Probability of Deep Venous Thrombosis*
Table 2. Wells Prediction Rule for Diagnosing Pulmonary Embolism: Clinical Evaluation Table for Predicting Pretest Probability of Pulmonary Embolism*
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David T. Lush
Univ of Pennsylvania
April 24, 2007
Delay in Thromboembolism Evaluation
The article by Quseem and colleagues provides a clinical practice guideline regarding the diagnosis of lower extremity deep vein thrombosis and pulmonary embolism specifically addressed to primary care physicians. High-sensitive D-dimer assay is recommended in appropriately selected patients with low pretest probability by the Wells predition rules.
Rapid institution of therapy has always been a priority in thromboembolism. Few primary care physicians have access to same day test results. The issue of time was not discussed in the guidelines but should be a factor in the decision making.
Raghava S Kumar Bhamidimarri
April 30, 2007
Applying your guidelines for Upper Limb Deep Vein Thrombosis?
This article highlights the important aspects of diagnosing venous thromboembolism. The article however does not clarify if these guidelines are applicable for suspected Upper limb deep vein thrombosis. I am aware that there has been no trial evidence testing the Well's score for suspected upper limb deep vein thrombosis but from a pragmatic sense, upper limb deep veins are not much different to lower limb deep veins.
American College of Physicians
May 15, 2007
Our recommendations are based on only evidence from randomized controlled trials. That is why the studies that were mentioned in the letters comparing the efficacy of LMWH vs. UFH as well as for safety of heparin and warfarin during pregnancy were not mentioned in the guideline. However, LMWH is more cost-effective compared to UFH. Although there are many studies evaluating prophylactic use of LMWH in pregnant women, the evidence is scarce for treating DVT or PE in pregnant women.
Qaseem A, Snow V, Barry P, Hornbake ER, Rodnick JE, Tobolic T, et al. Current Diagnosis of Venous Thromboembolism in Primary Care: A Clinical Practice Guideline from the American Academy of Family Physicians and the American College of Physicians*. Ann Intern Med. 2007;146:454–458. doi: 10.7326/0003-4819-146-6-200703200-00013
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Published: Ann Intern Med. 2007;146(6):454-458.
Guidelines, Venous Thromboembolism.
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