2018

Venous
Thromboembolic
Diseases: Diagnosis,
Management and
Thrombophilia Testing
NICE Clinical Guidelines, No. 144
National Clinical Guideline Centre (UK).
London: Royal College of Physicians (UK); 2012 Jun.

HALIMA IDHIL MOHAMUD

STUDENT ID: MOH18172837
Venous Thromboembolic Diseases:
Diagnosis, Management and
Thrombophilia Testing
A National Institute for Health and Clinical Excellence (NICE) guideline was made available in January
2012 concerning management of venous thromboembolic disease and thrombophilia testing (NICE,
2012). Its main concern was to put forward a detailed introduction of Venous Thromboembolism
diseases and offer various recommendations of practice which aid healthcare professionals in the
diagnosis and management of VTE.

This review of the NICE Clinical Guidelines 144 (NCG 144) will focus and discuss on a brief outline on
venous thromboembolic diseases, afford a brief critique of the outlined recommendation as well as
issues that were not covered by the NICE Guideline Development Group (GDG) due to newly updated
clinical and pharmacological advances.

Venous Thromboembolism (VTE) is the development of blood clots (referred to as a thrombus) in the
veins of the leg. The clinical manifestation of the disease is Deep Vein Thrombosis in the large veins
of the posterior limbs (Kesieme et al., 2011) and Pulmonary Embolism which generates when thrombi
dislodges from clots in vein walls and travels through the heart to pulmonary arteries in the lungs
(Goldhaber and Morrison, 2002). In 1884, the formation of a thrombus was linked with to the Rudolph
Virchow’s Triad; which involved principal risk factors such as “vascular endothelial damage, Immobility
and hypercoagulability of blood” (Anderson, 2003). A study done by Qaseem et al proposed that the
formation of clots in the popliteal veins were linked to an augmented risk of developing a pulmonary
embolism(Qaseem et al., 2007). They theorised that Calf vein thrombosis did not bring a higher risk
of developing a pulmonary embolism, but patients were at risk of acquiring Post Thrombotic
Syndrome.

Complications and death from VTE are highly avoidable with the appropriate treatment and
management. The NICE CG144 offers various recommendations on the diagnostic techniques for
suspected VTE patients. The guideline recommends a set of strategies to investigate, to begin a
preliminary investigative step for is the clinical probability assessment known as the Wells Score (Wells
et al., 1997). The DVT and PE Wells Scores are medical scoring systems that is able to forecast the
likelihood of a DVT or PE, for a score of less than 2 DVT and PE are highly unlikely and for a score of 2
or greater the chances of the patient having a DVT or PE would be likely (Wells et al., 1997). The
Probability scoring system is followed by a D-Dimer Test and Imaging procedures such as Ultrasound
(DVT), CTPA and V/Q SPECT or Planar to further confirm or rule out DVT and PE (NICE, 2012).
Performing a proximal or whole leg ultrasound is not recommended by the NCG144 as a first-line
diagnostic management in patients presenting with the clinical signs of PE and DVT, the Health care
provider is advised to proceed with a D- dimer test (NICE, 2012). Positive assays of the test thereby
demand supplementary imaging tests to be performed. The guidelines have summarised algorithm
schemes making it easier for MDTs to follow.
Previously, the standard therapy for VTE was Unfractionated Heparin (UFH) given intravenously
(McRae and Eikelboom, 2007). UFH needed careful supervision due to having various side effects such
as bleeding complications. In 2012, the NICE guidelines recommended low molecular weight heparin
(LMWH) or fondaparinux (NICE, 2012) offered intravenously for 5 days an INR of 2 to 3. In the proposed
update of the Guidelines, Anticoagulants Rivaroxaban and Apixaban have been relegated to be the
first line treatment of VTE (NICE., 2012; Perzborn et al., 2010). The guidance on Pharmacological
management of VTE has yet to be updated. The role and action of the New Direct Oral Anticoagulants
(DOACs) such as Rivaroxaban and Apixaban which work as an anti-Xa inhibitor and thrombin inhibitors
in the management of DVT as well as hindrance of a VTE relapse have not been explored and recorded
(NICE., 2012).

With the advances of medicine and changes in patient care, there are areas in the NCG 144 that are
due for updating. To begin with, the management of VTE and mostly with regards to PE in children
(<18 years) and pregnant women has been omitted in the NCG 144 guidelines. However, there are
recent guidelines that have published the missing VTE management guidance on these population
(Chalmers et al., 2011; Guyatt et al., 2012). The guideline does not offer any direction on how to
manage patients that qualify for home VTE thrombolytic treatment even with the opportuneness of
the Pulmonary Embolism Severity Index score (Choi et al., 2009) which can be used to highlight
patients at a lower risk of bleeding and that are therefore eligible for home management (Aujesky et
al., 2005).

In conclusion, NCG 144 provides a systematic standard profile for the primary investigation and
management of VTE. The guideline compromises of crucial recommendations for the pharmacological
treatment as well as general management that should be offered to patients with suspected VTE
diagnosis constructed on entrenched compelling clinical principles. On the other hand, due to recent
advances in Medicine and Pharmacological interventions, several crucial areas have yet to be
highlighted, leaving areas of clinical ambiguity for MDTs pertaining to the management of VTE both in
hospital and outpatient care. There is an update due in 2019 which would highlight the areas where
evidence has amplified. This should significantly be beneficial.

Word count =880

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