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Deep Vein Thrombosis (DVT)

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General Information

Description

  • DVT is a blood clot in the deep vein system causing obstruction of blood flow1
  • DVT most often occurs in the legs, but may also develop in the upper extremities, splanchnic veins, and cerebral veins1
  • DynaMed commentary -- this topic focuses mainly on the DVT of the legs

Definitions

  • venous thromboembolism (VTE)
  • a provoked DVT is caused by a clear inciting factor, including
    • transient factors (risk factors that resolve after incidence of provoked VTE); these include
      • major transient inciting factors that occur during 3 months prior to diagnosis
        • inciting factors are considered 'major' if associated with
          • half the risk of recurrent VTE after end of anticoagulant therapy compared to no transient risk factor
          • 10-fold higher risk of having first VTE
        • examples of major transient inciting factors include
          • surgery with general anesthesia lasting > 30 minutes
          • bed confinement in hospital ≥ 3 days with acute illness
          • Cesarean section
      • minor transient inciting factors that occur during 2 months prior to diagnosis
        • inciting factors considered 'minor' if associated with
          • half the risk of recurrent VTE after end of anticoagulant therapy compared to no transient risk factor
          • 3- to 10-fold increase in risk of having first VTE
        • examples of minor transient inciting factors include
          • surgery with general anesthesia for < 30 minutes
          • hospitalization for < 3 days with acute illness
          • estrogen therapy
          • pregnancy or puerperium
          • bed confinement out of hospital ≥ 3 days with acute illness
          • reduced mobility due to leg injury ≥ 3 days
    • persistent risk factors
      • persistent risk factors include chronic conditions that are known to increase risk of VTE
      • active cancer is considered persistent risk factor if any of the following
        • no potentially curative treatment has been administered
        • no evidence that treatment was curative (for example, disease recurrence or progression)
        • ongoing treatment
      • other persistent noncancer risk factors associated with 2-fold increase in risk of recurrent VTE after end of anticoagulant therapy include conditions associated with chronic inflammatory diseases such as inflammatory bowel disease, autoimmune disease, and chronic infections
    • Reference - 27428935J Thromb Haemost 2016 Jul;14(7):1480OpenInNew
  • unprovoked DVT - DVT that is not provoked by transient or persistent risk factors (27428935J Thromb Haemost 2016 Jul;14(7):1480OpenInNew)
  • massive DVT
  • superficial femoral vein
    • inappropriate term that is not recognized anatomically but has been used frequently in lower limb venous duplex reports
    • superficial femoral vein is a deep vein and thrombosis should be treated as DVT
    • Reference - 7563535JAMA 1995 Oct 25;274(16):1296OpenInNew
  • postthrombotic syndrome (PTS)

Types

References

General references used

  1. Di Nisio M, van Es N, Büller HR. Deep vein thrombosis and pulmonary embolism. Lancet. 2016 Dec 17;388(10063):3060-3073OpenInNew
  2. Bates SM, Jaeschke R, Stevens SM, et al; American College of Chest Physicians. Diagnosis of DVT: Antithrombotic Therapy and Prevention of Thrombosis, Ninth Edition: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):e351S-418SOpenInNewfull-textOpenInNew
  3. Kearon C, Akl EA, Ornelas J, et al; Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest. 2016 Feb;149(2):315-52OpenInNew, editorial can be found in Chest 2016 Feb;149(2):293OpenInNew

Recommendation grading systems used

  • American College of Chest Physicians (ACCP) grades
    • Grade 1 - strong recommendation based on clear risk/benefit balance
    • Grade 2 - weak recommendation based on unclear or close risk/benefit balance
    • Grade A - high-quality evidence based on consistent evidence from randomized trials without important limitations or exceptionally strong evidence from observational studies
    • Grade B - moderate-quality evidence based on randomized trials with important limitations (inconsistent results, methodologic flaws, indirect or imprecise results) or very strong evidence from observational studies
    • Grade C - low- or very low-quality evidence based on evidence for ≥ 1 critical outcome from observational studies, case series, or randomized trials with serious flaws or indirect evidence
    • Reference - ACCP evidence-based clinical practice guideline on methodology for development of antithrombotic therapy and prevention of thrombosis (22315256Chest 2012 Feb;141(2 Suppl):53SOpenInNewfull-textOpenInNew), commentary can be found in 23546508Chest 2013 Apr;143(4):1190OpenInNew
  • American Heart Association/American Stroke Association (AHA/ASA) grading system for recommendations
    • classifications of recommendations
      • Class I - procedure or treatment should be performed or administered
      • Class IIa - reasonable to perform procedure or administer treatment, but additional studies with focused objectives needed
      • Class IIb - procedure or treatment may be considered; additional studies with broad objectives needed, additional registry data would be useful
      • Class III - procedure or treatment should not be performed or administered because it is not helpful or may be harmful
        • Class III ratings may be subclassified as Class III No Benefit or Class III Harm
    • levels of evidence
      • Level A - data derived from multiple randomized clinical trials or meta-analyses
      • Level B - data derived from single randomized trial or nonrandomized studies
      • Level C - only expert opinion, case studies, or standard of care
  • Canadian Interdisciplinary Expert Panel on iliofemoral deep vein thrombosis (InterEPID) levels of evidence and classification of recommendations
    • classifications of recommendations
      • Class I - procedure or treatment should be performed or administered
      • Class IIa - reasonable to perform procedure or administer treatment, but additional studies with focused objectives needed
      • Class IIb - procedure or treatment may be considered; additional studies with broad objectives needed, additional registry data would be useful
      • Class III - procedure or treatment should not be performed or administered because it is not helpful or may be harmful
        • Class III ratings may be subclassified as Class III No Benefit or Class III Harm
    • levels of evidence
      • Level A - data derived from multiple randomized clinical trials or meta-analyses
      • Level B - data derived from single randomized trial or nonrandomized studies
      • Level C - only expert opinion, case studies, or standard of care

Synthesized Recommendation Grading System for DynaMed

  • DynaMed systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based MethodologyOpenInNew).
  • Guideline recommendations summarized in the body of a DynaMed topic are provided with the recommendation grading system used in the original guideline(s), and allow DynaMed users to quickly see where guidelines agree and where guidelines differ from each other and from the current evidence.
  • In DynaMed (DM), we synthesize the current evidence, current guidelines from leading authorities, and clinical expertise to provide recommendations to support clinical decision-making in the Overview & Recommendations section.
  • We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE)OpenInNew to classify synthesized recommendations as Strong or Weak.
    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
    • Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
  • DynaMed (DM) synthesized recommendations (in the Overview & Recommendations section) are determined with a systematic methodology:
    • Recommendations are initially drafted by clinical editors (including ≥ 1 with methodological expertise and ≥ 1 with content domain expertise) aware of the best current evidence for benefits and harms, and the recommendations from guidelines.
    • Recommendations are phrased to match the strength of recommendation. Strong recommendations use "should do" phrasing, or phrasing implying an expectation to perform the recommended action for most patients. Weak recommendations use "consider" or "suggested" phrasing.
    • Recommendations are explicitly labeled as Strong recommendations or Weak recommendations when a qualified group has explicitly deliberated on making such a recommendation. Group deliberation may occur during guideline development. When group deliberation occurs through DynaMed-initiated groups:
      • Clinical questions will be formulated using the PICO (Population, Intervention, Comparison, Outcome) framework for all outcomes of interest specific to the recommendation to be developed.
      • Systematic searches will be conducted for any clinical questions where systematic searches were not already completed through DynaMed content development.
      • Evidence will be summarized for recommendation panel review including for each outcome, the relative importance of the outcome, the estimated effects comparing intervention and comparison, the sample size, and the overall quality rating for the body of evidence.
      • Recommendation panel members will be selected to include at least 3 members that together have sufficient clinical expertise for the subject(s) pertinent to the recommendation, methodological expertise for the evidence being considered, and experience with guideline development.
      • All recommendation panel members must disclose any potential conflicts of interest (professional, intellectual, and financial), and will not be included for the specific panel if a significant conflict exists for the recommendation in question.
      • Panel members will make Strong recommendations if and only if there is consistent agreement in a high confidence in the likelihood that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. Panel members will make Weak recommendations if there is limited confidence (or inconsistent assessment or dissenting opinions) that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. No recommendation will be made if there is insufficient confidence to make a recommendation.
      • All steps in this process (including evidence summaries which were shared with the panel, and identification of panel members) will be transparent and accessible in support of the recommendation.
    • Recommendations are verified by ≥ 1 editor with methodological expertise, not involved in recommendation drafting or development, with explicit confirmation that Strong recommendations are adequately supported.
    • Recommendations are published only after consensus is established with agreement in phrasing and strength of recommendation by all editors.
    • If consensus cannot be reached then the recommendation can be published with a notation of "dissenting commentary" and the dissenting commentary is included in the topic details.
    • If recommendations are questioned during peer review or post publication by a qualified individual, or reevaluation is warranted based on new information detected through systematic literature surveillance, the recommendation is subject to additional internal review.

DynaMed Editorial Process

Special acknowledgements

  • Zbys Fedorowicz, MSc, DPH, BDS, LDSRCS (Director of Bahrain Branch of the United Kingdom Cochrane Center, The Cochrane Collaboration; Awali, Bahrain)
  • Dr. Fedorowicz declares no relevant financial conflicts of interest.
  • William Aird, MD (Deputy Editor of Hematology, Nephrology, and Oncology; Professor of Medicine, Harvard Medical School; Massachusetts, United States)
  • Dr. Aird declares no relevant financial conflicts of interest.
On behalf of the American College of Physicians
  • Barbara Turner, MD, MSEd, MACP, ACP Deputy Editor, Clinical Decision Resource, as part of the ACP-EBSCO Health collaboration, managed the ACP peer review of the Overview and Recommendations section and related clinical content in this topic.
  • Michael B. Streiff, MD, FACP (Professor, Department of Medicine and Pathology, and Associate Professor, Department of Pathology, Johns Hopkins University School of Medicine; Associate Faculty, Armstrong Institute for Patient Safety and Quality; Attending Physician, The Johns Hopkins Hospital; Medical Director, The Johns Hopkins Hospital Special Coagulation Laboratory; Attending Physician, The Johns Hopkins Hospital Comprehensive Hemophilia Treatment Center; Maryland, United States)
  • Dr. Streiff declares no relevant financial conflicts of interest.
  • DynaMed topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or evaluation of guidelines.
  • Editorial Team role definitions
    Topic Editors define the scope and focus of each topic by formulating a set of clinical questions and suggesting important guidelines, clinical trials, and other data to be addressed within each topic. Topic Editors also serve as consultants for the internal DynaMed Editorial Team during the writing and editing process, and review the final topic drafts prior to publication.
    Section Editors have similar responsibilities to Topic Editors but have a broader role that includes the review of multiple topics, oversight of Topic Editors, and systematic surveillance of the medical literature.
    Recommendations Editors provide explicit review of DynaMed Overview and Recommendations sections to ensure that all recommendations are sound, supported, and evidence-based. This process is described in "Synthesized Recommendation Grading."
    Deputy Editors are employees of DynaMed and oversee DynaMed internal publishing groups. Each is responsible for all content published within that group, including supervising topic development at all stages of the writing and editing process, final review of all topics prior to publication, and direction of an internal team.

How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T133588, Deep Vein Thrombosis (DVT); [updated 2018 Nov 30, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T133588. Registration and login required.
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    Overview and Recommendations

    • Background

    • Evaluation

    • Management

  • Related Summaries

  • KeyboardArrowRight

    General Information

    • Description

    • Definitions

    • Types

  • KeyboardArrowRight

    Epidemiology

    • Who is most affected

    • KeyboardArrowRight

      Incidence/Prevalence

      • General population

      • Hospitalized patients

      • Patients with cancer

      • Surgery patients

      • Pregnancy, delivery, and postpartum period

    • Associated conditions

  • KeyboardArrowRight

    Etiology and Pathogenesis

    • Pathogenesis

    • Risk factors

  • Clinical Presentation

  • Evaluation of DVT

  • Management of DVT

  • Complications of DVT

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    Prognosis

    • Mortality

    • Recurrent venous thromboembolism (VTE)

  • KeyboardArrowRight

    Quality Improvement

    • Choosing Wisely

    • Choosing Wisely Canada

    • Choosing Wisely Australia

    • Medicare/Joint Commission National Hospital Inpatient Quality Measures

    • Physician Quality Reporting System Quality Measures

  • KeyboardArrowRight

    Guidelines and Resources

    • KeyboardArrowRight

      Guidelines

      • International guidelines

      • United States guidelines

      • United Kingdom guidelines

      • Canadian guidelines

      • European guidelines

      • Asian guidelines

      • Mexican guidelines

      • Australian and New Zealand guidelines

    • Review articles

    • MEDLINE search

  • Patient Information

  • KeyboardArrowRight

    ICD Codes

    • ICD-10 codes

  • KeyboardArrowRight

    References

    • General references used

    • Recommendation grading systems used

    • Synthesized Recommendation Grading System for DynaMed

    • DynaMed Editorial Process

    • Special acknowledgements

    • How to cite

Recommendations Editor
Zbys Fedorowicz MSc, DPH, BDS, LDSRCS
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Affiliations

Director of Bahrain Branch of the United Kingdom Cochrane Center, The Cochrane Collaboration; Awali, Bahrain

Conflicts of Interest

Dr. Fedorowicz declares no relevant financial conflicts of interest.

Deputy Editor
William Aird MD
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Affiliations

Deputy Editor of Hematology, Nephrology and Oncology, Dynamed; Massachusetts, United States; Professor of Medicine, Harvard Medical School; Massachusetts, United States

Conflicts of Interest

Dr. Aird declares no relevant financial conflicts of interest.

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