Venous Thromboembolism (VTE)

[2014 update]

Introduction to this self-study CME activity

Purpose

Deep venous thrombosis (DVT), along with pulmonary embolism (PE), is one of the most frequent causes of hospitalization for adults, often complicates surgery and childbirth, carries significant risk of death and of long-term sequelae, and is one of the most challenging and often subtle diagnoses in clinical practice.  Improved therapy (LMWH) and diagnostic modalities (duplex Doppler ultrasound for DVT, formal risk scores and D-dimer testing) are available.  This self-study CME activity helps physicians:

  1. Improve the recognition of VTE and selection of appropriate testing.
  2. Improve selection of appropriate therapy. 
  3. Shorten resolution time for clinical symptoms.
  4. Reduce bleeding and other complications. 
  5. Reduce recurrence of VTE
  6. Reduce incidence of pulmonary embolism. 
  7. Reduce mortality. 
  8. Avoid preventable Emergency Department visits and hospital admissions

New information in this update regarding treatment includes:

  • Initiate both heparin and warfarin anticoagulation.  Initiate heparin immediately upon diagnosis. (Low molecular weight heparin is preferred over UFH for both PE and DVT.) Warfarin should also be started on day 1 of treatment simultaneous to heparin initiation (no longer delay for heparin loading).
  • Outpatient management.  Patients who are clinically stable and not at elevated risk due to comorbidities can be managed entirely as outpatients.
  • If heparin contraindicated.  Patients who are not candidates for heparin anticoagulation due to risk of major bleeding or to drug sensitivity may be candidates for one of the new non-heparin anticoagulant agents (e.g., argatroban).   Those who cannot use any anticoagulant should have an inferior vena cava filter placed.
  • Rivaroxaban.  Rivaroxaban is FDA approved for VTE prophylaxis and treatment. It can be initiated as oral monotherapy in place of heparin/warfarin.  It does not have the drug and diet limitations of warfarin, as it has little hepatic metabolism, and is not affected by vitamin K intake, but it is far more expensive.

 Key aspects for diagnosis include:

  • DVT.  Formal clinical likelihood estimation is necessary and should precede imaging with a single duplex color Doppler venous ultrasound scan.
  • PE.  Formal clinical likelihood estimation is necessary, and should precede imaging by CT scanning.
  • Alternate for diagnosis exclusion.  Patients with low prior probability on clinical likelihood estimation (Wells criteria scoring) can have high-sensitivity D-dimer testing to exclude DVT or PE without imaging.  D-dimer testing is not indicated for patients at moderate or high prior probability.

Objectives

Participants in this CME activity will understand and be able to implement evidence-based cost-effective clinical strategies for the diagnosis and treatment of adults with suspected acute deep venous thrombosis of the upper and lower extremity, pulmonary embolus, or both.

Audience

This self-study activity on VTE is appropriate for primary care clinicians and other health care providers who treat adult patients with suspected acute deep venous thrombosis (DVT) of the lower or upper extremity, pulmonary embolus (PE), or both.

Authors

Team Leaders

  • Grant M. Greenberg, MD, MA, MHSA
    Family Medicine

Team Members

  • Brian J Brophy, MD
    General Medicine
  • Kirk A Frey, MD, PhD
    Nuclear Medicine
  • James B Froehlich, MD, MPH
    Director, Anticoagulation Services
  • R Van Harrison, PhD
    Medical Education
  • Steven Kronick, MD
    Emergency Medicine
  • Melissa A. Miller, MD, MS
    Pulmonary & Critical Care Medicine
  • Marc J. Moote, MS, PA-C, MD
    Surgery
  • David M Williams, MD
    Radiology
  • Thomas W Wakefield, MD
    Vascular Surgery

Author Disclosures

Neither the team lead, the team members, nor the consultants have financial relationships with commercial companies whose products are discussed in this CME activity.
Brian Brophy, MD
(None)
Krik Frey, MD, PhD
Consultant, grant, stock
MIM Software, Lilly, AVID Radiopharmaceuticals, Bayer-Schering, Semiens and Piramal Imaging
James Froelich, MD
Consultant
Boeringer-Ingelheim, Janssen, Merck, Pfizer, Sanofi-Aventis
Grant Greenberg, MD, MA, MHSA
(None)
R Van Harrison, PhD
(None)
Steven Kronick, MD
(None)
Melissa Miller, MD, MS
(None)
Marc Moote, PA-C
(None)
Thomas Wakefield, MD
(None)
David Williams, MD
(None)

Other Acknowledgements

UMHS Guidelines Oversight Team

  • Grant Greenberg, MD, MA, MHSA
  • R. Van Harrison, PhD

Literature Search Services

  • Taubman Medical Library

Production of Internet Format and Website Maintenance

  • Ellen Patrick-Dunlavey, MA

CME Accreditation and Credit Designation

The University of Michigan Medical School is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

The University of Michigan Medical School designates this enduring material for a maximum of 1 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This CME activity was prepared for release in May 2014.  Credit may be awarded for a maximum of three years from its release date, specifically from May 2014 through April 2017.  Continuation of credit from that date depends on a thorough review of the content currency and accuracy.

Method of Participation

  1. View the web pages. You may print the self-study text to read off-line.
  2. Complete the on-line learning assessment test with a score of 70% or higher.  After you initially take the test, the test will be immediately electronically scored. 
    If fewer than 70% of the questions are answered correctly, the questions that were not answered correctly will be noted in red.  Review the CME content related to those topics and retake the test.
    If 70% or more of the questions are answered correctly, the correct and incorrect answers for all questions will be shown along with explanations of the basis for the correct answer.  The link to register and receive credit is shown at the end of the items and explanations. 
  3. Complete the electronic credit request and activity evaluation.  An electronic certificate of participation will be provided immediately.
  4. Print the certificate of participation for your personal records.