Hospital-based approach to the management of venous thromboembolism.

Abstract

The primary goal of venous thromboembolism (VTE) management is to prevent fatal pulmonary embolism (PE). It has long been recognized that venous thrombi in the deep veins of the legs are the source of more than 90% of fatal pulmonary emboli [1,2]. Thrombi that develop in the proximal deep leg veins (i.e. the iliofemoral system) are particularly prone to embolize. One of the great challenges confronting clinicians in hospital-based practice is that the clinical diagnosis of VTE is not speci~c. VTE is clinically suspected in approximately 600,000 patients each year, but is con~rmed in only one third [3]. Further increasing the diagnostic challenge, a clinical diagnosis of VTE is not sensitive [4]. Only one in three patients with clinically signi~cant VTE are clinically suspected (Figure 1). Even physicians who are aware of the dangers of VTE must struggle to identify high-risk patients and to make a ~rm diagnosis. The potential public health impact of VTE is considerable, with the potential for overuse of diagnostic tests, on the one hand, and high morbidity and mortality, on the other. Clearly, the identi~cation of high-risk patients and the institution of effective preventive strategies are vital in the comprehensive management of VTE[5]. The odds of acute proximal DVT vary widely from 1:2000 in the general population to 1:3 in hospitalized patients with VTE signs and symptoms (e.g., calf or thigh pain, leg swelling, unexplained dyspnea; Table 1). While VTE signs and symptoms are generally not suf~ciently speci~c to form a basis for treatment decisions, they are suf~cient to justify an order for objective tests. Because a majority of patients with VTE do not have clinical signs or symptoms, including patients with proximal thrombi involving the iliofemoral system (i.e., those most likely to embolize) and patients who die from PE [6], a high index of suspicion must be maintained in hospitalized patients. Particular attention should be given to patients with recognized VTE risk factors (Table 2).