CLINICAL PRACTICE GUIDELINES
MOH/P/PAK/264.13(GU)Clinical Pathways in thePrevention and Treatment of

Venous Thromboembolism

VTE

Ministry of Health

Malaysian Society of

National Heart Association

Academy of Medicine

Malaysia

Haematologyof Malaysia

Malaysia

Thromboprophylaxis in Hospitalised
Patients

Name of Assessor:

Ministry of Health
Malaysia

Date:" Metabolic, endocrine or respiratory pathologies !
# " Acute infectious disease !
# " Inflammatory conditions !
# " Sickle cell disease !
# " Thalassaemia !
v Varicose veins with phlebitis !

4. Risk factors for bleeding

1. Patient information
NAME:

DOB:

SEX:

v
v
v
v
v

HOSPITAL NO.

IC NO.

2. Assess the risk for VTE and the risk for bleedingv Assess all patients on admission to identify:
 t those who are at increased risk of VTE
 t those who are at increased risk of bleeding

5. Hospitalised Patients at increased Risk for VTE

v Reassess patients’ risks of VTE and bleeding within 24 hours ofadmission and whenever the clinical situation changes

v Regard medical patients as being at increased risk of VTE if they:t have had or are expected to have significantly reduced mobility! ! "#$!%&!'()*!+,
t are expected to have ongoing reduced mobility relative to their normal
state AND t have one or more of the risk factors for VTE

v Weigh the risk of VTE against the risk of bleeding

3. Risk factors for VTE
v
v
v
v
v
v
v
v
v
v
v

01

v
v
v

Active bleeding !
Acquired bleeding disorders (such as acute liver failure) !
Concurrent use of anticoagulants (e.g. warfarin with INR >2.0) !
Lumbar puncture/epidural/spinal anaesthesia expected within the next
12 hours !
Lumbar puncture/epidural/spinal anaesthesia within the previous
4 hours !
Acute stroke !
Uncontrolled systolic hypertension (230/120 mmHg or higher) !
Untreated inherited bleeding disorder !
(e.g. haemophilia or von Willebrand disease)

Active cancer !
Age >60 years !
Dehydration !
Critical care admission !
Obesity (BMI >30 kg/m2) !
Use of oestrogen­containing oral contraceptive pill !
Use of Hormone Replacement Therapy !
Post­partum (within 6 weeks) !
Previous VTE !
Family h/o VTE !
One or more significant medical comorbidities:" Heart disease !

Medical patients

Surgical & trauma patientsv Regard surgical patients and patients with trauma as being at increased
risk of VTE if they meet one of the following criteria:t Surgical procedure with a total anaesthetic and surgical time of>90 minutes, or 60 minutes if the surgery involves the pelvis or
lower limbt Acute surgical admission with inflammatory or intra­abdominal
condition
 t Expected significant reduction in mobility t One or more of the risk factors for VTE
02

6. Methods for VTE prophylaxis
A. Mechanicalv Base the choice of mechanical VTE prophylaxis on individual patient
factors including clinical condition, surgical procedure, patient preference
and if bleeding risk outweighs the risk of VTEv Choose any one of:# " Anti­embolism stockings !
# " Foot impulse devices !
# " Intermittent pneumatic compression devices !

Anti­embolism stockings (thigh or knee length)v Do not offer anti­embolism stockings to patients who have:# " Suspected or proven peripheral artery disease# " Peripheral arterial bypass grafting# " Peripheral neuropathy# " Any local conditions in which stockings may cause damage e.g.
dermatitis, gangrene, recent skin graft" Known allergy to material# " Cardiac failure# " Severe leg oedema# " Unusual leg size
# " Major limb deformity
v Use stockings that provide graduated compression and produce a calfpressure of 14 ­ 15 mmHg
v Encourage patients to wear their stockings day and night until they nolonger have significantly reduced mobility
v Remove stockings daily for hygiene purposes and to inspect skin

Foot impulse devices
v Encourage patient to use foot devices both in bed and when sitting ina chair

Intermittent pneumatic compression devices (thigh or knee length)v Encourage patient to use IPC devices for as much time as possible bothin bed and when sitting in a chair

B. Pharmacologicalv Base the choice of pharmacological VTE agents on individual patient
factors, including clinical condition and patient preferences
03

v Choose any one of:# " Low molecular weight heparin SC !
# " Fondaparinux sodium SC !
# " Rivaroxaban PO (at present, licensed for THR and TKR) !
# " Dabigatran etexilate PO (at present, licensed for THR and TKR) !
# " Unfractionated heparin SC !

Low molecular weight heparinv Choose either:# " Enoxaparin !
  tEnoxaparin 40 mg daily or  t Enoxaparin 20 mg daily (for moderate renal impairment with eGFR
15 ­ 30 mL/min/1.73/m2)" Tinzaparin !
  tTinzaparin 3500 units daily (lower VTE risk or moderate
renal impairment) or  t Tinzaparin 4500 units daily (higher VTE risk e.g. hip or knee
surgery or during pregnancy)

Fondaparinux sodium" Fondaparinux !
  tStarting dose at 2.5 mg (6 hours after surgery) followed by
2.5 mg daily  tContraindicated in severe renal impairment(eGFR <30 mL/min/1.73/m2)

Rivaroxaban" Rivaroxaban !
  t Starting dose at 10 mg (6 ­ 10 hours after surgery) followed by
10 mg daily  tNo dose adjustment in renal impairment with prophylactic dose

Dabigatran etexilate" Dabigatran !
  t Starting dose at 110 mg (1 ­ 4 hours after surgery) followed by
220 mg daily  tFor elderly >75 years, moderate renal impairment: 75 mg starting
dose, followed by 150 mg daily04

Unfractionated heparinv Choose UFH for patients with severe renal impairment(eGFR <15 mL/min/1.73/m2)# " UFH dose is 5000 units bd !

7. Monitoring platelet counts
v Patients who are to receive any heparin should have a baseline
platelet countv Post­operative patients, including obstetric cases, receiving UFH shouldhave platelet count monitoring performed every 2 ­ 3 days from days
4 to 14 until heparin is stopped
v Post­cardiopulmonary bypass patients receiving LMWH should haveplatelet count monitoring performed every 2 ­ 3 days from days 4 to 14
until heparin is stopped
v Post­operative patients (other than cardiopulmonary bypass patients)
receiving LMWH do not need routine platelet monitoringv Post­operative patients and cardiopulmonary bypass patients who havebeen exposed to heparin in the previous 100 days and are receiving any
type of heparin should have a platelet count determined 24 hours after
starting heparinv Medical patients and obstetric patients receiving heparin do not needroutine platelet monitoring

8. Using VTE prophylaxis in hospitalised patients
General medical patientsv Offer pharmacological VTE prophylaxis
v Start pharmacological VTE prophylaxis as soon as possible after risk
assessmentv Continue until patient is no longer at risk of VTE
Patients with stroke
v Do not offer anti­embolism stockings for VTE prophylaxis to patients
who are admitted for strokev Consider prophylactic­dose LMWH if a haemorrhagic stroke has been
excluded and the risk of bleeding is lowv Until the patient can have pharmacological VTE prophylaxis consider
a foot impulse or IPC device
05

Patients with cancer
v Offer pharmacological VTE prophylaxis and continue until the patient
is no longer at increased risk of VTE
Patients in palliative carev Consider pharmacological VTE prophylaxis in patients who havepotentially reversible acute pathology
v Do not routinely offer pharmacological or mechanical VTE prophylaxis
to patients admitted for terminal care
All surgical patientsv Assess the risks and benefits of stopping pre­existing establishedantiplatelet therapy 1 week before surgery
v Consider regional anaesthesia for individual patients as it carries alower risk of VTE than general anaesthesia
v If regional anaesthesia is used, plan the timing of pharmacological
VTE prophylaxis to inimize the risk of epidural haematoma
v Continue pharmacological VTE prophylaxis until the patient no longer
has significantly reduced mobility (generally 5 ­ 7 days)
Cardiac surgery
v Start mechanical VTE prophylaxisv Add pharmacological VTE prophylaxis for patients who have a
low risk of bleeding
Gastrointestinal, gynaecological, thoracic and urological surgery
v Start mechanical VTE prophylaxisv Add pharmacological VTE prophylaxis for patients who have a
low risk of bleedingv Extend pharmacological VTE prophylaxis to 28 days post­operatively
for patients who have had major cancer surgery in the abdomenor pelvis
Neurological (cranial or spinal) surgery
v Start mechanical VTE prophylaxisv Add pharmacological VTE prophylaxis for patients who have a
low risk of bleedingv Do not offer pharmacological VTE prophylaxis to patients witht ruptured cranial or spinal vascular malformations ort acute traumatic or non­traumatic haemorrhage until the lesion has
been secured or the condition is stable
06

Orthopaedic surgery
v Offer combined VTE prophylaxis with mechanical andpharmacological methods for lower limb surgery
v Do not routinely offer VTE prophylaxis to patients undergoing upper
limb surgery

Elective hip replacement" Start mechanical VTE prophylaxis at admission and continue until thepatient no longer has significantly reduced mobility# " Start pharmacological VTE prophylaxis after surgery.
Choose any one of:t LMWH: starting 6 ­ 12 hours after surgery !
t Fondaparinux: starting 6 hours after surgical closure, provided
haemostasis has been established !
  tRivaroxaban: starting 6 ­ 10 hours after surgery !
t Dabigatran etexilate: starting 1 ­ 4 hours after surgery !
" Continue pharmacological VTE prophylaxis for 35 days

Elective knee replacement" Start mechanical VTE prophylaxis at admission and continue until thepatient no longer has significantly reduced mobility# " Start pharmacological VTE prophylaxis after surgery.
Choose any one of:t LMWH: starting 6 ­ 12 hours after surgery !
t Fondaparinux: starting 6 hours after surgical closure, provided
haemostasis has been established !
t Rivaroxaban: starting 6 ­ 10 hours after surgery !
t Dabigatran etexilate: starting 1 ­ 4 hours after surgery !
# " Continue pharmacological VTE prophylaxis for 35 days

Hip fracture" Start mechanical VTE prophylaxis at admission# " Add pharmacological VTE prophylaxis. Choose any one of:t LMWH: starting at admission, stopping 12 hours before surgery andrestarting 6 ­ 12 hours after surgery !
t Fondaparinux: starting 6 hours after surgical closure. It is notrecommended for use pre­operatively for patients undergoing hip
fracture surgery !
# " Continue pharmacological VTE prophylaxis for 35 days
07

Vascular surgery
v Offer VTE prophylaxis to patients undergoing vascular surgery who
are not having other anticoagulant therapy and are assessed to be atincreased risk of VTEv Start mechanical VTE prophylaxisv Add pharmacological VTE prophylaxis for patients who have a
low risk of bleedingv Continue pharmacological VTE prophylaxis until the patient no longer
has significantly reduced mobility
Major trauma
v Offer combined VTE prophylaxis with mechanical andpharmacological methods to patients with major trauma
v Regularly reassess the patient’s risks of VTE and bleedingv Start mechanical VTE prophylaxis at admission or as early as
clinically possiblev Continue mechanical VTE prophylaxis until the patient no longer has
significantly reduced mobilityv Add pharmacological VTE prophylaxis if the benefits of reducing therisk of VTE outweighs the risk of bleeding and the bleeding risk has
been established as low
v Continue pharmacological VTE prophylaxis until the patient no longer
has significantly reduced mobility
Spinal injury
v Offer combined VTE prophylaxis with mechanical andpharmacological methods to patients with spinal injury
v Regularly reassess the patient’s risks of VTE and bleedingv Start mechanical VTE prophylaxis at admission or as early as
clinically possiblev Continue mechanical VTE prophylaxis until the patient no longer has
significantly reduced mobilityv Add pharmacological VTE prophylaxis if the benefits of reducing therisk of VTE outweighs the risk of bleeding and the bleeding risk has
been established as low
v Continue pharmacological VTE prophylaxis until the patient no longer
has significantly reduced mobility
Lower limb plaster castsv Consider pharmacological VTE prophylaxis to patients with lower limb
plaster casts after evaluating the risks and benefits based on clinicaldiscussion with the patientv Offer pharmacological VTE prophylaxis until lower limb plaster cast removal
08

Pregnancy and up to 6 weeks post­partumv All women should be assessed at booking and after delivery andstratified into risk groups according to risk factors and offeredthromboprophylaxis with LMWH where appropriate
v This assessment should be repeated if the woman is admitted to thehospital for any reason or develops other intercurrent problems during
the antenatal and postpartum period
Critical carev Assess all patients on admission to the critical care unit for their risks
of VTE and bleedingv Reassess patients’ risks of VTE and bleeding daily and more
frequently if their clinical condition is changing rapidly
v Offer VTE prophylaxis to patients admitted to the critical care unit
according to the reason for admission, taking into account:t Any planned interventions
t The use of other therapies that may increase the risk ofcomplications
Patients taking anti­platelet agents or anticoagulants on admission or
needing them for treatment
v Consider additional pharmacological VTE prophylaxis to patients
who are taking one but not two anti­platelet agents to treat otherconditions and who are assessed to be at increased risk of VTEv Consider additional mechanical prophylaxis to patients who are taking
two anti­platelet agents to treat other conditions and who areassessed to be at increased risk of VTEv Do not offer additional pharmacological or mechanical VTE
prophylaxis to patients who are taking vitamin K antagonists andwho are within their therapeutic range, provided anticoagulant therapy
is continued
v Do not offer additional pharmacological or mechanical VTE
prophylaxis to patients who are having full anticoagulant therapy

9. Timing of regional anaesthesia / analgesia
Unfractionated heparin (subcutaneous)v Wait at least 4 hours after a dose before block or catheter removalv Wait at least 1 hour before dosing after procedure (catheter insertion
or withdrawal)
Unfractionated heparin (intraveneous)v Stop infusion 2 ­ 4 hours before block09

v Start infusion >1 hour after blockv Remove epidural catheter no sooner than 2 ­ 4 hours after
discontinuation of infusion
Low Molecular Weight Heparinvv
v
v

Wait at least 12 hours after a prophylactic dose before block
Wait at least 24 hours after a therapeutic dose before block
Wait at least 10 hours after dose before removing catheter
After catheter removal wait 2 ­ 4 hours before next dose

Warfarin
v! -$#.//'!0"!12,!3456
Rivaroxaban
Rivaroxaban is started post­operatively
v Wait 12 ­ 18 hours after dose for epidural catheter removalv Wait 6 hours before next dose
Dabigatran
Dabigatran is started post­operatively
v Wait 12 ­ 18 hours after dose for epidural catheter removalv Wait 6 hours before next dose
Aspirin and NSAIDs
v No issue
Clopidogrelv Stop 7 days pre­op if possiblev If not, proceed with caution

10. Patient informationv Be aware that heparins are of animal origin and this may be ofconcern to some patientsv For patients who have concerns about using animal products,
consider offering synthetic alternatives based on clinical judgement
and after discussing their suitability, advantages and disadvantages
with the patientv In specific conditions such as pregnancy, LMWH is the anticoagulantof choice and is superior to UFH in its efficacy with less bleeding
complications10

v Before starting VTE prophylaxis, offer patients and their families
verbal and written information on:
t The risks and possible consequences of VTE
t The importance of VTE prophylaxis and its possible side­effects
t The correct use of VTE prophylaxis
t How patients can reduce the risk of VTE (keeping well hydrated
and mobilizing early)

Ministry of Health
Malaysia

Thromboprophylaxis in Pregnancy

Name of Assessor:

Date:

11. Discharge planv As part of the discharge plan, offer patients and their families orcarers verbal and written information on:# # "#The signs and symptoms of DVT and PE# # " The recommended duration of use of VTE prophylaxis at home (ifdischarged with prophylaxis)# # " Ensure that patients who are discharged with pharmacological ormechanical VTE prophylaxis are able to use it correctly# # " Know who to contact if DVT, PE or adverse events are suspected

Patient information
NAME:

DOB:

SEX:

HOSPITAL NO.

IC NO.

ANTENATAL RISK ASSESSMENT
v To be assessed at booking and with every admission into hospitalv Can be divided into 3 risk groups
v Management will depend on the risk group
These risk groups do not include those who are sufficiently high risk (veryhigh risk) to require anticoagulation when not pregnant (on long­term
warfarin):t Previous VTE on warfarint APLS with previous VTE
This group requires therapeutic dose of LMWH antenatally

1. High risk

Recommendations

Risk factors

Management

Any oneRequires antenatal prophylaxis with
LMWH

# "#
Single previous VTE with !
t Family history ort Unprovoked / estrogen­related# "#Previous recurrent VTE >1 !
11

# "#Enoxaparin 1 mg/kg daily ! or"#
Tinzaparin 4500 units daily !
(if BW >90kg, to dose at
75 units/kg daily)12

2. Intermediate risk

Recommendations

A. Risk factors

Management

Any one (if admitted into hospital):

Consider antenatal prophylaxis with
LMWH

# "#
Single previous VTE with nofamily history !
# "#Medical comorbidities e.g.
  t Heart/lung diseaser !
  t SLE !
t Cancer !

# "#Enoxaparin 1 mg/kg daily ! or

NAME:

DOB:

HOSPITAL NO.

IC NO.

SEX:"#
Tinzaparin 4500 units daily !
(if BW >90kg, to dose at
75 units/kg daily)t Inflammatory conditions !
t Nephrotic syndrome !

POSTNATAL RISK ASSESSMENT
v To be assessed in delivery suitev Can be divided into 3 risk groups  t Appendicectomy !

These risk groups do not include those who are sufficiently high risk (veryhigh risk) to require anticoagulation when not pregnant (on long­term
warfarin):t Previous VTE on warfarint APLS with previous VTE
Switch from therapeutic LMWH to long­term warfarin postnatally

B. Patient risk factors (see below)

1. High risk

Recommendations# "#78)!%& ! or# "#%9!:0"!(';0<</'!08<#!=#*>0<(?@!!

Risk factors

Managementt Sickle cell disease !
t Thalassaemia !
t IVDU !
# "#Surgical procedures e.g.

13

Patient Information"#
Any previous VTE !

3. Low risk

Recommendations

Patient risk factors

Management

Any 2 or less (not admitted into
hospital):# "#Age >35 years !
# "#Obesity BMI >30 !
# "! -($0<)!%&!!
# " Smoker !
# " Gross varicose veins !
# " Current systemic infection !
# " Immobility e.g. paraplegia,
long­haul travel >4 hours !
# " Pre­eclampsia !
# " Dehydration/ hyperemesis/
OHSS !
# " Multiple pregnancy !
# " Assisted reproductive
treatment !

Mobilisation
Avoid dehydration# "#Anyone requiring antenatal
prophylactic LMWH !

At least 6 weeks postnatal
prophylactic LMWH

2. Intermediate risk

Recommendations

A. Risk factors

Management

Any one# "#Caesarean section in labour !
# "#BMI >40 !
# "#Prolonged hospital
admission !
# "#Medical comorbidities e.g. !
  t Heart/lung disease !
t SLE !
  t Cancer !
  t Inflammatory conditions !
  t Nephrotic syndrome !

At least 7 days postnatal
prophylactic LMWH
If persisting or >3 risk factors,
consider extending
thromboprophylaxis with LMWH

14  t Sickle cell disease !
t Thalassaemia !
  t IVDU !

Diagnosis and Treatment of Venous
Thromboembolism

Ministry of Health
Malaysia

B. Patient risk factors (see below)%!9!$0*A!"(.<#$*Name of Assessor:

3. Low risk

Recommendations

Patient risk factors

Management

Any 1 risk factor:# "#Age >35 years !
# "#Obesity BMI >30 !
# "! -($0<)!%&!!
# " Smoker !
# " Elective CS !
# " Any surgical procedure in thepuerperium !
# " Gross varicose veins !
# " Current systemic infection !
# " Immobility e.g. paraplegia,
long­haul travel >4 hours !
# " Pre­eclampsia !
# " Mid­cavity rotational operative
delivery !
# " Prolonged labour>24 hours !
# " Assisted reproductive
treatment !
# " PPH >1 litre or bloodtransfusion !

Mobilisation

1. Patient information

Avoid dehydration

NAME:

DOB:

HOSPITAL NO.

IC NO.

SEX:

2. Triaging" Suspected PE!

Duration of Symptom(s):" Suspected DVT

!

Site:

" Suspected PE + DVT!

" LegR !

L !

" ChestR !

L !

3. Vital Signs
Temp

Calf
circumference(cm)

Peripheral pulses

BP

R

PoplitealO2 sat

L

Pedal

Pulse

Wt (kg)

15

Date:

RR

Ht (cm)

BMI

Skin:

R

L

Warm / Cold16

4. Clinical Probability

17

5. History

DVT

Yes NoPE

Yes NoActive cancer or cancer
within 6 months

1

Clinical signs & symptomsof DVT (minimum of leg
swelling and pain withpalpation of the deep veins

3

0

0

History of present illness
Past medical history
Drug history

Paralysis or recent leg
plaster

10

An alternative diagnosis isless likely than PE

30Bedridden >3 daysor major surgery <12
weeks

1

0

Heart rate >100 beats/min

1.50Tenderness along deep
venous system

10Immobilization >3 days orsurgery in the previous 4
weeks

1.5

0

Entire leg swollen

10Previous DVT/PE

1.5

0

Calf swelling >3 cm thanasymptomatic leg

10

Haemoptysis

1

0

Pitting edema(symptomatic leg)

1

0

Malignancy (on treatment;
treated in the last 6months; or palliative

1

0

Collateral superficial
veins

1

0

Previously documented
DVT

1

Alternative diagnosis
more likely­2Allergies

6. Risk Factors
v
v
v
v
v
v
v
v
v
v
v
v
v
v
v
v
v

Obesity !
Smoking !
Malignancy !
Anti­phospholipid syndrome !
OCP !
HRT !
Pregnancy !
Post­partum (within 12 weeks) !
Previous VTE !
Family h/o VTE !
Recent leg trauma or plaster !
Recent abdominal or pelvic surgery !
Bedridden >3 days !
Nephrotic syndrome !
Sickle cell disease !
Thalassaemia !
Inflammatory bowel disease !

7. Blood tests
FBC

0
Coagulation profile0

Renal profile

DVT likely!2

PE likely>4

Liver function

DVT unlikely<1

PE unlikely"#

Urinalysis
1811. Initial treatment for confirmed VTE

8. DVT likely
Request for Doppler UltrasoundDate of US:

DVT confirmed

DVT not confirmed

Below knee

Above kneea. Heparin or Fondaparinux and vitamin K antagonists (VKA)

Suggest repeat scan in 7 days
Date:

Repeat scan negative
Proceed to treatment
Discharge patient to Health Clinic

9. Other investigations
CXR

v For pregnancy, LMWH is the treatment of choicev Fondaparinux is not recommended in pregnancy as it may cross theplacenta

ECG

10. PE likely
Date of CTPA:

PE confirmed

PE not confirmed

Full report

Doppler US both legs

Consider systemic thrombolytic
therapy for patients with PE andhaemodynamic instability
19

v For severe renal impairment or established renal failure(eGFR <30 mL/min/1.73 m2)
t offer intravenous unfractionated heparin with dose adjustment
based on APTT ort LMWH daily with dose adjustments based on anti­Xa assay(Fondaparinux is contraindicated in patients with renal impairment)

Perform immediate computed
tomography pulmonary angiogram(CTPA)

Proceed to treatment

v Offer a choice of low molecular weight heparin (LMWH) or
fondaparinux to patients with confirmed proximal DVT or PE taking
into account comorbidities, contraindications and drug costs
v Start LMWH (enoxaparin or tinzaparin) or fondaparinux as soon as
possible and continue for at least 5 days or until the INR is 2 or above
for 2 consecutive days, whichever is longer# # " Tinzaparin dose is 175 IU/kg once daily !
# # " Enoxaparin dose is 1 mg/kg twice daily !
# # " Fondaparinux dose is 7.5 mg daily(5 mg if <50 kg; 10 mg if >100 kg) !
v Start VKA i.e. warfarin at 5 mg daily within 24 hours of diagnosis andcontinue for 3 months for provoked VTE or consider long term forunprovoked VTE

DVT confirmed

No DVT

Proceed totreatment

No further
actionv For patients with PE and haemodynamic instability
t offer IV UFH and consider thrombolytic therapy
t once patient is haemodynamically stable, switch to LMWH andstart warfarin
v For patients with active cancer and confirmed proximal DVT or PE,
continue LMWH for 6 months. At 6 months, assess the risks andbenefits of continuing anticoagulationb. Rivaroxaban
Rivaroxaban is indicated for the treatment of acute deep vein thrombosis andpulmonary embolism and the prevention of recurrence20

v For the initial treatment of acute DVT or PEt the recommended dose of rivaroxaban is 15 mg twice daily for the
first 21 days followed by 20 mg once daily for continued treatment
and prevention of recurrence !

12. Thrombolytic Therapy
Deep vein thrombosis
v Consider catheter­directed thrombolytic therapy for patients withsymptomatic ilio­femoral DVT who have:t Symptoms of less than 14 days duration AND
t Good functional status AND
t A life expectancy of 1 year or more ANDt A low risk of bleeding

Pulmonary embolism
v Consider systemic thrombolytic therapy for patients with PE andhaemodynamic instability (e.g. systolic BP <90 mmHg)
v Do not offer systemic thrombolytic therapy to patients with PE andhaemodynamic stability
v The most commonly used agent is t­PA infused at 100 mg over 2
hours followed by continuation of therapeutic heparin infusionv Consider thoracotomy in critically ill / not suitable for thrombolysis

13. Mechanical Intervention
Compression stockings
v Prescribe below­knee graduated compression stockings with an ankle
pressure greater than 23 mmHg to patients with proximal DVT a week
after diagnosis or when swelling is reduced sufficiently and if there
are no contraindications
v advice patients to continue wearing the stockings for at least 2years
v ensure that the stockings are replaced two or three times per year
or according to the manufacturer's instructions
v advice patients that the stockings need to be worn only on theaffected leg or legsInferior vena cava filtersv Offer temporary inferior vena cava filters ONLY to patients withproximal DVT or PE who cannot have anticoagulation treatment
21

v Remove the inferior vena cava filter when the patient becomes
eligible for anticoagulation treatment, at the earliest possible
opportunity

14. Investigations for Cancerv All patients diagnosed with unprovoked DVT or PE who are notknown to have cancer should be offered:# # " A physical examination (further specific tests are guided by thepatient’s history)# # " Chest X­ray# # " Blood tests (FBC, LFT, RP, urinalysis)v Consider further investigations for cancer with an abdomino­pelvic CT
scan (and a mammogram for women) in all patients aged over 40
years with a first unprovoked VTE who do not have signs andsymptoms of cancer based on initial investigationv Tumour markers are not recommended for cancer screening

15. Thrombophilia testingv DO NOT offer thrombophilia testing to patients who are continuing
anticoagulant treatment
v Consider testing for lupus anticoagulant and anti­phospholipid
antibodies in patients who have had an unprovoked DVT or PE if it isplanned to stop anticoagulant treatment
v Consider testing for hereditary thrombophilia in patients who have
had an unprovoked DVT or PE and who have a first­degree relative
who has had a DVT or PE if it is planned to stop anticoagulant
treatment
v DO NOT offer thrombophilia testing to patients who have had a
provoked DVT or PE
v DO NOT offer thrombophilia testing to first­degree relatives of people
with a history of DVT or PE and thrombophilia
v DO NOT offer heritable thrombophilia testing to patients who have
had an arterial thrombosis (young stroke or myocardial infarction)v Consider testing for lupus anticoagulant and anti­phospholipid
antibodies in the following:# # "#
in the presence of both arterial and venous thrombosis# # " unexplained arterial thrombosis (young stroke or myocardial
infarction with no risk factors)# # "!%&!B8/C>?(08/'!;0*.($$0(D/*!E4F!G//A*!D/*<(<0#8# # " a fetal death >10 weeks gestation# # " premature birth <35 weeks gestation due to severe pre­eclampsia
or IUGR
22

16. Duration of anticoagulation therapy
v Consider extending anticoagulation beyond 3 months for patientswith unprovoked proximal DVT if their risk of VTE recurrence is high(e.g. male, family history) and there is no additional risk of major
bleeding. Discuss with the patient the benefits and risks of extending
their treatment
v Offer anticoagulation beyond 3 months to patients with an
unprovoked PE, taking into account the patient's risk of VTE
recurrence and whether they are at increased risk of bleeding.
Discuss with the patient the benefits and risks of extending theirtreatmentv Offer LMWH to patients with active cancer and confirmed proximal
DVT or PE, and continue the LMWH for 6 months. At 6 months,
assess the risks and benefits of continuing anticoagulationv Experience with rivaroxaban in extending anticoagulation beyond 12
months is limited
v DO NOT routinely do D­dimer test and Doppler US on completion of
anticoagulation except guided by clinical symptoms and signs

17. Follow up
v Arrange for follow­up at medical or haematology clinicv Arrange for INR monitoring at the anticoagulation clinic(MTAC­Warfarin)

18. Patient informationv Verbal and written information are given to patients having
anticoagulant treatment about:t Duration of anticoagulation treatment
t Anticoagulation booklett Possible side effects and what to do if these occurt The effects of other medication, food and alcohol on oral
anticoagulantt Monitoring their anticoagulant treatment
t Pregnancy and contraceptiont Surgery and dental treatment
t Future risk reduction measures including travelt Clear advice on long term use of stockings

23