Guidance

Update information

Update information

August 2023: We have reviewed the evidence on the use of Wells score and D‑dimer in the diagnostic pathways for pulmonary embolism (PE) and deep vein thrombosis (DVT) in people with COVID‑19, and updated recommendations.

We have also refreshed the wording in recommendation 1.1.16 on the use of the pulmonary embolism rule-out criteria (PERC).

Recommendations are marked [2023] if the evidence has been reviewed. The recommendation marked [2020, amended 2023] has been refreshed without an evidence review.

Recommendations marked [2012] and [2012, amended 2020] last had an evidence review in 2012. Recommendations marked [2020] last had an evidence review in 2020.

March 2020: This guideline updates and replaces NICE guideline CG144 (published June 2012, updated November 2015).

We have reviewed the evidence and made new recommendations on:

  • D‑dimer testing

  • the PERC rule for PE

  • outpatient management of low-risk PE

  • anticoagulation treatment for suspected and confirmed DVT or PE

  • reviewing anticoagulation treatment after DVT or PE

  • inferior vena caval filters

  • investigations for cancer for people with suspected or confirmed DVT or PE.

These recommendations are marked [2020].

We have also made some changes without an evidence review:

  • In section 1.1 on diagnosis and initial management we have:

    • replaced '24-hour dose of a parenteral anticoagulant' with 'interim therapeutic anticoagulation' because the updated guideline includes direct-acting oral anticoagulants (DOACs)

    • amended recommendation 1.1.4 to clarify that the D‑dimer test should be carried out before interim therapeutic anticoagulation is started because anticoagulation can affect the D‑dimer result

    • added 'stop interim therapeutic anticoagulation' to replace '24-hour dose' and ensure that interim anticoagulation is not continued when it is no longer needed

    • added a limit of 4 hours for D‑dimer test results to correspond with the limit of 4 hours recommended for proximal leg vein ultrasound scan results

    • changed 'offer a mechanical intervention' if PE is identified to 'consider a mechanical intervention' to align with the updated recommendations on mechanical interventions

    • defined renal impairment in people with suspected PE as 'severe (estimated creatinine clearance less than 30 ml/min)' to clarify that investigation with CTPA is not excluded in all degrees of renal impairment.

  • In section 1. 5 on information and support for people having anticoagulation treatment we have:

    • added information about animal products contained in direct-acting anticoagulants

    • updated the link to the section in the NICE guideline 'Venous thromboembolism: reducing the risk' on information for people concerned about using animal products.

  • In section 1.9 on thrombophilia testing we have:

    • changed 'do not offer thrombophilia testing' to 'do not offer testing for hereditary thrombophilia' to differentiate between hereditary thrombophilia and antiphospholipid syndrome, which is an acquired form of thrombophilia. This is to align with the addition of a recommendation on anticoagulation treatment for people with triple positive antiphospholipid syndrome in the updated guideline

    • added wording to the recommendation on testing for antiphospholipid antibodies to ensure that clinicians are aware that anticoagulants can affect the interpretation of thrombophilia test results.

  • In the section 'Terms used in this guideline' we have:

    • added a definition of 'active cancer' for clarification

    • amended the definition of 'unprovoked DVT or PE' to reflect the 2020 guideline committee's use of the term.

These recommendations are marked [2012, amended 2020]

Recommendations marked [2012] last had an evidence review in 2012. Those marked [2015] last had an evidence review in 2015.

Minor changes since publication

September 2022: In recommendation 1.1.21 we clarified that the 4-hour time window for the D‑dimer test result applies to any setting. See the surveillance decision for more information.

August 2022: We amended and clarified recommendation 1.1.11, and corrected an error in the visual summary.

July 2022: We clarified the information in recommendations 1.1.6, 1.1.7, 1.1.20 and 1.1.21 about stopping interim therapeutic anticoagulation. We also corrected a cross-reference in recommendation 1.1.11.

October 2021: We added a link to NICE's guideline on shared decision making in recommendation 1.3.1.

ISBN: 978-1-4731-5295-3