Venous thromboembolism management and the new NICE guidance: what the busy GP needs to know.

Abstract

This article summarises the 2020 National Institute for Health and Care Excellence (NICE) venous thromboembolism (VTE) guidelines, which are also covered in Royal College of General Practitioners (RCGP) Essential Knowledge Updates (EKU) e-learning. This article focuses on rapid detection and treatment, changes in recommendations around anticoagulation, and implications for primary care practice.1 Individual signs and symptoms have a low positive predictive value (PPV) for VTE, making the clinical diagnosis difficult. For example, one primary care study found 77.8% of patients with a pulmonary embolism (PE) were breathless at time of assessment and 59.8% had chest pain, but only 29.5% were tachycardic and 28.0% had calf pain.2 The PPV of unilateral leg swelling ≥2 cm is just 27% for deep vein thrombosis (DVT).3 Reassuringly, the absence of any clinical signs suggestive of DVT in low-risk patients has a negative predictive value of 97%.3 To help exclude a PE on clinical grounds, the NICE now recommends using the PERC rule (Pulmonary Embolism Rule-Out Criteria) among selected low-risk patients.4 A patient must score zero to exclude a PE. One external validation study including over 8000 patients found that a PERC score of 0 had a false negative rate of just 1.0% (95% confidence interval [CI] = 0.6% to 1.6%) in low-risk patients.4 It is important to note that the PERC score was developed in emergency departments and is yet to be externally …