By American College of Chest Physicians
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Thrombolytic therapy is currently recommended for patients with acute PE who show signs of hemodynamic instability, unless there are major contraindications related to the bleeding risk. Inferior Vena Cava Interruption Inferior vena cava interruption is most commonly achieved with the use of an intravascular filter. A randomized trial found that the use of an inferior vena cava filter reduced the rate of PE, had no effect on mortality, and was associated with a greater risk of recurrent DVT. These devices are being used more frequently, especially now that many can be safely retrieved after several months.
Therefore, patients presenting with suspected DVT should first have the pretest probability of disease determined. The Wells clinical prediction rule (Table 1) has been assessed and validated in multiple studies, and it can accurately categorize patients into low, moderate, or high probability of having the disease. Obtaining a d-dimer level at this point in the evaluation further simplifies the approach and may obviate the need for further testing. Sensitive d-dimer assays (ie, enzyme-linked immunosorbent assay [ELISA] or semiquantitative rapid ELISA) have sufficient Table 1.
8th ed. Chest 2008; 133:454S−545S. Comprehensive evidence-based literature review and graded recommendations on treatment of DVT and PE. Kearon C, Ginsberg JS, Hirsh J. The role of venous ultrasonography in the diagnosis of suspected deep venous thrombosis and pulmonary embolism. Ann Intern Med 1998; 129:1044−1049 Pulmonary Vascular Diseases (Moores) 7/10/09 8:03:55 PM Venous ultrasonography is a valuable test for the diagnosis and management of patients with suspected DVT or PE. However, the following factors reduce the positive predictive value of venous ultrasonography for detecting acute thromboembolism: asymptomatic for DVT, low clinical suspicion for DVT, abnormality confined to a short segment of a proximal vein, abnormality confined to the calf veins; history of VTE, negative result of another test that is sensitive for DVT (such as d-dimer), and low prevalence of DVT in a referral population.
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