Need for tailored strategies to diagnose venous thrombo-embolism in older primary care patients. Extension of a keynote presentation at the 2012 Wonca Europe conference

Figures & data

Figure 1. Diagnostic and treatment strategies for patients with suspected DVT.

Table 1. ‘Blind treatment’ in patients suspected of DVT (i.e. without confirmation by ultrasonography): clinical probability score for DVT against HAS-BLED. We recommend cautious interpretation of this consideration. First, though standard of care, the assumption that anticoagulant treatment would benefit the outcome of thrombosis is based on scarce and old data. Improved imaging techniques led to a substantial increase of the detection rates of smaller thrombi over the past decades which led to a doubling of the incidence. Hence, assumptions concerning the natural course of disease and the benefit of anticoagulation are derived from populations distinct from that being treated nowadays. For the latter, the clinical benefit of anticoagulation treatment might thus be over-estimated (23). Second, we compared the complication risk of VTE with the major bleeding risk. However, the impact of major bleeding - especially intracranial bleeding - on the quality of life, mortality risk and healthcare costs- might be higher than the impact of pulmonary embolism (24–26).

Score on diagnostic decision strategy for DVT^a,b		0 to 3	4 to 5	7 to 9	10 to 13
	Risk of DVT^a	0.7	4.5	21.7	51.3
HAS-BLED score	Estimated subsequent risk of PE^bMajor bleeding risk within 0.5 year^c	0.3	1.7	8.2	19.5
0	0.6	^f	^d	^d	^d
1	0.5	^f	^d	^d	^d
2	0.9	^f	^d	^d	^d
3	1.9	^f	^e	^d	^d
4	4.4	^f	^f	^d	^d
5	6.3	^f	^f	^e	^d

^aBased on the diagnostic decision strategy for deep vein thrombosis of Oudega et al., (15).

^bRisk of DVT multiplied by subsequent PE risk of 38%, according to Bauer et al., (18).

^cRisk of major bleeding within 6 months according to the HAS-BLED score (annual bleeding rate divided by 2) (20) (21). Used with the permission of the American College of Chest Physicians.

^dThough the majority of these patients do not have thrombosis, the average bleeding risk might be lower than the average estimated risk of developing PE in this group.

^eBleeding risk might be (approximately) equal to estimated risk of prolongation of the possible DVT to PE.

^fEstimated bleeding risk is higher than estimated risk of prolongation of the possible DVT to PE.

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