Venous thromboembolism: Difference between revisions

	Venous thromboembolism Microchapters
Patient Information Deep vein thrombosis Pulmonary embolism
Overview
Classification
Epidemiology
Risk Factors
Diagnosis
Treatment Deep Vein Thrombosis Pulmonary Embolism
Prevention

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Latest revision as of 05:48, 10 February 2019

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2]; Associate Editor(s)-in-Chief: Syed Hassan A. Kazmi BSc, MD [3], Iqra Qamar M.D.[4], Anmol Pitliya, M.B.B.S. M.D.[5], Aravind Reddy Kothagadi M.B.B.S [6]

To review the risk of VTE according to IMPROVEDD score, click here.

To review the risk of VTE according to IMPROVE score, click here.

To review the risk of VTE according to Caprini scores click here.

To predict the clinical risk of Pulmonary thromboembolism according to Wells score, click here.

Overiew

Venous thromboembolism (VTE) may be classified into deep vein thrombosis (DVT) and pulmonary embolism (PE). Pulmonary embolism may arise as a consequence of deep vein thrombosis as a result of embolization of the clot from deep veins of the legs. Pulmonary embolism (PE) is an acute obstruction of the pulmonary artery (or one of its branches). The obstruction in the pulmonary artery that causes a PE can be due to thrombus, air, tumor, or fat. Most often, pulmonary embolism is due to a venous thrombosis (blood clot from a vein), which has been dislodged from its site of formation in the lower extremities. It has then embolized to the arterial blood supply of one of the lungs. Deep vein thrombosis (also known as deep venous thrombosis or DVT and colloquially referred to as "economy class syndrome") is the formation of a blood clot ("thrombus") in a deep vein.

Classification

Venous thromboembolism (VTE) may be classified into:^[1]^[2]

Deep vein thrombosis (DVT)
Pulmonary embolism (PE)

The following table further classifies DVT and PE:^[3]^[4]^[5]^[6]^[5]^[7]^[8]^[9]

Classification of Venous Thromboembolism
Clinical diagnosis	Sub-classification	Comments
Deep vein thrombosis	Upper extremity	Uncommon (accounts for 1-5% of all DVT) Most likely due to: Central venous catheter Cardiac pacemaker Implantable cardioverter defibrillator Effort thrombosis (Paget–Schroetter disease) Cancer
Deep vein thrombosis	Lower extremity	Proximal: Popliteal veins Femoral veins Iliac veins Isolated distal: Calf veins (Peroneal, soleal, posterior tibial, gastrocnemial)
Pulmonary embolism (PE)	Massive PE (High risk)	Sustained hypotension (systolic blood pressure <90 mm Hg) not due to arrhythmia, hypovolemia, sepsis, or left ventricular dysfunction, and either lasting for at least 15 minutes or necessitating the administration of inotropes OR Pulselessness OR Persistent profound bradycardia (heart rate <40 bpm) plus findings of shock
	Sub-massive PE (Intermediate risk PE)	Right ventricular dysfunction OR myocardial necrosis AND Absence of systemic hypotension (systolic blood pressure >90 mm Hg)
	Low risk PE	Absence of hypotension, shock, right ventricular dysfunction, and myocardial necrosis

Epidemiology

Prevalence

The precise number of people affected by DVT/PE is unknown,although as many as 900,000 people could be affected (100 to 200 per 100,000) each year in the United States.^[10]

Incidence

The incidence of VTE increases with age, ranging from less than 5 cases per 100,000 people in childhood to 500 cases per 100,000 people in the elderly.^[11]
Those who are more than 65 years of age are at three times higher risk for VTE compared to those who are 45-54 years old.^[12]
In the United States, the annual incidence of VTE is estimated to be approximately 100 per 100,000 persons.^[11]

Age

The incidence of VTE increases with age, ranging from less than 5 cases per 100,000 people in childhood to 500 cases per 100,000 people in the elderly.^[11]
Those who are more than 65 years of age are at three times higher risk for VTE compared to those who are 45-54 years old.^[12]

Gender

Studies about differences in the incidence of VTE by gender have yielded mixed results:
- Some reported a higher incidence of DVT among young females.^[13]
- Some reported a higher incidence of DVT among older females.^[14]
- Some reported a higher incidence of DVT in men.^[12]^[15]
In addition, the risk for DVT was reported to consistently increase with age across both genders.^[12]

Race

There is a significant difference in the incidence of DVT as it relates to race. African Americans characteristically have the highest incidence of DVT while Caucasians rank as the second highest incidence of DVT.^[11]
Compared to African Americans and Caucasians, the incidence of DVT is noted to be two to four times lower in Hispanics and Asian-Pacific Islanders.^[11]
Lower incidence of thrombosis in non-Caucasians may be related to a lower prevalence of disorders like Factor V Leiden or Prothrombin 20210A mutation.^[16]^[17]

Hospitalization for VTE

During 2007–2009, an estimated annual average of 547,596 hospitalizations culminated in a diagnosis of VTE for adults aged ≥18 years. Estimates for DVT and PE diagnoses were not mutually exclusive. An estimated annual average of 348,558 adult hospitalizations resulted in a diagnosis of DVT, and 277,549 adult hospitalizations resulted in a diagnosis of PE. An estimated annual average of 78,511 adult hospitalizations (14% of overall VTE hospitalizations) had diagnoses of both DVT and PE.^[18]

The estimated average annual number of hospitalizations with VTE was successively greater among older age groups: 54,034 for persons aged 18–39 years; 143,354 for persons aged 40–59 years; and 350,208 for persons aged ≥60 years. The estimated average annual number of hospitalizations with VTE was comparable for men (250,973) and women (296,623).^[18]

Shown below is an image depicting the estimated average annual number of hospitalization with a diagnosis of DVT, PE, or VTE by age and sex.

Estimated average annual number of hospitalizations with a diagnosis of deep thrombosis (DVT), pulmonary embolism (PE), or venous thromboembolism (VTE), by patient sex and age group — National Hospital Discharge Survey, United States, 2007–2009 - Source:CDC

The average annual rates of hospitalizations with a discharge diagnosis of DVT, PE, or VTE among adults were 152, 121, and 239 per 100,000 population, respectively. For VTE, the average annual rates were 60 per 100,000 population aged 18–39 years, 143 for persons aged 40–49 years, 200 for persons aged 50–59 years, 391 for persons aged 60–69 years, 727 for persons aged 70–79 years, and 1,134 for persons aged ≥80 years. The rates of hospitalization were similar for men and women, and the point estimates increased for both sexes by age.^[18]

On average, 28,726 hospitalized adults with a VTE diagnosis died each year. Of these patients, an average of 13,164 had a DVT diagnosis and 19,297 had a PE diagnosis; 3,735 had both DVT and PE diagnoses.^[18]

Recurrence of VTE

Approximately 33% (1 in 3) of people with VTE will have a recurrence within 10 years.^[19]^[20]

The risk of recurrence of VTE in patients diagnosed with first-time VTE is estimated to be approximately 7-8% per year during an average follow up period of 2.2 years of subsequent observation.^[12]

Among patients with a first episode of VTE, the risk of recurrence of VTE is particularly elevated in the first 6 to 12 months following the first episode of VTE. The risk of recurrent VTE remains up to 10 years, with a estimated cumulative incidence of first overall VTE recurrence of 30%. Predictors for recurrence of VTE include malignancy, neurological diseases, and paresis.^[21]

The recent increase in thrombosis incidence may be related to improved diagnostic modalities and increased awareness by clinicians.^[11]

Complications of VTE

Estimates suggest that 60,000-100,000 Americans die of VTE, 10 to 30% of which will die within one month of diagnosis.^[19]^[20]

Among people who have had a DVT, one-half will have long-term complications (post-thrombotic syndrome) such as swelling, pain, discoloration, and scaling in the affected limb.^[19]^[20]

Risk Factors

Shown below is a list of predisposing factors for VTE. The risk factors are classified as moderate or weak depending on how strongly they are associated with a VTE.^[22]^[23]^[24]^[25]

Moderate risk factors

Weak risk factors

❑ Chemotherapy
❑ Obesity

❑ Chronic heart failure
❑ Respiratory failure
❑ Hormone replacement therapy
❑ Cancer
❑ Oral contraceptive pills
❑ Stroke
❑ Pregnancy
❑ Postpartum
❑ Prior history of VTE
❑ Thrombophilia

❑ Hospitalization

❑ Advanced age

❑ Laparoscopic surgery
❑ Prepartum
❑ Varicose veins

Risk factors of VTE may be categorized into modifiable, non-modifiable, temporary, and other risk factors.

Modifiable Risk Factors

Non-Modifiable Risk Factors

Temporary Risk Factors

Other Risk Factors

❑ Modifiable risk factors are reversible based upon lifestyle/behavior modification.
❑ Obesity is defined as a body-mass index (BMI) above 30 kg/m2.^[26] ^[27] ^[28]
❑ Smoking:^[26] Smoking significantly increases the risk of DVT, particularly among women who are taking oral contraceptive pills as well as among obese people.
❑ Use of oral contraceptives^[29]
❑ Hyperhomocysteinemia:^[30] Hyperhomocysteinemia can be reduced with vitamin B supplementation.

❑ Advanced age
❑ Heart failure
❑ Thrombophilia or hypercoagulable state
❑ Polycythemia vera

❑ Factor V Leiden

❑ Prothrombin G20210A mutation

❑ Protein C deficiency

❑ Protein S deficiency

❑ Activated protein C resistance

❑ Antithrombin III deficiency

❑ Factor VIII mutation

❑ Antiphospholipid syndrome

❑ Heparin induced thrombocytopenia

❑ Nephrotic syndrome

❑ Paroxysmal nocturnal hemoglobinuria

❑ Pregnancy and the peri-partum period
❑ Active cancer
❑ Central venous catheterization

❑ Other possible factors associated with VTE include:^[31]

❑ Nutrition low in fish

❑ Psychological stress

❑ Cardiovascular risk factors such as diabetes and hypercholesterolemia

Diagnosis

The diagnostic guidelines for venous thromboembolism are as follows:^[32]^[33]^[34]^[35]

Deep Vein Thrombosis

Suspected DVT

Clinical probability
likely

Clinical probability
unlikely

Ultrasound

Normal

Abnormal

D-dimer

Treat

Positive

Negative

Positive

Negative

Ultrasound

Stop

Repeat ultrasound in 1 week

Stop

Abnormal

Normal

Treat

Stop

Pulmonary Embolism

Suspected pulmonary embolism

D-dimer

Negative

Positive

Stop

CXR

Ultrasound
If signs of DVT present

Normal
PE unlikely with positive D-dimer or PE likely

Abnormal
PE unlikely with positive D-dimer or PE likely

V/Q scan

CTPA

Normal

Non diagnostic

High probability

PE present

PE absent

Stop

Treat

Stop

PE unlikely

PE likely

Serial ultrasound

CTPA or serial ultrasound

Pulmonary embolism Wells Score Calculator

Variable	Wells Score^[36]
Clinically suspected DVT (leg swelling, pain with palpation)	3.0
Alternative diagnosis is less likely than PE	3.0
Immobilization/surgery in previous four weeks	1.5
Previous history of DVT or PE	1.5
Tachycardia (heart rate more than 100 bpm)	1.5
Malignancy (treatment for within 6 months, palliative)	1.0
Hemoptysis	1.0

Prevention

The following table summarizes major scoring criteria for risk assessment of VTE:^[37]^[38]^[39]^[40]

Scoring criteria for risk assessment*
Type of patient	Scoring system	Score	Risk
Non-surgical patient	IMPROVEDD Score		Predicted % VTE risk through 42 days
		0	0.4%
		1	0.6%
		2	0.8%
		3	1.2%
		4	1.6%
		5-10	2.2%
			Predicted % VTE risk through 77 days
		0	0.5%
		1	0.7%
		2	1.0%
		3	1.4%
		4	1.9%
		5-10	2.75
	IMPROVE score		Predicted % VTE risk through 3 months
		0	0.5%
		1	1.0%
		2	1.7%
		3	3.1%
		4	4%
		5-8	11%
	Padua Score	< 4	Low risk for VTE
	Padua Score	≥ 4	High risk for VTE
Surgical patient	Caprini score	0-1	Low risk of VTE
		2	Moderate of VTE
		3-4	High risk of VTE
		≥ 5	Highest risk for VTE

The following table summarizes the major scoring criteria used for risk assessment of VTE and their prophylaxis options:^[41]^[42]^[43]^[44]^[45]^[39]^[46]^[38]^[47]^[48]^[49]

Patient population	Sub-population	Scoring criteria for risk assessment			Major predisposing risk factors and their score	Prophylaxis recommendations
Patient population	Sub-population	Padua score	IMPROVE score	Caprini score	Major predisposing risk factors and their score	Prophylaxis recommendations
Non-surgical patients	Acutely ill patients	✔	✔	-	IMPROVE: Active cancer: 3 Previous VTE: 3 Decreased mobility: 3 Thrombophilia: 3 Previous trauma or surgery within that last month: 2 Age≥ 70: 1 Heart and/or respiratory failure: 1 Ischemic stroke or acute myocardial infarction: 1 Acute rheumatologic disorder and/or acute infection: 1 Obesity: 1 Hormonal therapy	Hospitalized medical patients: Increased risk of thrombosis LMWH LDUH OR Fondaparinux Betrixaban 160 mg PO, THEN 80 mg PO qDay Low risk of thrombosis Use of pharmacological prophylaxis or mechanical prophylaxis is not recommended Bleeding or at high risk of bleeding: Anticoagulant thromboprophylaxis is not recommended Increased risk of thrombosis who are bleeding or at high risk for major bleeding: Optimal use of mechanical thromboprophylaxis with graduated compression stockings (GCS) or intermittent pneumatic compression (IPC) Note: When bleeding risk decreases, and if risk persist, pharmacologic thromboprophylaxis be substituted for mechanical thromboprophylaxis. Who receive an initial course of thromboprophylaxis: Extending the duration of thromboprophylaxis beyond the period of patient immobilization or acute hospital stay is not recommended
	Acutely ill patients	✔	✔	-	IMPROVE bleeding risk: Active gastric or duodenal ulcer: 4.5 Prior bleeding within the last 3 months: 4 Thrombocytopenia (<50x109/L): 4 Age ≥ 85 years: 3.5 Liver failure (INR>1.5): 2.5 Severe kidney failure (GFR< 30 mL/min/m2): 2.5 Admission to ICU or CCU: 2.5 Central venous catheter: 2 Rheumatic disease: 2 Active malignancy: 2 Age: 40-84 years: 1.5 Male: 1 Moderate kidney failure (GFR: 30-59 mL/min/m2): 1
	Cancer in outpatient	-	-	-	Does the patient have a solid tumor AND Additional risk factors for VTE? Previous VTE Hormonal therapy Immobilization Angiogenesis inhibitors Thalidomide Lenalidomide	If major predisposing risk factors present: LMWH LDUH If no major predisposing risk factors present: No VTE prophylaxis
	Long travel	-	-	-	Prior VTE episode Recent trauma Recent surgery Active cancer Advanced age Immobility Severe obesity Estrogen intake Thrombophilia	Frequent ambulation Calf muscle excercise Sitting in an isle seat Below knee compression stockings (15-30 mm Hg pressure at ankle)
Surgical patients	Orthopedic surgery patients	-	-	✔	-	Total hip or knee arthroplasty: Pharmacological VTE prophylaxis Begin at least 12 hours before and 12 hours after the surgery and administer for at least 14 days Extend the therapy to 35 days as outpatient. Choose ONE of the following: LMWH (first line) Fondaparinux Apixaban Dabigatran Rivaroxaban LDUH VKA Aspirin AND/OR Intermittent pneumatic compression device Hip fracture surgery: Pharmacological VTE prophylaxis Begin at least 12 hours before and 12 hours after the surgery and administer for at least 14 days Extend the therapy to 35 days as outpatient. Choose ONE of the following: LMWH (first line) Fondaparinux LDUH VKA Aspirin AND/OR Intermittent pneumatic compression device
	General and abdominal pelvic surgeries	-	-	✔	Caprini: 5 points: Stroke (in the previous month) Fracture of the hip, pelvis, or leg Elective arthroplasty Acute spinal cord injury (in the previous month) 3 points: Age≥ 75 years Prior episodes of VTE Positive family history for VTE Prothrombin 20210 A Factor V Leiden Lupus anticoagulants Anticardiolipin antibodies High homocysteine in the blood Heparin induced thrombocytopenia Other congenital or acquired thrombophilia 2 points: Age: 61-74 years Arthroscopic surgery Laparoscopy lasting more than 45 minutes General surgerylasting more than 45 minutes Cancer Plaster cast Bed bound for more than 72 hours Central venous access 1 point: Age 41-60 years BMI > 25 Kg/m2 Minor surgery Edema in the lower extremities Varicose veins Pregnancy Post-partum Oral contraceptive Hormonal therapy Unexplained or recurrent abortion Sepsis (in the previous month) Serious lung disease such as pneumonia (in the previous month) Abnormal pulmonary function test Acute myocardial infarction Congestive heart failure (in the previous month) Bed rest Inflammatory bowel disease	Low risk of VTE: Early ambulation No mechanical VTE prophylaxis No pharmacological VTE prophylaxis Mechanical VTE prophylaxis (Intermittent pneumatic compression is preferred) Moderate risk of VTE: If no bleeding risk: LMWH OR LDUH OR Mechanical VTE prophylaxis (Intermittent pneumatic compression is preferred) If high bleeding risk: Mechanical VTE prophylaxis (Intermittent pneumatic compressionis preferred) High risk of VTE: If no bleeding risk: LMWH OR LDUH OR Mechanical VTE prophylaxis Extended treatment with LMWH for 4 weeks PLUS mechanical VTE prophylaxis (in case of cancer) If high risk of bleeding: Mechanical VTE prophylaxis (Intermittent pneumatic compression is preferred)
	Cardiac surgery	-	-	✔		Non-hemorrhagic post-op complications: LDUH OR LMWH PLUS Mechanical VTE prophylaxis Un-complicated post-op period: Mechanical VTE prophylaxis (Intermittent pneumatic compression is preferred)
	Thoracic surgery	-	-	✔		In case of pulmonary resection, pneumonectomy, extrapleural pneumonectomy, esophagectomy: No bleeding risk: LDUH OR LMWH PLUS Mechanical VTE prophylaxis Elastic stocking Intermittent pneumatic compression High bleeding risk: Mechanical VTE prophylaxis (intermittent pneumatic compression is preferred), start LDUH or LMWH after bleeding risk subsides
	Craniotomy	-	-	✔		In case of craniotomy for malignancy: (Very high risk for VTE) Mechanical VTE prophylaxis (Intermittent pneumatic compression is preferred) PLUS Pharmacological VTE prophylaxis (when the risk of bleeding subsides) In case of craniotomy for other reasons: (High risk of VTE) Mechanical VTE prophylaxis (Intermittent pneumatic compression is preferred)
	Spinal surgery	-	-	✔		In case of spinal surgery for malignancy OR antero-posterior approach: (High risk for VTE) Mechanical VTE prophylaxis (intermittent pneumatic compression is preferred) PLUS Pharmacological VTE prophylaxis when the risk of bleeding subsides In case of spinal surgery for other reasons: Mechanical VTE prophylaxis (Intermittent pneumatic compression is preferred)
	Trauma	-	-	✔		No contraindiction to LDUH or LMWH: LDUH OR LMWH PLUS Mechanical VTE prophylaxis (Intermittent pneumatic compression is preferred) Contraindication to LDUH or LMWH: Mechanical VTE prophylaxis (Intermittent pneumatic compression is preferred) PLUS Pharmacological VTE prophylaxis when the risk of bleeding subsides

Abbreviations: LDUH: low dose unfractionated heparin; LMWH: low molecular weight heparin; VTE: Venous thromboembolism

References

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↑ ^38.0 ^38.1 Spyropoulos AC, Anderson FA, FitzGerald G, Decousus H, Pini M, Chong BH; et al. (2011). "Predictive and associative models to identify hospitalized medical patients at risk for VTE". Chest. 140 (3): 706–714. doi:10.1378/chest.10-1944. PMID 21436241.
↑ ^39.0 ^39.1 Barbar S, Noventa F, Rossetto V, Ferrari A, Brandolin B, Perlati M; et al. (2010). "A risk assessment model for the identification of hospitalized medical patients at risk for venous thromboembolism: the Padua Prediction Score". J Thromb Haemost. 8 (11): 2450–7. doi:10.1111/j.1538-7836.2010.04044.x. PMID 20738765.
↑ Caprini JA, Arcelus JI, Hasty JH, Tamhane AC, Fabrega F (1991). "Clinical assessment of venous thromboembolic risk in surgical patients". Semin Thromb Hemost. 17 Suppl 3: 304–12. PMID 1754886.
↑ Cohen, Alexander T.; Harrington, Robert A.; Goldhaber, Samuel Z.; Hull, Russell D.; Wiens, Brian L.; Gold, Alex; Hernandez, Adrian F.; Gibson, C. Michael (2016). "Extended Thromboprophylaxis with Betrixaban in Acutely Ill Medical Patients". New England Journal of Medicine. 375 (6): 534–544. doi:10.1056/NEJMoa1601747. ISSN 0028-4793.
↑ Kahn SR, Lim W, Dunn AS, Cushman M, Dentali F, Akl EA, Cook DJ, Balekian AA, Klein RC, Le H, Schulman S, Murad MH (2012). "Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e195S–e226S. doi:10.1378/chest.11-2296. PMC 3278052. PMID 22315261.
↑ Gould MK, Garcia DA, Wren SM, Karanicolas PJ, Arcelus JI, Heit JA, Samama CM (2012). "Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e227S–e277S. doi:10.1378/chest.11-2297. PMC 3278061. PMID 22315263.
↑ Cohen, Alexander T.; Spiro, Theodore E.; Büller, Harry R.; Haskell, Lloyd; Hu, Dayi; Hull, Russell; Mebazaa, Alexandre; Merli, Geno; Schellong, Sebastian; Spyropoulos, Alex C.; Tapson, Victor (2013). "Rivaroxaban for Thromboprophylaxis in Acutely Ill Medical Patients". New England Journal of Medicine. 368 (6): 513–523. doi:10.1056/NEJMoa1111096. ISSN 0028-4793.
↑ "FDA approved betrixaban (BEVYXXA, Portola) for the prophylaxis of venous thromboembolism (VTE) in adult patients".
↑ Steel K (1989). "Bathing problems in the over 70s". BMJ. 298 (6687): 1578–9. PMC 1836788. PMID 2503127.
↑ "Deep vein thrombosis assessment of probability of subsequent VTE and risk scores - wikidoc".
↑ "Venous Thromboembolism Prophylaxis and Treatment in Patients With Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update: Journal of Clinical Oncology: Vol 31, No 17".
↑ "Abstract 19875: IMPROVEDD Score: Addition of D-Dimer to the IMPROVE Score Improves Venous Thromboembolism Risk Stratification. An APEX Trial Substudy | Circulation".

[pmid22084692-1] Moheimani F, Jackson DE (2011). "Venous thromboembolism: classification, risk factors, diagnosis, and management". ISRN Hematol. 2011: 124610. doi:10.5402/2011/124610. PMC 3196154. PMID 22084692.

[2] Kasper, Dennis (2015). Harrison's principles of internal medicine. New York: McGraw Hill Education. ISBN 978-0071802154.

[pmid9546569-3] Anand SS, Wells PS, Hunt D, Brill-Edwards P, Cook D, Ginsberg JS (1998). "Does this patient have deep vein thrombosis?". JAMA. 279 (14): 1094–9. PMID 9546569.

[pmid7752753-4] Wells PS, Hirsh J, Anderson DR, Lensing AW, Foster G, Kearon C; et al. (1995). "Accuracy of clinical assessment of deep-vein thrombosis". Lancet. 345 (8961): 1326–30. PMID 7752753.

[pmid8257253-5] 5.0 ^5.1 Cogo A, Lensing AW, Prandoni P, Hirsh J (1993). "Distribution of thrombosis in patients with symptomatic deep vein thrombosis. Implications for simplifying the diagnostic process with compression ultrasound". Arch Intern Med. 153 (24): 2777–80. PMID 8257253.

[pmid19718469-6] Galanaud JP, Sevestre-Pietri MA, Bosson JL, Laroche JP, Righini M, Brisot D; et al. (2009). "Comparative study on risk factors and early outcome of symptomatic distal versus proximal deep vein thrombosis: results from the OPTIMEV study". Thromb Haemost. 102 (3): 493–500. doi:10.1160/TH09-01-0053. PMID 19718469.

[pmid15353493-7] Joffe HV, Kucher N, Tapson VF, Goldhaber SZ, Deep Vein Thrombosis (DVT) FREE Steering Committee (2004). "Upper-extremity deep vein thrombosis: a prospective registry of 592 patients". Circulation. 110 (12): 1605–11. doi:10.1161/01.CIR.0000142289.94369.D7. PMID 15353493.

[pmid20406709-8] Isma N, Svensson PJ, Gottsäter A, Lindblad B (2010). "Upper extremity deep venous thrombosis in the population-based Malmö thrombophilia study (MATS). Epidemiology, risk factors, recurrence risk, and mortality". Thromb Res. 125 (6): e335–8. doi:10.1016/j.thromres.2010.03.005. PMID 20406709.

[pmid17925416-9] Muñoz FJ, Mismetti P, Poggio R, Valle R, Barrón M, Guil M; et al. (2008). "Clinical outcome of patients with upper-extremity deep vein thrombosis: results from the RIETE Registry". Chest. 133 (1): 143–8. doi:10.1378/chest.07-1432. PMID 17925416.

[urlData_and_Statistics_|_DVT/PE_|_NCBDDD_|_CDC-10] "Data and Statistics | DVT/PE | NCBDDD | CDC".

[pmid12814979-11] 11.0 ^11.1 ^11.2 ^11.3 ^11.4 ^11.5 White RH (2003). "The epidemiology of venous thromboembolism". Circulation. 107 (23 Suppl 1): I4–8. doi:10.1161/01.CIR.0000078468.11849.66. PMID 12814979.

[pmid15210384-12] 12.0 ^12.1 ^12.2 ^12.3 ^12.4 Cushman M, Tsai AW, White RH, Heckbert SR, Rosamond WD, Enright P; et al. (2004). "Deep vein thrombosis and pulmonary embolism in two cohorts: the longitudinal investigation of thromboembolism etiology". Am J Med. 117 (1): 19–25. doi:10.1016/j.amjmed.2004.01.018. PMID 15210384.

[pmid9521222-13] Silverstein MD, Heit JA, Mohr DN, Petterson TM, O'Fallon WM, Melton LJ (1998). "Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based study". Arch Intern Med. 158 (6): 585–93. PMID 9521222.

[pmid8154949-14] Kniffin WD, Baron JA, Barrett J, Birkmeyer JD, Anderson FA (1994). "The epidemiology of diagnosed pulmonary embolism and deep venous thrombosis in the elderly". Arch Intern Med. 154 (8): 861–6. PMID 8154949.

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[pmid9109469-16] Ridker PM, Miletich JP, Hennekens CH, Buring JE (1997). "Ethnic distribution of factor V Leiden in 4047 men and women. Implications for venous thromboembolism screening". JAMA. 277 (16): 1305–7. PMID 9109469.

[pmid9415695-17] Gregg JP, Yamane AJ, Grody WW (1997). "Prevalence of the factor V-Leiden mutation in four distinct American ethnic populations". Am J Med Genet. 73 (3): 334–6. PMID 9415695.

[CDC2-18] 18.0 ^18.1 ^18.2 ^18.3 [1] Hussain R. Yusuf, MD, James Tsai, MD, Hani K. Atrash, MD, Sheree Boulet, DrPH, Scott D. Grosse, PhD, Div of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, CDC. Venous Thromboembolism in Adult Hospitalizations — United States, 2007–2009

[pmid20331949-19] 19.0 ^19.1 ^19.2 Beckman MG, Hooper WC, Critchley SE, Ortel TL (2010). "Venous thromboembolism: a public health concern". Am J Prev Med. 38 (4 Suppl): S495–501. doi:10.1016/j.amepre.2009.12.017. PMID 20331949.

[CDC3-20] 20.0 ^20.1 ^20.2 CDC- Deep Vein Thrombosis (DVT) / Pulmonary Embolism (PE) — Blood Clot Forming in a Vein

[pmid10737275-21] Heit JA, Mohr DN, Silverstein MD, Petterson TM, O'Fallon WM, Melton LJ (2000). "Predictors of recurrence after deep vein thrombosis and pulmonary embolism: a population-based cohort study". Arch Intern Med. 160 (6): 761–8. PMID 10737275.

[pmid9842042-22] Massicotte MP, Dix D, Monagle P, Adams M, Andrew M (1998). "Central venous catheter related thrombosis in children: analysis of the Canadian Registry of Venous Thromboembolic Complications". J. Pediatr. 133 (6): 770–6. PMID 9842042.

[pmid14702496-23] Worly JM, Fortenberry JD, Hansen I, Chambliss CR, Stockwell J (2004). "Deep venous thrombosis in children with diabetic ketoacidosis and femoral central venous catheters". Pediatrics. 113 (1 Pt 1): e57–60. PMID 14702496.

[pmid12814980-24] Anderson FA, Spencer FA (2003). "Risk factors for venous thromboembolism". Circulation. 107 (23 Suppl 1): I9–16. doi:10.1161/01.CIR.0000078469.07362.E6. PMID 12814980.

[pmid18757870-25] Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P; et al. (2008). "Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)". Eur Heart J. 29 (18): 2276–315. doi:10.1093/eurheartj/ehn310. PMID 18757870.

[pmid20404252-26] 26.0 ^26.1 Holst AG, Jensen G, Prescott E (2010). "Risk factors for venous thromboembolism: results from the Copenhagen City Heart Study". Circulation. 121 (17): 1896–903. doi:10.1161/CIRCULATIONAHA.109.921460. PMID 20404252.

[pmid21352080-27] Vayá A, Martínez-Triguero ML, España F, Todolí JA, Bonet E, Corella D (2011). "The metabolic syndrome and its individual components: its association with venous thromboembolism in a Mediterranean population". Metab Syndr Relat Disord. 9 (3): 197–201. doi:10.1089/met.2010.0117. PMID 21352080.

[pmid18695082-28] Eichinger S, Hron G, Bialonczyk C, Hirschl M, Minar E, Wagner O; et al. (2008). "Overweight, obesity, and the risk of recurrent venous thromboembolism". Arch Intern Med. 168 (15): 1678–83. doi:10.1001/archinte.168.15.1678. PMID 18695082.

[pmid17726684-29] Pomp ER, Rosendaal FR, Doggen CJ (2008). "Smoking increases the risk of venous thrombosis and acts synergistically with oral contraceptive use". Am J Hematol. 83 (2): 97–102. doi:10.1002/ajh.21059. PMID 17726684.

[pmid8592549-30] Heijer M, Koster T, Blom HJ, Bos GM, Briet E, Reitsma PH; et al. (1996). "Hyperhomocysteinemia as a risk factor for deep-vein thrombosis". N Engl J Med. 334 (12): 759–62. doi:10.1056/NEJM199603213341203. PMID 8592549.

[pmid20620109-31] Konofal E, Lecendreux M, Cortese S (2010). "Sleep and ADHD". Sleep Med. 11 (7): 652–8. doi:10.1016/j.sleep.2010.02.012. PMID 20620109.

[pmid24319219-32] Wells P, Anderson D (2013). "The diagnosis and treatment of venous thromboembolism". Hematology Am Soc Hematol Educ Program. 2013: 457–63. doi:10.1182/asheducation-2013.1.457. PMID 24319219.

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[pmid10744147-36] Wells PS, Anderson DR, Rodger M, Ginsberg JS, Kearon C, Gent M, Turpie AG, Bormanis J, Weitz J, Chamberlain M, Bowie D, Barnes D, Hirsh J (2000). "Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer". Thromb. Haemost. 83 (3): 416–20. PMID 10744147. Retrieved 2012-05-01.

[37] "The IMPROVEDD VTE Risk Score: Incorporation of D-Dimer into the IMPROVE Score to Improve Venous Thromboembolism Risk Stratification". doi:10.1055/s-0037-160392910.1055/s-0037-1603929.

[pmid21436241-38] 38.0 ^38.1 Spyropoulos AC, Anderson FA, FitzGerald G, Decousus H, Pini M, Chong BH; et al. (2011). "Predictive and associative models to identify hospitalized medical patients at risk for VTE". Chest. 140 (3): 706–714. doi:10.1378/chest.10-1944. PMID 21436241.

[pmid20738765-39] 39.0 ^39.1 Barbar S, Noventa F, Rossetto V, Ferrari A, Brandolin B, Perlati M; et al. (2010). "A risk assessment model for the identification of hospitalized medical patients at risk for venous thromboembolism: the Padua Prediction Score". J Thromb Haemost. 8 (11): 2450–7. doi:10.1111/j.1538-7836.2010.04044.x. PMID 20738765.

[pmid1754886-40] Caprini JA, Arcelus JI, Hasty JH, Tamhane AC, Fabrega F (1991). "Clinical assessment of venous thromboembolic risk in surgical patients". Semin Thromb Hemost. 17 Suppl 3: 304–12. PMID 1754886.

[CohenHarrington2016-41] Cohen, Alexander T.; Harrington, Robert A.; Goldhaber, Samuel Z.; Hull, Russell D.; Wiens, Brian L.; Gold, Alex; Hernandez, Adrian F.; Gibson, C. Michael (2016). "Extended Thromboprophylaxis with Betrixaban in Acutely Ill Medical Patients". New England Journal of Medicine. 375 (6): 534–544. doi:10.1056/NEJMoa1601747. ISSN 0028-4793.

[pmid22315261-42] Kahn SR, Lim W, Dunn AS, Cushman M, Dentali F, Akl EA, Cook DJ, Balekian AA, Klein RC, Le H, Schulman S, Murad MH (2012). "Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e195S–e226S. doi:10.1378/chest.11-2296. PMC 3278052. PMID 22315261.

[pmid22315263-43] Gould MK, Garcia DA, Wren SM, Karanicolas PJ, Arcelus JI, Heit JA, Samama CM (2012). "Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e227S–e277S. doi:10.1378/chest.11-2297. PMC 3278061. PMID 22315263.

[CohenSpiro2013-44] Cohen, Alexander T.; Spiro, Theodore E.; Büller, Harry R.; Haskell, Lloyd; Hu, Dayi; Hull, Russell; Mebazaa, Alexandre; Merli, Geno; Schellong, Sebastian; Spyropoulos, Alex C.; Tapson, Victor (2013). "Rivaroxaban for Thromboprophylaxis in Acutely Ill Medical Patients". New England Journal of Medicine. 368 (6): 513–523. doi:10.1056/NEJMoa1111096. ISSN 0028-4793.

[urlFDA_approved_betrixaban_(BEVYXXA,_Portola)_for_the_prophylaxis_of_venous_thromboembolism_(VTE)_in_adult_patients-45] "FDA approved betrixaban (BEVYXXA, Portola) for the prophylaxis of venous thromboembolism (VTE) in adult patients".

[pmid2503127-46] Steel K (1989). "Bathing problems in the over 70s". BMJ. 298 (6687): 1578–9. PMC 1836788. PMID 2503127.

[urlDeep_vein_thrombosis_assessment_of_probability_of_subsequent_VTE_and_risk_scores_-_wikidoc-47] "Deep vein thrombosis assessment of probability of subsequent VTE and risk scores - wikidoc".

[urlVenous_Thromboembolism_Prophylaxis_and_Treatment_in_Patients_With_Cancer:_American_Society_of_Clinical_Oncology_Clinical_Practice_Guideline_Update:_Journal_of_Clinical_Oncology:_Vol_31,_No_17-48] "Venous Thromboembolism Prophylaxis and Treatment in Patients With Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update: Journal of Clinical Oncology: Vol 31, No 17".

[urlAbstract_19875:_IMPROVEDD_Score:_Addition_of_D-Dimer_to_the_IMPROVE_Score_Improves_Venous_Thromboembolism_Risk_Stratification._An_APEX_Trial_Substudy_|_Circulation-49] "Abstract 19875: IMPROVEDD Score: Addition of D-Dimer to the IMPROVE Score Improves Venous Thromboembolism Risk Stratification. An APEX Trial Substudy | Circulation".

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@@ Line 1: / Line 1: @@
 __NOTOC__
 {{Venous thromboembolism}}
-{{CMG}}:{{AE}}{{HK}}
+{{CMG}}; {{AE}} {{HK}}, {{IQ}}, {{Anmol}}, {{ARK}}
+<br>
+'''''To review the risk of VTE according to IMPROVEDD score, click [[IMPROVEDD risk score calculator|here]]'''.''
+'''''To review the risk of VTE according to IMPROVE score, click [[IMPROVE VTE risk score|here]]'''.''
+'''''To review the risk of VTE according to Caprini scores click [[Caprini score|here]]'''.''
+'''''To predict the clinical risk of [[Pulmonary thromboembolism]] according to Wells score, click [[Wells score calculator|here]]'''.''
 ==Overiew==
+Venous thromboembolism (VTE) may be classified into [[deep vein thrombosis]] ([[DVT]]) and [[pulmonary embolism]] ([[Pulmonary embolism|PE]]). [[Pulmonary embolism]] may arise as a consequence of [[deep vein thrombosis]] as a result of [[embolization]] of the [[clot]] from deep [[veins]] of the legs. [[Pulmonary embolism]] (PE) is an [[acute]] obstruction of the [[pulmonary artery]] (or one of its branches). The obstruction in the [[pulmonary artery]] that causes a [[PE]] can be due to [[thrombus]], air, [[tumor]], or [[fat]]. Most often, [[pulmonary embolism]] is due to a [[venous thrombosis]] ([[blood clot]] from a [[vein]]), which has been dislodged from its site of formation in the [[lower extremities]]. It has then [[Embolism|embolized]] to the [[Pulmonary artery|arterial]] blood supply of one of the [[lungs]]. [[Deep vein thrombosis]] (also known as [[deep venous thrombosis]] or [[DVT]] and colloquially referred to as "[[economy class syndrome]]") is the formation of a [[blood clot]] ("[[thrombus]]") in a [[deep vein]].
 ==Classification==
-Venous thromboembolism (VTE) may be classified into:<ref name="pmid22084692">{{cite journal |vauthors=Moheimani F, Jackson DE |title=Venous thromboembolism: classification, risk factors, diagnosis, and management |journal=ISRN Hematol |volume=2011 |issue= |pages=124610 |year=2011 |pmid=22084692 |pmc=3196154 |doi=10.5402/2011/124610 |url=}}</ref>
+Venous thromboembolism (VTE) may be classified into:<ref name="pmid22084692">{{cite journal |vauthors=Moheimani F, Jackson DE |title=Venous thromboembolism: classification, risk factors, diagnosis, and management |journal=ISRN Hematol |volume=2011 |issue= |pages=124610 |year=2011 |pmid=22084692 |pmc=3196154 |doi=10.5402/2011/124610 |url=}}</ref><ref>{{cite book | last = Kasper | first = Dennis | title = Harrison's principles of internal medicine | publisher = McGraw Hill Education | location = New York | year = 2015 | isbn = 978-0071802154 }}</ref>
 * [[Deep vein thrombosis]] ([[DVT]])
 * [[Pulmonary embolism]] ([[PE]])
-The following table further classifies [[DVT]] and [[PE]]:<ref name="pmid9546569">{{cite journal |author=Anand SS, Wells PS, Hunt D, Brill-Edwards P, Cook D, Ginsberg JS |title=Does this patient have deep vein thrombosis? |journal=JAMA |volume=279 |issue=14 |pages=1094–9 |year=1998 |month=April |pmid=9546569 |doi= |url=}}</ref><ref name="pmid7752753">{{cite journal |author=Wells PS, Hirsh J, Anderson DR, ''et al.'' |title=Accuracy of clinical assessment of deep-vein thrombosis |journal=Lancet |volume=345 |issue=8961 |pages=1326–30 |year=1995 |month=May |pmid=7752753 |doi= |url=}}</ref><ref name="pmid8257253">{{cite journal |author=Cogo A, Lensing AW, Prandoni P, Hirsh J |title=Distribution of thrombosis in patients with symptomatic deep vein thrombosis. Implications for simplifying the diagnostic process with compression ultrasound |journal=Arch. Intern. Med. |volume=153 |issue=24 |pages=2777–80 |year=1993 |month=December |pmid=8257253 |doi= |url=}}</ref><ref name="pmid19718469">{{cite journal |author=Galanaud JP, Sevestre-Pietri MA, Bosson JL, Laroche JP, Righini M, Brisot D, Boge G, van Kien AK, Gattolliat O, Bettarel-Binon C, Gris JC, Genty C, Quere I |title=Comparative study on risk factors and early outcome of symptomatic distal versus proximal deep vein thrombosis: results from the OPTIMEV study |journal=Thromb. Haemost. |volume=102 |issue=3 |pages=493–500 |year=2009 |month=September|pmid=19718469|doi=10.1160/TH09-01-0053 |url=http://www.schattauer.de/index.php?id=1268&L=1&pii=th09-01-0053&no_cache=1|accessdate=2011-12-14}}</ref><ref name="pmid8257253">{{cite journal| author=Cogo A, Lensing AW, Prandoni P, Hirsh J| title=Distribution of thrombosis in patients with symptomatic deep vein thrombosis. Implications for simplifying the diagnostic process with compression ultrasound. | journal=Arch Intern Med | year= 1993 | volume= 153 | issue= 24 | pages= 2777-80 | pmid=8257253 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8257253  }} </ref><ref name="pmid15353493">{{cite journal |author=Joffe HV, Kucher N, Tapson VF, Goldhaber SZ |title=Upper-extremity deep vein thrombosis: a prospective registry of 592 patients |journal=[[Circulation]] |volume=110 |issue=12 |pages=1605–11 |year=2004 |month=September |pmid=15353493 |doi=10.1161/01.CIR.0000142289.94369.D7 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=15353493 |accessdate=2012-10-07}}</ref><ref name="pmid20406709">{{cite journal| author=Isma N, Svensson PJ, Gottsäter A, Lindblad B| title=Upper extremity deep venous thrombosis in the population-based Malmö thrombophilia study (MATS). Epidemiology, risk factors, recurrence risk, and mortality. | journal=Thromb Res | year= 2010 | volume= 125 | issue= 6 | pages= e335-8 | pmid=20406709 | doi=10.1016/j.thromres.2010.03.005 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20406709  }} </ref><ref name="pmid17925416">{{cite journal| author=Muñoz FJ, Mismetti P, Poggio R, Valle R, Barrón M, Guil M et al.| title=Clinical outcome of patients with upper-extremity deep vein thrombosis: results from the RIETE Registry. | journal=Chest | year= 2008 | volume= 133 | issue= 1 | pages= 143-8 | pmid=17925416 | doi=10.1378/chest.07-1432 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17925416  }} </ref>
+The following table further classifies [[DVT]] and [[PE]]:<ref name="pmid9546569">{{cite journal| author=Anand SS, Wells PS, Hunt D, Brill-Edwards P, Cook D, Ginsberg JS| title=Does this patient have deep vein thrombosis? | journal=JAMA | year= 1998 | volume= 279 | issue= 14 | pages= 1094-9 | pmid=9546569 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9546569  }} </ref><ref name="pmid7752753">{{cite journal| author=Wells PS, Hirsh J, Anderson DR, Lensing AW, Foster G, Kearon C et al.| title=Accuracy of clinical assessment of deep-vein thrombosis. | journal=Lancet | year= 1995 | volume= 345 | issue= 8961 | pages= 1326-30 | pmid=7752753 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7752753  }} </ref><ref name="pmid8257253">{{cite journal| author=Cogo A, Lensing AW, Prandoni P, Hirsh J| title=Distribution of thrombosis in patients with symptomatic deep vein thrombosis. Implications for simplifying the diagnostic process with compression ultrasound. | journal=Arch Intern Med | year= 1993 | volume= 153 | issue= 24 | pages= 2777-80 | pmid=8257253 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8257253  }} </ref><ref name="pmid19718469">{{cite journal| author=Galanaud JP, Sevestre-Pietri MA, Bosson JL, Laroche JP, Righini M, Brisot D et al.| title=Comparative study on risk factors and early outcome of symptomatic distal versus proximal deep vein thrombosis: results from the OPTIMEV study. | journal=Thromb Haemost | year= 2009 | volume= 102 | issue= 3 | pages= 493-500 | pmid=19718469 | doi=10.1160/TH09-01-0053 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19718469  }} </ref><ref name="pmid8257253">{{cite journal| author=Cogo A, Lensing AW, Prandoni P, Hirsh J| title=Distribution of thrombosis in patients with symptomatic deep vein thrombosis. Implications for simplifying the diagnostic process with compression ultrasound. | journal=Arch Intern Med | year= 1993 | volume= 153 | issue= 24 | pages= 2777-80 | pmid=8257253 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8257253  }} </ref><ref name="pmid15353493">{{cite journal| author=Joffe HV, Kucher N, Tapson VF, Goldhaber SZ, Deep Vein Thrombosis (DVT) FREE Steering Committee| title=Upper-extremity deep vein thrombosis: a prospective registry of 592 patients. | journal=Circulation | year= 2004 | volume= 110 | issue= 12 | pages= 1605-11 | pmid=15353493 | doi=10.1161/01.CIR.0000142289.94369.D7 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15353493  }} </ref><ref name="pmid20406709">{{cite journal| author=Isma N, Svensson PJ, Gottsäter A, Lindblad B| title=Upper extremity deep venous thrombosis in the population-based Malmö thrombophilia study (MATS). Epidemiology, risk factors, recurrence risk, and mortality. | journal=Thromb Res | year= 2010 | volume= 125 | issue= 6 | pages= e335-8 | pmid=20406709 | doi=10.1016/j.thromres.2010.03.005 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20406709  }} </ref><ref name="pmid17925416">{{cite journal| author=Muñoz FJ, Mismetti P, Poggio R, Valle R, Barrón M, Guil M et al.| title=Clinical outcome of patients with upper-extremity deep vein thrombosis: results from the RIETE Registry. | journal=Chest | year= 2008 | volume= 133 | issue= 1 | pages= 143-8 | pmid=17925416 | doi=10.1378/chest.07-1432 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17925416  }} </ref>
 {|
-! colspan="3" style="background: #4479BA; text-align: center;" |{{fontcolor|#FFF| Classification of Venous thromboembolism}}
+! colspan="3" style="background: #4479BA; text-align: center;" |{{fontcolor|#FFF| Classification of Venous Thromboembolism}}
 |-
-! style="background: #7d7d7d; text-align: center;" |{{fontcolor|#FFF|Clinical diagnosis}}
+! style="background: #4479BA; text-align: center;" |{{fontcolor|#FFF|Clinical diagnosis}}
-! style="background: #7d7d7d; text-align: center;" |{{fontcolor|#FFF|Sub-classification}}
+! style="background: #4479BA; text-align: center;" |{{fontcolor|#FFF|Sub-classification}}
-! style="background: #7d7d7d; text-align: center;" |{{fontcolor|#FFF|Comments}}
+! style="background: #4479BA; text-align: center;" |{{fontcolor|#FFF|Comments}}
 |-
 | rowspan="2" style="background: #DCDCDC; text-align: center;" |[[Deep vein thrombosis]]
 | style="background: #F5F5F5; text-align: center;" |Upper extremity
 | style="background: #F5F5F5;" |
-*Uncommon and accounts for 1-5 % of all [[DVT]]
+*Uncommon (accounts for 1-5% of all [[DVT]])
 *Most likely due to:
 **[[Central venous catheter]]
@@ Line 41: / Line 51: @@
 | style="background: #F5F5F5; text-align: center;" |Massive [[PE]] (High risk)
 | style="background: #F5F5F5;" |
-* Sustained [[hypotension]] ([[systolic blood pressure]] <90 mm Hg), not due to [[Arrhythmias|arrhythmia]], [[hypovolemia]], [[sepsis]], or [[left ventricular dysfunction]], and either lasting for at least 15 minutes or necessitating the administration of [[inotropes]]
+* Sustained [[hypotension]] ([[systolic blood pressure]] <90 mm Hg) not due to [[Arrhythmias|arrhythmia]], [[hypovolemia]], [[sepsis]], or [[left ventricular dysfunction]], and either lasting for at least 15 minutes or necessitating the administration of [[inotropes]]
 OR
 * [[Pulselessness]]
 OR
-* Persistent profound [[bradycardia]] (heart rate < 40 bpm) plus findings of [[shock]]
+* Persistent profound [[bradycardia]] (heart rate <40 bpm) plus findings of [[shock]]
 |-
 | style="background: #F5F5F5; text-align: center;" |Sub-massive [[PE]] (Intermediate risk [[PE]])
@@ Line 51: / Line 61: @@
 * [[Right ventricular failure|Right ventricular dysfunction]] OR [[myocardial necrosis]]
 AND
-*Absence of systemic hypotension (systolic blood pressure >90 mm Hg)
+*Absence of systemic [[hypotension]] ([[systolic blood pressure]] >90 mm Hg)
 |-
 | style="background: #F5F5F5; text-align: center;" |Low risk [[PE]]
 | style="background: #F5F5F5;" |
-* Absence of [[hypotension]], [[shock]], [[Pulmonary embolism classification#Right Ventricular Dysfunction|right ventricular dysfunction]]<nowiki/>and [[Pulmonary embolism classification#Myocardial Necrosis|myocardial necrosis]]
+* Absence of [[hypotension]], [[shock]], [[Pulmonary embolism classification#Right Ventricular Dysfunction|right ventricular dysfunction]], <nowiki/>and [[Pulmonary embolism classification#Myocardial Necrosis|myocardial necrosis]]
 |}
 ==Epidemiology==
+=== Prevalence ===
+* The precise number of people affected by [[Deep vein thrombosis|DVT]]/[[Pulmonary embolism|PE]] is unknown,although as many as 900,000 people could be affected (100 to 200 per 100,000) each year in the United States.<ref name="urlData and Statistics | DVT/PE | NCBDDD | CDC">{{cite web |url=https://www.cdc.gov/ncbddd/dvt/data.html |title=Data and Statistics &#124; DVT/PE &#124; NCBDDD &#124; CDC |format= |work= |accessdate=}}</ref>
 ===Incidence===
-*The incidence of VTE increases with age, ranging from less than 5 cases per 100,000 people in childhood to 500 cases per 100,000 people in the elderly.<ref name="pmid12814979">{{cite journal| author=White RH| title=The epidemiology of venous thromboembolism. | journal=Circulation | year= 2003 | volume= 107 | issue= 23 Suppl 1 | pages= I4-8 | pmid=12814979 | doi=10.1161/01.CIR.0000078468.11849.66 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12814979  }} </ref>
+*The [[incidence]] of VTE increases with [[age]], ranging from less than 5 cases per 100,000 people in childhood to 500 cases per 100,000 people in the elderly.<ref name="pmid12814979">{{cite journal| author=White RH| title=The epidemiology of venous thromboembolism. | journal=Circulation | year= 2003 | volume= 107 | issue= 23 Suppl 1 | pages= I4-8 | pmid=12814979 | doi=10.1161/01.CIR.0000078468.11849.66 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12814979  }} </ref>
-*Subjects who are more than 65 years of age are at three times higher risk for VTE compared to those who are 45-54 years old.<ref name="pmid15210384">{{cite journal| author=Cushman M, Tsai AW, White RH, Heckbert SR, Rosamond WD, Enright P et al.| title=Deep vein thrombosis and pulmonary embolism in two cohorts: the longitudinal investigation of thromboembolism etiology. | journal=Am J Med | year= 2004 | volume= 117 | issue= 1 | pages= 19-25 | pmid=15210384 | doi=10.1016/j.amjmed.2004.01.018 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15210384  }} </ref>
+*Those who are more than 65 years of [[age]] are at three times higher risk for VTE compared to those who are 45-54 years old.<ref name="pmid15210384">{{cite journal| author=Cushman M, Tsai AW, White RH, Heckbert SR, Rosamond WD, Enright P et al.| title=Deep vein thrombosis and pulmonary embolism in two cohorts: the longitudinal investigation of thromboembolism etiology. | journal=Am J Med | year= 2004 | volume= 117 | issue= 1 | pages= 19-25 | pmid=15210384 | doi=10.1016/j.amjmed.2004.01.018 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15210384  }} </ref>
-*In the United States, the annual incidence of VTE is estimated to be approximately 100 per 100,000 persons.<ref name="pmid12814979">{{cite journal |author=White RH |title=The epidemiology of venous thromboembolism |journal=Circulation |volume=107 |issue=23 Suppl 1 |pages=I4–8 |year=2003 |month=June |pmid=12814979 |doi=10.1161/01.CIR.0000078468.11849.66 |url=}}</ref>
+*In the United States, the annual [[incidence]] of VTE is estimated to be approximately 100 per 100,000 persons.<ref name="pmid12814979">{{cite journal |author=White RH |title=The epidemiology of venous thromboembolism |journal=Circulation |volume=107 |issue=23 Suppl 1 |pages=I4–8 |year=2003 |month=June |pmid=12814979 |doi=10.1161/01.CIR.0000078468.11849.66 |url=}}</ref>
 ===Age===
-*The incidence of VTE increases with age, ranging from less than 5 cases per 100,000 people in childhood to 500 cases per 100,000 people in the elderly.<ref name="pmid12814979">{{cite journal| author=White RH| title=The epidemiology of venous thromboembolism. | journal=Circulation | year= 2003 | volume= 107 | issue= 23 Suppl 1 | pages= I4-8 | pmid=12814979 | doi=10.1161/01.CIR.0000078468.11849.66 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12814979  }} </ref>
+*The [[incidence]] of VTE increases with [[age]], ranging from less than 5 cases per 100,000 people in childhood to 500 cases per 100,000 people in the elderly.<ref name="pmid12814979">{{cite journal| author=White RH| title=The epidemiology of venous thromboembolism. | journal=Circulation | year= 2003 | volume= 107 | issue= 23 Suppl 1 | pages= I4-8 | pmid=12814979 | doi=10.1161/01.CIR.0000078468.11849.66 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12814979  }} </ref>
-*Subjects who are more than 65 years of age are at three times higher risk for VTE compared to those who are 45-54 years old.<ref name="pmid15210384">{{cite journal| author=Cushman M, Tsai AW, White RH, Heckbert SR, Rosamond WD, Enright P et al.| title=Deep vein thrombosis and pulmonary embolism in two cohorts: the longitudinal investigation of thromboembolism etiology. | journal=Am J Med | year= 2004 | volume= 117 | issue= 1 | pages= 19-25 | pmid=15210384 | doi=10.1016/j.amjmed.2004.01.018 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15210384  }} </ref>
+*Those who are more than 65 years of [[age]] are at three times higher risk for VTE compared to those who are 45-54 years old.<ref name="pmid15210384">{{cite journal| author=Cushman M, Tsai AW, White RH, Heckbert SR, Rosamond WD, Enright P et al.| title=Deep vein thrombosis and pulmonary embolism in two cohorts: the longitudinal investigation of thromboembolism etiology. | journal=Am J Med | year= 2004 | volume= 117 | issue= 1 | pages= 19-25 | pmid=15210384 | doi=10.1016/j.amjmed.2004.01.018 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15210384  }} </ref>
 ===Gender===
-*Studies about differences in the incidence of VTE by gender have mixed results.
+*Studies about differences in the [[incidence]] of VTE by gender have yielded mixed results:
-**Some reported a higher incidence of [[DVT]] among young females<ref name="pmid9521222">{{cite journal| author=Silverstein MD, Heit JA, Mohr DN, Petterson TM, O'Fallon WM, Melton LJ| title=Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based study. | journal=Arch Intern Med | year= 1998 | volume= 158 | issue= 6 | pages= 585-93 | pmid=9521222 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9521222  }} </ref>
+**Some reported a higher [[incidence]] of [[DVT]] among young females.<ref name="pmid9521222">{{cite journal| author=Silverstein MD, Heit JA, Mohr DN, Petterson TM, O'Fallon WM, Melton LJ| title=Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based study. | journal=Arch Intern Med | year= 1998 | volume= 158 | issue= 6 | pages= 585-93 | pmid=9521222 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9521222  }} </ref>
-**Some reported it higher among either older females<ref name="pmid8154949">{{cite journal| author=Kniffin WD, Baron JA, Barrett J, Birkmeyer JD, Anderson FA| title=The epidemiology of diagnosed pulmonary embolism and deep venous thrombosis in the elderly. | journal=Arch Intern Med | year= 1994 | volume= 154 | issue= 8 | pages= 861-6 | pmid=8154949 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8154949  }} </ref>
+**Some reported a higher [[incidence]] of [[DVT]] among older females.<ref name="pmid8154949">{{cite journal| author=Kniffin WD, Baron JA, Barrett J, Birkmeyer JD, Anderson FA| title=The epidemiology of diagnosed pulmonary embolism and deep venous thrombosis in the elderly. | journal=Arch Intern Med | year= 1994 | volume= 154 | issue= 8 | pages= 861-6 | pmid=8154949 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8154949  }} </ref>
-**Some reported it higher in men.<ref name="pmid15210384">{{cite journal |author=Cushman M, Tsai AW, White RH, ''et al.'' |title=Deep vein thrombosis and pulmonary embolism in two cohorts: the longitudinal investigation of thromboembolism etiology |journal=Am. J. Med. |volume=117 |issue=1 |pages=19–25 |year=2004 |month=July |pmid=15210384 |doi=10.1016/j.amjmed.2004.01.018 |url=}}</ref><ref name="urlVenous Thromboembolism in Adult Hospitalizations — United States, 2007–2009">{{cite web |url=http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6122a1.htm?s_cid=mm6122a1_w |title=Venous Thromboembolism in Adult Hospitalizations — United States, 2007–2009 |format= |work= |accessdate=2012-10-06}}</ref>
+**Some reported a higher [[incidence]] of [[DVT]] in men.<ref name="pmid15210384">{{cite journal |author=Cushman M, Tsai AW, White RH, ''et al.'' |title=Deep vein thrombosis and pulmonary embolism in two cohorts: the longitudinal investigation of thromboembolism etiology |journal=Am. J. Med. |volume=117 |issue=1 |pages=19–25 |year=2004 |month=July |pmid=15210384 |doi=10.1016/j.amjmed.2004.01.018 |url=}}</ref><ref name="urlVenous Thromboembolism in Adult Hospitalizations — United States, 2007–2009">{{cite web |url=http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6122a1.htm?s_cid=mm6122a1_w |title=Venous Thromboembolism in Adult Hospitalizations — United States, 2007–2009 |format= |work= |accessdate=2012-10-06}}</ref>
-*In addition, the risk for [[DVT]] was reported to consistently increase with age across both genders.<ref name="pmid15210384">{{cite journal |author=Cushman M, Tsai AW, White RH, ''et al.'' |title=Deep vein thrombosis and pulmonary embolism in two cohorts: the longitudinal investigation of thromboembolism etiology |journal=Am. J. Med. |volume=117 |issue=1 |pages=19–25 |year=2004 |month=July |pmid=15210384 |doi=10.1016/j.amjmed.2004.01.018 |url=}}</ref>
+*In addition, the risk for [[DVT]] was reported to consistently increase with [[age]] across both genders.<ref name="pmid15210384">{{cite journal |author=Cushman M, Tsai AW, White RH, ''et al.'' |title=Deep vein thrombosis and pulmonary embolism in two cohorts: the longitudinal investigation of thromboembolism etiology |journal=Am. J. Med. |volume=117 |issue=1 |pages=19–25 |year=2004 |month=July |pmid=15210384 |doi=10.1016/j.amjmed.2004.01.018 |url=}}</ref>
 ===Race===
-* There is a significant difference in the incidence of DVT as it relates to race. African Americans characteristically have the highest incidence of [[DVT]] while Caucasians rank as the second highest incidence of [[DVT]].<ref name="pmid12814979">{{cite journal| author=White RH| title=The epidemiology of venous thromboembolism. | journal=Circulation | year= 2003 | volume= 107 | issue= 23 Suppl 1 | pages= I4-8 | pmid=12814979 | doi=10.1161/01.CIR.0000078468.11849.66 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12814979  }} </ref>
+* There is a significant difference in the incidence of [[DVT]] as it relates to [[race]]. African Americans characteristically have the highest incidence of [[DVT]] while Caucasians rank as the second highest [[incidence]] of [[DVT]].<ref name="pmid12814979">{{cite journal| author=White RH| title=The epidemiology of venous thromboembolism. | journal=Circulation | year= 2003 | volume= 107 | issue= 23 Suppl 1 | pages= I4-8 | pmid=12814979 | doi=10.1161/01.CIR.0000078468.11849.66 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12814979  }} </ref>
-* When compared to African Americans and Caucasians, the incidence of [[DVT]] is noted to be two to four times lower in Hispanics and Asian-Pacific Islanders.<ref name="pmid12814979">{{cite journal| author=White RH| title=The epidemiology of venous thromboembolism. | journal=Circulation | year= 2003 | volume= 107 | issue= 23 Suppl 1 | pages= I4-8 | pmid=12814979 | doi=10.1161/01.CIR.0000078468.11849.66 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12814979  }} </ref>
+* Compared to African Americans and Caucasians, the incidence of [[DVT]] is noted to be two to four times lower in Hispanics and Asian-Pacific Islanders.<ref name="pmid12814979">{{cite journal| author=White RH| title=The epidemiology of venous thromboembolism. | journal=Circulation | year= 2003 | volume= 107 | issue= 23 Suppl 1 | pages= I4-8 | pmid=12814979 | doi=10.1161/01.CIR.0000078468.11849.66 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12814979  }} </ref>
 * Lower [[incidence]] of [[thrombosis]] in non-Caucasians may be related to a lower [[prevalence]] of disorders like [[Factor V Leiden]] or [[Thrombin#Prothrombin 20210a mutation|Prothrombin 20210A mutation]].<ref name="pmid9109469">{{cite journal| author=Ridker PM, Miletich JP, Hennekens CH, Buring JE| title=Ethnic distribution of factor V Leiden in 4047 men and women. Implications for venous thromboembolism screening. | journal=JAMA | year= 1997 | volume= 277 | issue= 16 | pages= 1305-7 | pmid=9109469 | doi= | pmc= | url= }} </ref><ref name="pmid9415695">{{cite journal| author=Gregg JP, Yamane AJ, Grody WW| title=Prevalence of the factor V-Leiden mutation in four distinct American ethnic populations. | journal=Am J Med Genet | year= 1997 | volume= 73 | issue= 3 | pages= 334-6 | pmid=9415695 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9415695  }} </ref>
 ===Hospitalization for VTE===
-* During 2007–2009, an estimated annual average of 547,596 hospitalizations had a diagnosis of VTE for adults aged ≥18 years. Estimates for [[DVT]] and [[PE]] diagnoses were not mutually exclusive. An estimated annual average of 348,558 adult hospitalizations had a diagnosis of DVT, and 277,549 adult hospitalizations had a diagnosis of PE. An estimated annual average of 78,511 adult hospitalizations (14% of overall VTE hospitalizations) had diagnoses of both [[DVT]] and [[PE]].<ref name="CDC2">[http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6122a1.htm?s_cid=mm6122a1_w] Hussain R. Yusuf, MD, James Tsai, MD, Hani K. Atrash, MD, Sheree Boulet, DrPH, Scott D. Grosse, PhD, Div of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, CDC. Venous Thromboembolism in Adult Hospitalizations — United States, 2007–2009</ref>
+* During 2007–2009, an estimated annual average of 547,596 hospitalizations culminated in a diagnosis of VTE for adults aged ≥18 years. Estimates for [[DVT]] and [[PE]] diagnoses were not mutually exclusive. An estimated annual average of 348,558 adult hospitalizations resulted in a diagnosis of DVT, and 277,549 adult hospitalizations resulted in a diagnosis of PE. An estimated annual average of 78,511 adult hospitalizations (14% of overall VTE hospitalizations) had diagnoses of both [[DVT]] and [[PE]].<ref name="CDC2">[http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6122a1.htm?s_cid=mm6122a1_w] Hussain R. Yusuf, MD, James Tsai, MD, Hani K. Atrash, MD, Sheree Boulet, DrPH, Scott D. Grosse, PhD, Div of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, CDC. Venous Thromboembolism in Adult Hospitalizations — United States, 2007–2009</ref>
 * The estimated average annual number of hospitalizations with VTE was successively greater among older age groups: 54,034 for persons aged 18–39 years; 143,354 for persons aged 40–59 years; and 350,208 for persons aged ≥60 years. The estimated average annual number of hospitalizations with VTE was comparable for men (250,973) and women (296,623).<ref name="CDC2">[http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6122a1.htm?s_cid=mm6122a1_w] Hussain R. Yusuf, MD, James Tsai, MD, Hani K. Atrash, MD, Sheree Boulet, DrPH, Scott D. Grosse, PhD, Div of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, CDC. Venous Thromboembolism in Adult Hospitalizations — United States, 2007–2009</ref>
-* Shown below is an image depicting the estimated average annual number of hospitalization with a diagnosis of [[DVT]], [[PE]], or VTE by age and sex.
+* Shown below is an image depicting the estimated average annual number of hospitalization with a diagnosis of [[DVT]], [[PE]], or VTE by [[age]] and sex.
 [[Image:Estimated average annual number of hospitalization VTE.gif|frame|center|Estimated average annual number of hospitalizations with a diagnosis of deep thrombosis (DVT), pulmonary embolism (PE), or venous thromboembolism (VTE), by patient sex and age group — National Hospital Discharge Survey, United States, 2007–2009 - [https://www.cdc.gov/mmwr/pdf/wk/mm6122.pdf Source:CDC]]]
-* The average annual rates of hospitalizations with a discharge diagnosis of [[DVT]], [[PE]], or VTE among adults were 152, 121, and 239 per 100,000 population, respectively. For VTE, the average annual rates were 60 per 100,000 population aged 18–39 years, 143 for persons aged 40–49 years, 200 for persons aged 50–59 years, 391 for persons aged 60–69 years, 727 for persons aged 70–79 years, and 1,134 for persons aged ≥80 years. The rates of hospitalization were similar for men and women, and the point estimates increased for both sexes by age.<ref name="CDC2">[http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6122a1.htm?s_cid=mm6122a1_w] Hussain R. Yusuf, MD, James Tsai, MD, Hani K. Atrash, MD, Sheree Boulet, DrPH, Scott D. Grosse, PhD, Div of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, CDC. Venous Thromboembolism in Adult Hospitalizations — United States, 2007–2009</ref>
+* The average annual rates of hospitalizations with a discharge diagnosis of [[DVT]], [[PE]], or VTE among adults were 152, 121, and 239 per 100,000 population, respectively. For VTE, the average annual rates were 60 per 100,000 population aged 18–39 years, 143 for persons aged 40–49 years, 200 for persons aged 50–59 years, 391 for persons aged 60–69 years, 727 for persons aged 70–79 years, and 1,134 for persons aged ≥80 years. The rates of hospitalization were similar for men and women, and the point estimates increased for both sexes by [[age]].<ref name="CDC2">[http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6122a1.htm?s_cid=mm6122a1_w] Hussain R. Yusuf, MD, James Tsai, MD, Hani K. Atrash, MD, Sheree Boulet, DrPH, Scott D. Grosse, PhD, Div of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, CDC. Venous Thromboembolism in Adult Hospitalizations — United States, 2007–2009</ref>
 * On average, 28,726 hospitalized adults with a VTE diagnosis died each year. Of these patients, an average of 13,164 had a DVT diagnosis and 19,297 had a PE diagnosis; 3,735 had both [[DVT]] and [[PE]] diagnoses.<ref name="CDC2">[http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6122a1.htm?s_cid=mm6122a1_w] Hussain R. Yusuf, MD, James Tsai, MD, Hani K. Atrash, MD, Sheree Boulet, DrPH, Scott D. Grosse, PhD, Div of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, CDC. Venous Thromboembolism in Adult Hospitalizations — United States, 2007–2009</ref>
 ===Recurrence of VTE===
-* One-third (about 33%) of people with VTE will have a recurrence within 10 years.<ref name="pmid20331949">{{cite journal| author=Beckman MG, Hooper WC, Critchley SE, Ortel TL| title=Venous thromboembolism: a public health concern. | journal=Am J Prev Med | year= 2010 | volume= 38 | issue= 4 Suppl | pages= S495-501 | pmid=20331949 | doi=10.1016/j.amepre.2009.12.017 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20331949  }} </ref><ref name="CDC3">[http://www.cdc.gov/ncbddd/dvt/data.html CDC- Deep Vein Thrombosis (DVT) / Pulmonary Embolism (PE) — Blood Clot Forming in a Vein]</ref>
+*Approximately 33% (1 in 3) of people with VTE will have a recurrence within 10 years.<ref name="pmid20331949">{{cite journal| author=Beckman MG, Hooper WC, Critchley SE, Ortel TL| title=Venous thromboembolism: a public health concern. | journal=Am J Prev Med | year= 2010 | volume= 38 | issue= 4 Suppl | pages= S495-501 | pmid=20331949 | doi=10.1016/j.amepre.2009.12.017 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20331949  }} </ref><ref name="CDC3">[http://www.cdc.gov/ncbddd/dvt/data.html CDC- Deep Vein Thrombosis (DVT) / Pulmonary Embolism (PE) — Blood Clot Forming in a Vein]</ref>
-* The risk of recurrence of [[VTE]] in patients diagnosed with first-time [[VTE]] is estimated to be around 7-8 percent per year during an average follow up period of 2.2 years of subsequent observation of 265 patients.<ref name="pmid15210384">{{cite journal |author=Cushman M, Tsai AW, White RH, ''et al.''|title=Deep vein thrombosis and pulmonary embolism in two cohorts: the longitudinal investigation of thromboembolism etiology |journal=Am. J. Med.|volume=117 |issue=1 |pages=19–25 |year=2004 |month=July |pmid=15210384 |doi=10.1016/j.amjmed.2004.01.018 |url=}}</ref>
+*The risk of recurrence of [[VTE]] in patients diagnosed with first-time [[VTE]] is estimated to be approximately 7-8% per year during an average follow up period of 2.2 years of subsequent observation.<ref name="pmid15210384">{{cite journal |author=Cushman M, Tsai AW, White RH, ''et al.''|title=Deep vein thrombosis and pulmonary embolism in two cohorts: the longitudinal investigation of thromboembolism etiology |journal=Am. J. Med.|volume=117 |issue=1 |pages=19–25 |year=2004 |month=July |pmid=15210384 |doi=10.1016/j.amjmed.2004.01.018 |url=}}</ref>
-* Among patients with a first episode of VTE, the risk of recurrence of VTE is particularly elevated in the first 6 to 12 months following the first episode of VTE.  The risk of recurrent VTE remains up to 10 years, with a estimated cumulative incidence of first overall VTE recurrence of 30 %.  Predictors for recurrence of [[VTE]] include [[malignancy]], [[Neurology|neurological]] diseases, and [[paresis]].<ref name="pmid10737275">{{cite journal| author=Heit JA, Mohr DN, Silverstein MD, Petterson TM, O'Fallon WM, Melton LJ| title=Predictors of recurrence after deep vein thrombosis and pulmonary embolism: a population-based cohort study. | journal=Arch Intern Med | year= 2000 | volume= 160 | issue= 6 | pages= 761-8 | pmid=10737275 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10737275  }} </ref>
+*Among patients with a first episode of VTE, the risk of recurrence of VTE is particularly elevated in the first 6 to 12 months following the first episode of VTE.  The risk of recurrent VTE remains up to 10 years, with a estimated cumulative incidence of first overall VTE recurrence of 30%. Predictors for recurrence of [[VTE]] include [[malignancy]], [[Neurology|neurological]] diseases, and [[paresis]].<ref name="pmid10737275">{{cite journal| author=Heit JA, Mohr DN, Silverstein MD, Petterson TM, O'Fallon WM, Melton LJ| title=Predictors of recurrence after deep vein thrombosis and pulmonary embolism: a population-based cohort study. | journal=Arch Intern Med | year= 2000 | volume= 160 | issue= 6 | pages= 761-8 | pmid=10737275 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10737275  }} </ref>
-* In recent years, the increase in [[thrombosis]] incidence may be related to improved diagnostic modalities and increased awareness by clinicians.<ref name="pmid12814979">{{cite journal |author=White RH |title=The epidemiology of venous thromboembolism |journal=Circulation |volume=107 |issue=23 Suppl 1 |pages=I4–8 |year=2003|month=June |pmid=12814979 |doi=10.1161/01.CIR.0000078468.11849.66 |url=}}</ref>
+*The recent increase in [[thrombosis]] incidence may be related to improved diagnostic modalities and increased awareness by clinicians.<ref name="pmid12814979">{{cite journal |author=White RH |title=The epidemiology of venous thromboembolism |journal=Circulation |volume=107 |issue=23 Suppl 1 |pages=I4–8 |year=2003|month=June |pmid=12814979 |doi=10.1161/01.CIR.0000078468.11849.66 |url=}}</ref>
 ===Complications of VTE===
@@ Line 107: / Line 121: @@
 ==Risk Factors==
-Shown below is a list of predisposing factors for [[VTE]].<ref name="pmid12814980">{{cite journal| author=Anderson FA, Spencer FA| title=Risk factors for venous thromboembolism. | journal=Circulation | year= 2003 | volume= 107 | issue= 23 Suppl 1 | pages= I9-16 | pmid=12814980 | doi=10.1161/01.CIR.0000078469.07362.E6 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12814980  }} </ref><ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref> The risk factors are classified as moderate or weak depending on how strongly they predispose for a VTE.
+Shown below is a list of predisposing factors for [[VTE]]. The risk factors are classified as moderate or weak depending on how strongly they are associated with a VTE.<ref name="pmid9842042">{{cite journal |vauthors=Massicotte MP, Dix D, Monagle P, Adams M, Andrew M |title=Central venous catheter related thrombosis in children: analysis of the Canadian Registry of Venous Thromboembolic Complications |journal=J. Pediatr. |volume=133 |issue=6 |pages=770–6 |year=1998 |pmid=9842042 |doi= |url=}}</ref><ref name="pmid14702496">{{cite journal |vauthors=Worly JM, Fortenberry JD, Hansen I, Chambliss CR, Stockwell J |title=Deep venous thrombosis in children with diabetic ketoacidosis and femoral central venous catheters |journal=Pediatrics |volume=113 |issue=1 Pt 1 |pages=e57–60 |year=2004 |pmid=14702496 |doi= |url=}}</ref><ref name="pmid12814980">{{cite journal| author=Anderson FA, Spencer FA| title=Risk factors for venous thromboembolism. | journal=Circulation | year= 2003 | volume= 107 | issue= 23 Suppl 1 | pages= I9-16 | pmid=12814980 | doi=10.1161/01.CIR.0000078469.07362.E6 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12814980  }} </ref><ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref>
 {| style="cellpadding=0; cellspacing= 0; width: 600px;"
 |-
-! align="center" style="background:#4479BA; color: #FFFFFF;" + |Moderate risk factors
+! style="background:#4479BA; color: #FFFFFF;" align="center" + |Moderate risk factors
-! align="center" style="background:#4479BA; color: #FFFFFF;" + |Weak risk factors
+! style="background:#4479BA; color: #FFFFFF;" align="center" + |Weak risk factors
 |-
 | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align="left" |❑ [[Chemotherapy]]<br>❑ [[Obesity]]
@@ Line 133: / Line 147: @@
 |}
-'''Risk factors of VTE may be categorized in to modifiable, non-modifiable, temporary and other risk factors.'''
+'''Risk factors of VTE may be categorized into modifiable, non-modifiable, temporary, and other risk factors.'''
 {| style="cellpadding=0; cellspacing= 0; width: 600px;"
@@ Line 141: / Line 155: @@
 | style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align="left" |
 ❑ Modifiable risk factors are reversible based upon lifestyle/behavior modification. <br>
-❑ [[Obesity]] is defined as a body-mass index (BMI) above 30 kg/m2.<ref name="pmid20404252">{{cite journal| author=Holst AG, Jensen G, Prescott E| title=Risk factors for venous thromboembolism: results from the Copenhagen City Heart Study. | journal=Circulation | year= 2010 | volume= 121 | issue= 17 | pages= 1896-903 | pmid=20404252 | doi=10.1161/CIRCULATIONAHA.109.921460 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20404252  }} </ref> <ref name="pmid21352080">{{cite journal| author=Vayá A, Martínez-Triguero ML, España F, Todolí JA, Bonet E, Corella D| title=The metabolic syndrome and its individual components: its association with venous thromboembolism in a Mediterranean population. | journal=Metab Syndr Relat Disord | year= 2011 | volume= 9 | issue= 3 | pages= 197-201 | pmid=21352080 | doi=10.1089/met.2010.0117 | pmc= | url= }} </ref> <ref name="pmid18695082">{{cite journal| author=Eichinger S, Hron G, Bialonczyk C, Hirschl M, Minar E, Wagner O et al.| title=Overweight, obesity, and the risk of recurrent venous thromboembolism. | journal=Arch Intern Med | year= 2008 | volume= 168 | issue= 15 | pages= 1678-83 | pmid=18695082 | doi=10.1001/archinte.168.15.1678 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18695082  }} </ref> <br>
+❑ [[Obesity]] is defined as a [[Body mass index|body-mass index]] ([[Body mass index|BMI]]) above 30 kg/m2.<ref name="pmid20404252">{{cite journal| author=Holst AG, Jensen G, Prescott E| title=Risk factors for venous thromboembolism: results from the Copenhagen City Heart Study. | journal=Circulation | year= 2010 | volume= 121 | issue= 17 | pages= 1896-903 | pmid=20404252 | doi=10.1161/CIRCULATIONAHA.109.921460 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20404252  }} </ref> <ref name="pmid21352080">{{cite journal| author=Vayá A, Martínez-Triguero ML, España F, Todolí JA, Bonet E, Corella D| title=The metabolic syndrome and its individual components: its association with venous thromboembolism in a Mediterranean population. | journal=Metab Syndr Relat Disord | year= 2011 | volume= 9 | issue= 3 | pages= 197-201 | pmid=21352080 | doi=10.1089/met.2010.0117 | pmc= | url= }} </ref> <ref name="pmid18695082">{{cite journal| author=Eichinger S, Hron G, Bialonczyk C, Hirschl M, Minar E, Wagner O et al.| title=Overweight, obesity, and the risk of recurrent venous thromboembolism. | journal=Arch Intern Med | year= 2008 | volume= 168 | issue= 15 | pages= 1678-83 | pmid=18695082 | doi=10.1001/archinte.168.15.1678 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18695082  }} </ref> <br>
 ❑ [[Smoking]]:<ref name="pmid20404252">{{cite journal| author=Holst AG, Jensen G, Prescott E| title=Risk factors for venous thromboembolism: results from the Copenhagen City Heart Study. | journal=Circulation | year= 2010 | volume= 121 | issue= 17 | pages= 1896-903 | pmid=20404252 | doi=10.1161/CIRCULATIONAHA.109.921460 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20404252  }} </ref> Smoking significantly increases the risk of [[DVT]], particularly among women who are taking [[oral contraceptive pills]] as well as among obese people. <br>
 ❑ Use of [[oral contraceptives]]<ref name="pmid17726684">{{cite journal| author=Pomp ER, Rosendaal FR, Doggen CJ| title=Smoking increases the risk of venous thrombosis and acts synergistically with oral contraceptive use. | journal=Am J Hematol | year= 2008 | volume= 83 | issue= 2 | pages= 97-102 | pmid=17726684 | doi=10.1002/ajh.21059 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17726684  }} </ref> <br>
-❑ [[Hyperhomocysteinemia]]:<ref name="pmid8592549">{{cite journal| author=den Heijer M, Koster T, Blom HJ, Bos GM, Briet E, Reitsma PH et al.| title=Hyperhomocysteinemia as a risk factor for deep-vein thrombosis. | journal=N Engl J Med | year= 1996 | volume= 334 | issue= 12 | pages= 759-62 | pmid=8592549 | doi=10.1056/NEJM199603213341203 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8592549  }} </ref> [[Hyperhomocysteinemia]] can be reduced with vitamin B supplementation.<br>
+❑ [[Hyperhomocysteinemia]]:<ref name="pmid8592549">{{cite journal| author=den Heijer M, Koster T, Blom HJ, Bos GM, Briet E, Reitsma PH et al.| title=Hyperhomocysteinemia as a risk factor for deep-vein thrombosis. | journal=N Engl J Med | year= 1996 | volume= 334 | issue= 12 | pages= 759-62 | pmid=8592549 | doi=10.1056/NEJM199603213341203 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8592549  }} </ref> [[Hyperhomocysteinemia]] can be reduced with [[vitamin B]] supplementation.<br>
 | style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align="left" |
 ❑ Advanced age <br>
@@ Line 167: / Line 181: @@
 | style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align="left" |
 ❑ Other possible factors associated with VTE include:<ref name="pmid20620109">{{cite journal| author=Konofal E, Lecendreux M, Cortese S| title=Sleep and ADHD. | journal=Sleep Med | year= 2010 | volume= 11 | issue= 7 | pages= 652-8 | pmid=20620109 | doi=10.1016/j.sleep.2010.02.012 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20620109  }} </ref> <br>
-:❑ Nutrition low in fish <br>
+:❑ [[Nutrition]] low in fish <br>
 :❑ [[Psychological stress]] <br>
 :❑ Cardiovascular risk factors such as [[diabetes]] and [[hypercholesterolemia]] <br>
@@ Line 173: / Line 187: @@
 ==Diagnosis==
+The diagnostic guidelines for venous thromboembolism are as follows:<ref name="pmid24319219">{{cite journal |vauthors=Wells P, Anderson D |title=The diagnosis and treatment of venous thromboembolism |journal=Hematology Am Soc Hematol Educ Program |volume=2013 |issue= |pages=457–63 |year=2013 |pmid=24319219 |doi=10.1182/asheducation-2013.1.457 |url=}}</ref><ref name="urlDoes This Patient Have Deep Vein Thrombosis? | Venous Thromboembolism | JAMA | The JAMA Network">{{cite web |url=https://jamanetwork.com/journals/jama/fullarticle/202182 |title=Does This Patient Have Deep Vein Thrombosis? &#124; Venous Thromboembolism &#124; JAMA &#124; The JAMA Network |format= |work= |accessdate=}}</ref><ref name="urlDiagnostic accuracy of D-dimer test for exclusion of venous thromboembolism: a systematic review - DI NISIO - 2007 - Journal of Thrombosis and Haemostasis - Wiley Online Library">{{cite web |url=http://onlinelibrary.wiley.com/doi/10.1111/j.1538-7836.2007.02328.x/abstract |title=Diagnostic accuracy of D-dimer test for exclusion of venous thromboembolism: a systematic review - DI NISIO - 2007 - Journal of Thrombosis and Haemostasis - Wiley Online Library |format= |work= |accessdate=}}</ref><ref name="urlComputed Tomographic Pulmonary Angiography vs Ventilation-Perfusion Lung Scanning in Patients With Suspected Pulmonary Embolism | Cardiology | JAMA | The JAMA Network">{{cite web |url=https://jamanetwork.com/journals/jama/fullarticle/1108374 |title=Computed Tomographic Pulmonary Angiography vs Ventilation-Perfusion Lung Scanning in Patients With Suspected Pulmonary Embolism &#124; Cardiology &#124; JAMA &#124; The JAMA Network |format= |work= |accessdate=}}</ref>
+===Deep Vein Thrombosis===
+{{familytree/start |summary=Sample 1}}
+{{familytree | | | | | | | | | A01 |A01=Suspected [[DVT]]}}
+{{familytree | | | | | |,|-|-|-|^|-|-|-|-|.| | | }}
+{{familytree | | | | B01 | | | | | | | | B02 | | |B01=Clinical probability<br>likely|B02=Clinical probability<br>unlikely}}
+{{familytree | | | | |!| | | | | | | | | |!| | | |}}
+{{familytree | | | | C01 | | | | | | | | |!| |C01=[[Ultrasound]]}}
+{{familytree | | |,|-|^|.| | | | | | | | |!| }}
+{{familytree | | D01 | | D02 | | | | | | D03 |D01=Normal|D02=Abnormal||D03=[[D-dimer]]}}
+{{familytree | | |!| | | |!| | | | |,|-|-|^|-|-|.| | | }}
+{{familytree | | E01 | | E02 | | | |!| | | | | E03 |E01=D-dimer|E02=Treat|E03=Positive}}
+{{familytree |,|-|^|-|.| | | | | | |!| | | | | |!| }}
+{{familytree |F01| | F02 | | | | | F03 | | | | F04 |F01=Negative|F02=Positive|F03=Negative|F04=[[Ultrasound]]}}
+{{familytree |!| | | |!| | | | | | |!| | | |,|-|^|-|.|}}
+{{familytree |G01| | G02 | | | | | G03 | | G04 | | G05 |G01=Stop|G02=Repeat [[ultrasound]] in 1 week|G03=Stop|G04=Abnormal|G05=Normal}}
+{{familytree | | | | | | | | | | | | | | | |!| | | |!| | |}}
+{{familytree | | | | | | | | | | | | | | | G04 | | G05 | |G04=Treat|G05=Stop}}
+{{familytree/end}}
+<br>
+===Pulmonary Embolism===
 {{familytree/start}}
 {{familytree | | | | | | | | | A01 | | | | | |A01=Suspected pulmonary embolism}}
@@ Line 181: / Line 221: @@
 {{familytree | | |!| | | | | | | | | | | | | |!| }}
 {{familytree | | D01 | | | | | | | | |,|-|-|-|^|-|-|-|-|.| | D01=Stop}}
-{{familytree | | | | | | | | | | | | E01 | | | | | | | E02 |E01=CXR|E02=Ultrasound<br>If signs of [[DVT]] present}}
+{{familytree | | | | | | | | | | | | E01 | | | | | | | E02 |E01=CXR|E02=[[Ultrasound]]<br>If signs of [[DVT]] present}}
 {{familytree | | | | | | | | | | | | |!| | | | | | | | | | |}}
-{{familytree | | | | | | | | | F01 |-|^|-|-|-|-|-| F02 | | | | | |F01=Normal<br> [[PE]] unlikely with positive D-dimer or [[PE]] likely|F02= Abnormal<br> [[PE]] unlikely with positive [[D-dimer]] or [[PE]] likely}}
+{{familytree | | | | | | | | | F01 |-|^|-|-|-|-|-| F02 | | | | | |F01=Normal<br> [[PE]] unlikely with positive [[D-dimer]] or [[PE]] likely|F02= Abnormal<br> [[PE]] unlikely with positive [[D-dimer]] or [[PE]] likely}}
 {{familytree | | | | | | | | | |!| | | | | | | | | |!| | | | |}}
 {{familytree | | | | | | | | | G01 | | | | | | | | G02 | | | | | |G01=[[V/Q scan]]|G02=[[CTPA]]}}
 {{familytree | | | | | |,|-|-|-|+|-|-|-|.| | | |,|-|^|-|.| | | | | |}}
-{{familytree | | | | | J01 | | J02 | | J03 | | j04 | | j05 | |J01=Nnormal|J02=Non diagnostic|J03=High probability|j04=PE present|j05=[[PE]] absent}}
+{{familytree | | | | | J01 | | J02 | | J03 | | j04 | | j05 | |J01=Normal|J02=Non diagnostic|J03=High probability|j04=PE present|j05=[[PE]] absent}}
 {{familytree | | | | | |!| | | |!| | | |!| | | |!| | | |!| |}}
 {{familytree | | | | | I01 | | |!| | | I02 | | I03 | | I04 | | |I01=Stop|I02=Treat|I03=Treat|I04=Stop}}
@@ Line 193: / Line 233: @@
 {{familytree | | | | | | J01 | | | | J02 | | | J01=PE unlikely|J02= [[PE]] likely}}
 {{familytree | | | | | | |!| | | | | |!| | | | | | | | | | | | |}}
-{{familytree | | | | | | F01 | | | | F02 | | | |F01=Serial ultrasound|F02=[[CTPA]] or serial ultrasound}}
+{{familytree | | | | | | F01 | | | | F02 | | | |F01=Serial [[ultrasound]]|F02=[[CTPA]] or serial [[ultrasound]]}}
 {{familytree/end}}
-==Prevention==
-{| class="wikitable"
+'''Pulmonary embolism Wells Score Calculator'''
-! rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" + |Patient population
+<small>
-! rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" + |Sub-population
+{| style="cellpadding=0; cellspacing= 0; width: 600px;"
-! colspan="5" align="center" style="background:#4479BA; color: #FFFFFF;" + |Scoring criteria for risk assessment
+|-
-! rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" + |Major predisposing risk factors and their score
+| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF; width: 70%" align="center" | '''Variable'''|| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align="center" | '''Wells Score'''<ref name="pmid10744147">{{cite journal |author=Wells PS, Anderson DR, Rodger M, Ginsberg JS, Kearon C, Gent M, Turpie AG, Bormanis J, Weitz J, Chamberlain M, Bowie D, Barnes D, Hirsh J |title=Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer |journal=Thromb. Haemost. |volume=83 |issue=3 |pages=416–20 |year=2000 |pmid=10744147 |doi=|url=http://www.schattauer.de/index.php?id=1268&L=1&pii=th00030416&no_cache=1 |accessdate=2012-05-01}}</ref>
-! rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" + |Prophylaxis recommendations
+|-
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align="left" | Clinically suspected [[DVT]] (leg swelling, pain with palpation)|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align="left" | 3.0
+|-
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align="left" | Alternative diagnosis is less likely than PE|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align="left" | 3.0
+|-
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align="left" | Immobilization/[[surgery]] in previous four weeks|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align="left" | 1.5
+|-
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align="left" | Previous history of [[DVT]] or [[PE]]|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align="left" | 1.5
+|-
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align="left" | [[Tachycardia]] (heart rate more than 100 bpm)|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align="left" | 1.5
+|-
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align="left" | [[Malignancy]] (treatment for within 6 months, palliative)|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align="left" | 1.0
+|-
+| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align="left" | [[Hemoptysis]]|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align="left" | 1.0
 |-
-|'''Padua score'''
+|}</small>
-(Score≥ 4: High risk for VTE
-Score< 4: Low risk for VTE)
+==Prevention==
-|'''IMPROVE score''' (0	0.5%
+The following table summarizes major scoring criteria for risk assessment of VTE:<ref>{{cite journal|title=The IMPROVEDD VTE Risk Score: Incorporation of D-Dimer into the IMPROVE Score to Improve Venous Thromboembolism Risk Stratification|doi=10.1055/s-0037-160392910.1055/s-0037-1603929}}</ref><ref name="pmid21436241">{{cite journal| author=Spyropoulos AC, Anderson FA, FitzGerald G, Decousus H, Pini M, Chong BH et al.| title=Predictive and associative models to identify hospitalized medical patients at risk for VTE. | journal=Chest | year= 2011 | volume= 140 | issue= 3 | pages= 706-714 | pmid=21436241 | doi=10.1378/chest.10-1944 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21436241  }} </ref><ref name="pmid20738765">{{cite journal| author=Barbar S, Noventa F, Rossetto V, Ferrari A, Brandolin B, Perlati M et al.| title=A risk assessment model for the identification of hospitalized medical patients at risk for venous thromboembolism: the Padua Prediction Score. | journal=J Thromb Haemost | year= 2010 | volume= 8 | issue= 11 | pages= 2450-7 | pmid=20738765 | doi=10.1111/j.1538-7836.2010.04044.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20738765  }} </ref><ref name="pmid1754886">{{cite journal| author=Caprini JA, Arcelus JI, Hasty JH, Tamhane AC, Fabrega F| title=Clinical assessment of venous thromboembolic risk in surgical patients. | journal=Semin Thromb Hemost | year= 1991 | volume= 17 Suppl 3 | issue=  | pages= 304-12 | pmid=1754886 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1754886  }} </ref>
-	1.0%
-	1.7%
+<small>
+{|
+! colspan="4" style="background:#4479BA; color: #FFFFFF;" align="center" + |Scoring criteria for risk assessment*
+|-
+! style="background:#4479BA; color: #FFFFFF;" align="center" + |Type of patient
+! style="background:#4479BA; color: #FFFFFF;" align="center" + |Scoring system
+! style="background:#4479BA; color: #FFFFFF;" align="center" + |Score
+! style="background:#4479BA; color: #FFFFFF;" align="center" + |Risk
+|-
+| rowspan="23" style="background:#DCDCDC;" align="center" + |Non-surgical patient
+| rowspan="14" style="background:#DCDCDC;" align="center" + |'''[[IMPROVE and IMPROVEDD scores for venous thromboembolism|IMPROVEDD Score]]'''
+| style="background:#DCDCDC;" align="center" + |
+| style="background:#DCDCDC;" align="center" + |Predicted % VTE risk through 42 days
+|-
+| style="background:#F5F5F5;" align="center" + |0
+| style="background:#F5F5F5;" + |0.4%
+|-
+| style="background:#F5F5F5;" align="center" + |1
+| style="background:#F5F5F5;" + |0.6%
+|-
+| style="background:#F5F5F5;" align="center" + |2
+| style="background:#F5F5F5;" + |0.8%
+|-
+| style="background:#F5F5F5;" align="center" + |3
+| style="background:#F5F5F5;" + |1.2%
+|-
+| style="background:#F5F5F5;" align="center" + |4
+| style="background:#F5F5F5;" + |1.6%
+|-
+| style="background:#F5F5F5;" align="center" + |5-10
+| style="background:#F5F5F5;" + |2.2%
+|-
+| style="background:#DCDCDC;" align="center" + |
+| style="background:#DCDCDC;" align="center" + |Predicted % VTE risk through 77 days
+|-
+| style="background:#F5F5F5;" align="center" + |0
+| style="background:#F5F5F5;" + |0.5%
+|-
+| style="background:#F5F5F5;" align="center" + |1
+| style="background:#F5F5F5;" + |0.7%
+|-
+| style="background:#F5F5F5;" align="center" + |2
+| style="background:#F5F5F5;" + |1.0%
+|-
+| style="background:#F5F5F5;" align="center" + |3
+| style="background:#F5F5F5;" + |1.4%
+|-
+| style="background:#F5F5F5;" align="center" + |4
+| style="background:#F5F5F5;" + |1.9%
+|-
+| style="background:#F5F5F5;" align="center" + |5-10
+| style="background:#F5F5F5;" + |2.75
+|-
+| rowspan="7" style="background:#DCDCDC;" align="center" + |'''[[IMPROVE and IMPROVEDD scores for venous thromboembolism|IMPROVE score]]'''
+| style="background:#DCDCDC;" align="center" + |
+| style="background:#DCDCDC;" align="center" + |Predicted % VTE risk through 3 months
+|-
+| style="background:#F5F5F5;" align="center" + |0
+| style="background:#F5F5F5;" + |0.5%
+|-
+| style="background:#F5F5F5;" align="center" + |1
+| style="background:#F5F5F5;" + |1.0%
+|-
+| style="background:#F5F5F5;" align="center" + |2
+| style="background:#F5F5F5;" + |1.7%
+|-
+| style="background:#F5F5F5;" align="center" + |3
+| style="background:#F5F5F5;" + |3.1%
+|-
+| style="background:#F5F5F5;" align="center" + |4
+| style="background:#F5F5F5;" + |4%
+|-
+| style="background:#F5F5F5;" align="center" + |5-8
+| style="background:#F5F5F5;" + |11%
+|-
+| rowspan="2" style="background:#DCDCDC;" align="center" + | '''Padua Score'''
+| style="background:#F5F5F5;" align="center" + |< 4
+| style="background:#F5F5F5;" + |Low risk for VTE
+|-
+| style="background:#F5F5F5;" align="center" + |≥ 4
+| style="background:#F5F5F5;" + |High risk for VTE
+|-
+| rowspan="4" style="background:#DCDCDC;" align="center" + | Surgical patient
+| rowspan="4" style="background:#DCDCDC;" align="center" + |'''Caprini score'''
+| style="background:#F5F5F5;" align="center" + |0-1
+| style="background:#F5F5F5;" + |Low risk of VTE
+|-
+| style="background:#F5F5F5;" align="center" + |2
+| style="background:#F5F5F5;" + |Moderate of VTE
+|-
+| style="background:#F5F5F5;" align="center" + |3-4
+| style="background:#F5F5F5;" + |High risk of VTE
+|-
+| style="background:#F5F5F5;" align="center" + |≥ 5
+| style="background:#F5F5F5;" + |Highest risk for VTE
+|}
+</small>
-	3.1%
+The following table summarizes the major scoring criteria used for risk assessment of VTE and their prophylaxis options:<ref name="CohenHarrington2016">{{cite journal|last1=Cohen|first1=Alexander T.|last2=Harrington|first2=Robert A.|last3=Goldhaber|first3=Samuel Z.|last4=Hull|first4=Russell D.|last5=Wiens|first5=Brian L.|last6=Gold|first6=Alex|last7=Hernandez|first7=Adrian F.|last8=Gibson|first8=C. Michael|title=Extended Thromboprophylaxis with Betrixaban in Acutely Ill Medical Patients|journal=New England Journal of Medicine|volume=375|issue=6|year=2016|pages=534–544|issn=0028-4793|doi=10.1056/NEJMoa1601747}}</ref><ref name="pmid22315261">{{cite journal |vauthors=Kahn SR, Lim W, Dunn AS, Cushman M, Dentali F, Akl EA, Cook DJ, Balekian AA, Klein RC, Le H, Schulman S, Murad MH |title=Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines |journal=Chest |volume=141 |issue=2 Suppl |pages=e195S–e226S |year=2012 |pmid=22315261 |pmc=3278052 |doi=10.1378/chest.11-2296 |url=}}</ref><ref name="pmid22315263">{{cite journal |vauthors=Gould MK, Garcia DA, Wren SM, Karanicolas PJ, Arcelus JI, Heit JA, Samama CM |title=Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines |journal=Chest |volume=141 |issue=2 Suppl |pages=e227S–e277S |year=2012 |pmid=22315263 |pmc=3278061 |doi=10.1378/chest.11-2297 |url=}}</ref><ref name="CohenSpiro2013">{{cite journal|last1=Cohen|first1=Alexander T.|last2=Spiro|first2=Theodore E.|last3=Büller|first3=Harry R.|last4=Haskell|first4=Lloyd|last5=Hu|first5=Dayi|last6=Hull|first6=Russell|last7=Mebazaa|first7=Alexandre|last8=Merli|first8=Geno|last9=Schellong|first9=Sebastian|last10=Spyropoulos|first10=Alex C.|last11=Tapson|first11=Victor|title=Rivaroxaban for Thromboprophylaxis in Acutely Ill Medical Patients|journal=New England Journal of Medicine|volume=368|issue=6|year=2013|pages=513–523|issn=0028-4793|doi=10.1056/NEJMoa1111096}}</ref><ref name="urlFDA approved betrixaban (BEVYXXA, Portola) for the prophylaxis of venous thromboembolism (VTE) in adult patients">{{cite web |url=https://www.fda.gov/drugs/informationondrugs/approveddrugs/ucm564422.htm |title=FDA approved betrixaban (BEVYXXA, Portola) for the prophylaxis of venous thromboembolism (VTE) in adult patients |format= |work= |accessdate=}}</ref><ref name="pmid20738765">{{cite journal |vauthors=Barbar S, Noventa F, Rossetto V, Ferrari A, Brandolin B, Perlati M, De Bon E, Tormene D, Pagnan A, Prandoni P |title=A risk assessment model for the identification of hospitalized medical patients at risk for venous thromboembolism: the Padua Prediction Score |journal=J. Thromb. Haemost. |volume=8 |issue=11 |pages=2450–7 |year=2010 |pmid=20738765 |doi=10.1111/j.1538-7836.2010.04044.x |url=}}</ref><ref name="pmid2503127">{{cite journal |vauthors=Steel K |title=Bathing problems in the over 70s |journal=BMJ |volume=298 |issue=6687 |pages=1578–9 |year=1989 |pmid=2503127 |pmc=1836788 |doi= |url=}}</ref><ref name="pmid21436241">{{cite journal| author=Spyropoulos AC, Anderson FA, FitzGerald G, Decousus H, Pini M, Chong BH et al.| title=Predictive and associative models to identify hospitalized medical patients at risk for VTE. | journal=Chest | year= 2011 | volume= 140 | issue= 3 | pages= 706-714 | pmid=21436241 | doi=10.1378/chest.10-1944 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21436241  }} </ref><ref name="urlDeep vein thrombosis assessment of probability of subsequent VTE and risk scores - wikidoc">{{cite web |url=http://www.wikidoc.org/index.php/Deep_vein_thrombosis_assessment_of_probability_of_subsequent_VTE_and_risk_scores |title=Deep vein thrombosis assessment of probability of subsequent VTE and risk scores - wikidoc |format= |work= |accessdate=}}</ref><ref name="urlVenous Thromboembolism Prophylaxis and Treatment in Patients With Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update: Journal of Clinical Oncology: Vol 31, No 17">{{cite web |url=http://ascopubs.org/doi/full/10.1200/jco.2013.49.1118 |title=Venous Thromboembolism Prophylaxis and Treatment in Patients With Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update: Journal of Clinical Oncology: Vol 31, No 17 |format= |work= |accessdate=}}</ref><ref name="urlAbstract 19875: IMPROVEDD Score: Addition of D-Dimer to the IMPROVE Score Improves Venous Thromboembolism Risk Stratification. An APEX Trial Substudy | Circulation">{{cite web |url=http://circ.ahajournals.org/content/134/Suppl_1/A19875 |title=Abstract 19875: IMPROVEDD Score: Addition of D-Dimer to the IMPROVE Score Improves Venous Thromboembolism Risk Stratification. An APEX Trial Substudy &#124; Circulation |format= |work= |accessdate=}}</ref>
+<small>
-	5.4%
+{|
+! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" + |Patient population
--8	11%)
+! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" + |Sub-population
-|'''IMPROVE bleeding risk score'''
+! colspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" + |Scoring criteria for risk assessment
-(Score ≥7: Elevated risk of bleeding
+! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" + |Major predisposing risk factors and their score
+! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" + |Prophylaxis recommendations
-Score <7: Not elevated risk of bleeding)
+|-
-|'''IMPROVE Associative score'''
+| style="background:#4479BA; color: #FFFFFF;" align="center" + |'''Padua score'''
-(Score 0-1: Low risk for VTE
+| style="background:#4479BA; color: #FFFFFF;" align="center" + |'''IMPROVE score'''
+| style="background:#4479BA; color: #FFFFFF;" align="center" + |'''Caprini score'''
-Score 2-3: Intermediate risk for VTE
-Score 4-10: Hight risk for VTE)
-|'''Caprini score'''
-(Score 0-1: Low risk of VTE
-Score 2: Moderate of VTE
-Score 3-4: High risk of VTE
-Score ≥ 5: Highest risk for VTE)
 |-
-| rowspan="6" |Non-surgical patients
+| rowspan="4" style="background:#DCDCDC;" align="center" + |Non-surgical patients
-| rowspan="2" |Acutely ill  patients
+| rowspan="2" style="background:#DCDCDC;" align="center" + |Acutely ill  patients
-| rowspan="2" |✔
+| rowspan="2" style="background:#F5F5F5;" align="center" + |✔
-| rowspan="2" |✔
+| rowspan="2" style="background:#F5F5F5;" align="center" + |✔
-| rowspan="2" |✔
+| rowspan="2" style="background:#F5F5F5;" align="center" + |<nowiki>-</nowiki>
-| rowspan="2" |<nowiki>-</nowiki>
+| style="background:#F5F5F5;" + |'''IMPROVE:'''
-| rowspan="2" |<nowiki>-</nowiki>
+* Active [[cancer]]: 3
-|'''IMPROVE:'''
-* Active cancer: 3
 * Previous VTE: 3
 * Decreased mobility: 3
-* Thrombophilia: 3
+* [[Thrombophilia]]: 3
 * Previous trauma or surgery within that last month: 2
 * Age≥ 70: 1
-* Heart and/or respiratory failure: 1
+* [[Heart]] and/or [[respiratory]] failure: 1
-* Ischemic stroke or acute myocardial infarction: 1
+* [[Ischemic stroke]] or acute [[myocardial infarction]]: 1
-* Acute rheumatologic disorder and/or acute infection: 1
+* Acute [[Rheumatologic disease|rheumatologic]] disorder and/or acute infection: 1
-* Obesity: 1
+* [[Obesity]]: 1
+* [[Hormonal]] therapy
-* Hormonal therapy
+| rowspan="2" style="background:#F5F5F5;" + |
-|
 * Hospitalized medical patients:
-** Increased risk of thrombosis
+** Increased risk of [[thrombosis]]
-*** Anticoagulant thromboprophylaxis with low-molecular-weight heparin [LMWH], low-dose unfractionated heparin (LDUH) bid, LDUH tid, or fondaparinux
+*** [[LMWH]]
-** Low risk of thrombosis
+*** [[LDUH]] OR
-*** Use of pharmacological prophylaxis or mechanical prophylaxis is not recommended
+*** [[Fondaparinux]]
-** Bleeding or at high risk of bleeding
+*** [[Betrixaban]] 160 mg PO, THEN 80 mg PO qDay
+** Low risk of [[thrombosis]]
+*** Use of pharmacological [[prophylaxis]] or mechanical [[prophylaxis]] is not recommended
+** [[Bleeding]] or at high risk of [[bleeding]]:
 *** Anticoagulant thromboprophylaxis is not recommended
-** Increased risk of thrombosis who are bleeding or at high risk for major bleeding
+** Increased risk of [[thrombosis]] who are bleeding or at high risk for major [[bleeding]]:
-*** Optimal use of mechanical thromboprophylaxis with graduated compression stockings (GCS) or intermittent pneumatic compression (IPC)
+*** Optimal use of mechanical thromboprophylaxis with [[graduated compression stockings]] (GCS) or [[intermittent pneumatic compression]] (IPC)
-**: '''Note:''' When bleeding risk decreases, and if risk persist, pharmacologic thromboprophylaxis be substituted for mechanical thromboprophylaxis.
+**: '''Note:''' When [[bleeding]] risk decreases, and if risk persist, pharmacologic thromboprophylaxis be substituted for mechanical thromboprophylaxis.
-** Who receive an initial course of thromboprophylaxis
+** Who receive an initial course of thromboprophylaxis:
-*** extending the duration of thromboprophylaxis beyond the period of patient immobilization or acute hospital stay is not recommended.
+*** Extending the duration of thromboprophylaxis beyond the period of patient immobilization or acute hospital stay is not recommended
 |-
-|'''IMPROVE bleeding risk:'''
+| style="background:#F5F5F5;" + |'''IMPROVE bleeding risk:'''
-* Active gastric or duodenal ulcer: 4.5
+* Active [[gastric]] or [[duodenal]] ulcer: 4.5
-* Prior bleeding within the last 3 months: 4
+* Prior [[bleeding]] within the last 3 months: 4
-* Thrombocytopenia (<50x109/L): 4
+* [[Thrombocytopenia]] (<50x109/L): 4
 * Age ≥ 85 years: 3.5
-* Liver failure (INR>1.5): 2.5
+* [[Hepatic failure|Liver failure]] (INR>1.5): 2.5
-* Severe kidney failure (GFR< 30 mL/min/m2): 2.5
+* Severe [[kidney failure]] (GFR< 30 mL/min/m2): 2.5
-* Admission to ICU or CCU: 2.5
+* Admission to [[ICU]] or [[CCU]]: 2.5
-* Central venous catheter: 2
+* [[Central venous catheter]]: 2
-* Rheumatic disease: 2
+* [[Rheumatic disease]]: 2
-* Active malignancy: 2
+* Active [[malignancy]]: 2
 * Age: 40-84 years: 1.5
-* Male: 1
+* [[Male]]: 1
-* Moderate kidney failure (GFR: 30-59 mL/min/m2): 1
+* Moderate [[kidney failure]] (GFR: 30-59 mL/min/m2): 1
-|
 |-
-|Cancer in outpatient
+| style="background:#DCDCDC;" align="center" + |Cancer in outpatient
-|
+| style="background:#F5F5F5;" align="center" + |<nowiki>-</nowiki>
-|
+| style="background:#F5F5F5;" align="center" + |<nowiki>-</nowiki>
-|
+| style="background:#F5F5F5;" align="center" + |<nowiki>-</nowiki>
-|
+| style="background:#F5F5F5;" + |
-|
-|
 * Does the patient have a solid tumor
 AND
 * Additional risk factors for VTE?
 * Previous VTE
 * Hormonal therapy
@@ Line 307: / Line 436: @@
 * Thalidomide
 * Lenalidomide
-|
+| style="background:#F5F5F5;" + |
+* If major predisposing risk factors present:
+** [[LMWH]]
+** [[LDUH]]
+* If no major predisposing risk factors present:
+** No VTE prophylaxis
 |-
-|Chronically immobilized patients
+| style="background:#DCDCDC;" align="center" + |Long travel
-|<nowiki>-</nowiki>
+| style="background:#F5F5F5;" align="center" + | -
-|<nowiki>-</nowiki>
+| style="background:#F5F5F5;" align="center" + | -
-|<nowiki>-</nowiki>
+| style="background:#F5F5F5;" align="center" + | -
-|<nowiki>-</nowiki>
+| style="background:#F5F5F5;" + |
-|<nowiki>-</nowiki>
-|<nowiki>-</nowiki>
-|Not indicated
-|-
-|Long travel
-|
-|
-|
-|
-|
-|
 * Prior VTE episode
-* Recent trauma
+* Recent [[trauma]]
 * Recent surgery
 * Active cancer
 * Advanced age
 * Immobility
-* Severe obesity
+* Severe [[obesity]]
-* Estrogen intake
+* [[Estrogen]] intake
-* Thrombophilia
+* [[Thrombophilia]]
-|
+| style="background:#F5F5F5;" + |
 * Frequent ambulation
-* Calf muscle excercise
+* Calf [[muscle]] excercise
 * Sitting in an isle seat
 * Below knee compression stockings (15-30 mm Hg pressure at ankle)
 |-
-|Asymptomatic thrombophilia
+| rowspan="7" style="background:#DCDCDC;" align="center" + |Surgical patients
-|<nowiki>-</nowiki>
+| style="background:#DCDCDC;" align="center" + |[[Orthopedic surgery|Orthopedic]] surgery patients
-|<nowiki>-</nowiki>
+| style="background:#F5F5F5;" align="center" + |<nowiki>-</nowiki>
-|<nowiki>-</nowiki>
+| style="background:#F5F5F5;" align="center" + |<nowiki>-</nowiki>
-|<nowiki>-</nowiki>
+| style="background:#F5F5F5;" align="center" + |<nowiki>✔</nowiki>
-|<nowiki>-</nowiki>
+| style="background:#F5F5F5;" align="center" + |<nowiki>-</nowiki>
-|<nowiki>-</nowiki>
+| style="background:#F5F5F5;" + |
-|Not indicated
+* Total hip or knee [[arthroplasty]]:
-|-
+** Pharmacological VTE [[prophylaxis]]
-| rowspan="7" |Surgical patients
-|Orthopedic surgery patients
-|
-|
-|
-|
-|
-|
-|
-* Total hip or knee arthroplasty:
-** Pharmacological VTE prophylaxis
 ** Begin at least 12 hours before and 12 hours after the surgery  and administer for at least 14 days
-** Extend the therapy to 35 days as outpatient   Choose ONE of the following:
+** Extend the therapy to 35 days as outpatient. Choose ONE of the following:
-*** LMWH (first line)
+*** [[LMWH]] (first line)
-*** Fondaparinux
+*** [[Fondaparinux]]
-*** Apixaban
+*** [[Apixaban]]
-*** Dabigatran
+*** [[Dabigatran]]
-*** Rivaroxaban
+*** [[Rivaroxaban]]
-*** LDUH
+*** [[LDUH]]
-*** VKA
+*** [[Vitamin K antagonist|VKA]]
-*** Aspirin  AND/OR
+*** [[Aspirin]]  AND/OR
-*** Intermittent pneumatic compression device
+*** [[Intermittent pneumatic compression|Intermittent pneumatic compression device]]
-** Hip fracture surgery:
+** Hip [[Fractures|fracture]] surgery:
-*** Pharmacological VTE prophylaxis
+*** Pharmacological VTE [[prophylaxis]]
 *** Begin at least 12 hours before and 12 hours after the surgery and administer for at least 14 days
-*** Extend the therapy to 35 days as outpatient   Choose ONE of the following:
+*** Extend the therapy to 35 days as outpatient. Choose ONE of the following:
-**** LMWH (first line)
+**** [[Low molecular weight heparin|LMWH]] (first line)
-**** Fondaparinux
+**** [[Fondaparinux]]
-**** LDUH
+**** [[LDUH]]
-**** VKA
+**** [[Vitamin K antagonist|VKA]]
-**** Aspirin  AND/OR
+**** [[Aspirin]]  AND/OR
-**** Intermittent pneumatic compression device
+**** [[Intermittent pneumatic compression|Intermittent pneumatic compression device]]
 |-
-|General and abdominal pelvic surgeries
+| style="background:#DCDCDC;" align="center" + |General and abdominal pelvic surgeries
-|<nowiki>-</nowiki>
+| style="background:#F5F5F5;" align="center" + |<nowiki>-</nowiki>
-|<nowiki>-</nowiki>
+| style="background:#F5F5F5;" align="center" + |<nowiki>-</nowiki>
-|<nowiki>-</nowiki>
+| style="background:#F5F5F5;" align="center" + |✔
-|<nowiki>-</nowiki>
+| rowspan="6" style="background:#F5F5F5;" + |'''Caprini''':
-|✔
-| rowspan="6" |'''Caprini''':
 * 5 points:
 ** [[Stroke]] (in the previous month)
-** Fracture of the hip, pelvis, or leg
+** [[Fractures|Fracture]] of the hip, pelvis, or leg
-** Elective arthroplasty
+** Elective [[arthroplasty]]
-** Acute spinal cord injury (in the previous month)
+** Acute [[spinal cord]] injury (in the previous month)
 * 3 points:
-**  Age≥ 75 years   Prior episodes of VTE
+**  Age≥ 75 years
-** Positive family history for VTE
+** Prior episodes of VTE
-** Prothrombin 20210 A
+** Positive [[family history]] for VTE
-** Factor V Leiden
+** [[Prothrombin 20210 A]]
-** Lupus anticoagulants
+** [[Factor V Leiden]]
-** Anticardiolipin antibodies
+** [[Lupus anticoagulant|Lupus anticoagulants]]
-** High homocysteine in the blood
+** [[Anticardiolipin antibodies]]
-** Heparin induced thrombocytopenia
+** High [[homocysteine]] in the [[blood]]
-** Other congenital or acquired thrombophilia
+** [[Heparin-induced thrombocytopenia|Heparin induced thrombocytopenia]]
+** Other [[congenital]] or acquired [[thrombophilia]]
 * 2 points:
 **  Age: 61-74 years  [[Arthroscopy|Arthroscopic surgery]]
-** [[Laparoscopy]]<nowiki/>lasting more than 45 minutes
+** [[Laparoscopy]] <nowiki/>lasting more than 45 minutes
 ** [[General surgery]]<nowiki/>lasting more than 45 minutes
 ** [[Cancer]]
 ** [[Plaster cast]]
 ** Bed bound for more than 72 hours
-** Central venous access
+** [[Central venous line|Central venous access]]
 * 1 point:
 ** Age 41-60 years
-** BMI > 25 Kg/m2
+** [[Body mass index|BMI]] > 25 Kg/m2
 ** Minor surgery
 ** [[Edema]] in the lower extremities
-** Varicose veins
+** [[Varicose veins]]
 ** [[Pregnancy]]
-** Post-partum
+** [[Post-partum]]
 ** [[Oral contraceptive]]
-** Hormonal therapy
+** [[Hormone therapy|Hormonal therapy]]
-** Unexplained or recurrent abortion
+** Unexplained or recurrent [[abortion]]
 ** [[Sepsis]] (in the previous month)
-** Serious lung disease such as pneumonia (in the previous month)
+** Serious [[lung]] disease such as [[pneumonia]] (in the previous month)
-** Abnormal pulmonary function test
+** Abnormal [[pulmonary function test]]
 ** [[Acute myocardial infarction]]
 ** [[Congestive heart failure]] (in the previous month)
 ** Bed rest
 ** [[Inflammatory bowel disease]]
-|
+| style="background:#F5F5F5;" + |
 * Low risk of VTE:
 ** Early ambulation
@@ Line 452: / Line 563: @@
 **** Mechanical VTE prophylaxis   ([[Intermittent pneumatic compression]] is preferred)
 |-
-|Cardiac surgery
+| style="background:#DCDCDC;" align="center" + |[[Cardiac]] surgery
-|<nowiki>-</nowiki>
+| style="background:#F5F5F5;" align="center" + |<nowiki>-</nowiki>
-|<nowiki>-</nowiki>
+| style="background:#F5F5F5;" align="center" + |<nowiki>-</nowiki>
-|<nowiki>-</nowiki>
+| style="background:#F5F5F5;" align="center" + |✔
-|<nowiki>-</nowiki>
+| style="background:#F5F5F5;" + |
-|✔
-|
 * Non-hemorrhagic post-op complications:
-** LDUH   OR
+** [[LDUH]]   OR
-** LMWH  PLUS
+** [[Low molecular weight heparin|LMWH]]  PLUS
-** Mechanical VTE prophylaxis
+** Mechanical VTE [[prophylaxis]]
 * Un-complicated post-op period:
-** Mechanical VTE prophylaxis   (Intermittent pneumatic compression is preferred)
+** Mechanical VTE [[prophylaxis]] ([[Intermittent pneumatic compression]] is preferred)
 |-
-|Thoracic surgery
+| style="background:#DCDCDC;" align="center" + |Thoracic surgery
-|<nowiki>-</nowiki>
+| style="background:#F5F5F5;" align="center" + |<nowiki>-</nowiki>
-| -
+| style="background:#F5F5F5;" align="center" + | -
-| -
+| style="background:#F5F5F5;" align="center" + |✔
-|<nowiki>-</nowiki>
+| style="background:#F5F5F5;" + |
-|✔
+* In case of [[pulmonary]] resection, [[pneumonectomy]], extrapleural [[pneumonectomy]], [[esophagectomy]]:
-|
-* In case of pulmonary resection, pneumonectomy, extrapleural pneumonectomy, esophagectomy:
 ** No bleeding risk:
-*** LDUH   OR
+*** [[LDUH]]   OR
-*** LMWH  PLUS
+*** [[Low molecular weight heparin|LMWH]]  PLUS
-*** Mechanical VTE prophylaxis
+*** Mechanical VTE [[prophylaxis]]
-*** Elastic stocking
+*** [[Compression stockings|Elastic stocking]]
-*** Intermittent pneumatic compression
+*** [[Intermittent pneumatic compression]]
 ** High bleeding risk:
-*** Mechanical VTE prophylaxis (intermittent pneumatic compression is preferred), start LDUH or LMWH after bleeding risk subsides
+*** Mechanical VTE [[prophylaxis]] ([[intermittent pneumatic compression]] is preferred), start [[LDUH]] or [[LMWH]] after bleeding risk subsides
 |-
-|Craniotomy
+| style="background:#DCDCDC;" align="center" + |[[Craniotomy]]
-|<nowiki>-</nowiki>
+| style="background:#F5F5F5;" align="center" + |<nowiki>-</nowiki>
-|<nowiki>-</nowiki>
+| style="background:#F5F5F5;" align="center" + |<nowiki>-</nowiki>
-|<nowiki>-</nowiki>
+| style="background:#F5F5F5;" align="center" + |✔
-|<nowiki>-</nowiki>
+| style="background:#F5F5F5;" + |
-|✔
-|
 * In case of craniotomy for malignancy: (Very high risk for VTE)
-** Mechanical VTE prophylaxis   (Intermittent pneumatic compression is preferred)  PLUS   Pharmacological VTE prophylaxis (when the risk of bleeding subsides)
+** Mechanical VTE [[prophylaxis]] ([[Intermittent pneumatic compression]] is preferred)  PLUS
-* In case of craniotomy for other reasons: (High risk of VTE)
+** Pharmacological VTE [[prophylaxis]] (when the risk of bleeding subsides)
-** Mechanical VTE prophylaxis   (Intermittent pneumatic compression is preferred)
+* In case of [[craniotomy]] for other reasons: (High risk of VTE)
+** Mechanical VTE [[prophylaxis]] ([[Intermittent pneumatic compression]] is preferred)
 |-
-|Spinal surgery
+| style="background:#DCDCDC;" align="center" + |Spinal surgery
-|<nowiki>-</nowiki>
+| style="background:#F5F5F5;" align="center" + |<nowiki>-</nowiki>
-|<nowiki>-</nowiki>
+| style="background:#F5F5F5;" align="center" + |<nowiki>-</nowiki>
-|<nowiki>-</nowiki>
+| style="background:#F5F5F5;" align="center" + |✔
-|<nowiki>-</nowiki>
+| style="background:#F5F5F5;" + |
-|✔
+* In case of spinal surgery for [[malignancy]] OR antero-posterior approach: (High risk for VTE)
-|
+** Mechanical VTE [[prophylaxis]] ([[intermittent pneumatic compression]] is preferred) PLUS
-* In case of spinal surgery for malignancy OR antero-posterior approach: (High risk for VTE)
+** Pharmacological VTE [[prophylaxis]] when the risk of [[bleeding]] subsides
-** Mechanical VTE prophylaxis (intermittent pneumatic compression is preferred)  PLUS
-** Pharmacological VTE prophylaxis when the risk of bleeding subsides
 * In case of spinal surgery for other reasons:
-** Mechanical VTE prophylaxis   (Intermittent pneumatic compression is preferred)
+** Mechanical VTE [[prophylaxis]] ([[Intermittent pneumatic compression]] is preferred)
 |-
-|Trauma
+| style="background:#DCDCDC;" align="center" + |Trauma
-|<nowiki>-</nowiki>
+| style="background:#F5F5F5;" align="center" + |<nowiki>-</nowiki>
-|<nowiki>-</nowiki>
+| style="background:#F5F5F5;" align="center" + |<nowiki>-</nowiki>
-|<nowiki>-</nowiki>
+| style="background:#F5F5F5;" align="center" + |✔
-|<nowiki>-</nowiki>
+| style="background:#F5F5F5;" + |
-|✔
+* No contraindiction to [[LDUH]] or [[Low molecular weight heparin|LMWH]]:
-|
+** [[LDUH]]   OR
-* No contraindiction to LDUH or LMWH:
+** [[Low molecular weight heparin|LMWH]]  PLUS
-** LDUH   OR
+** Mechanical VTE [[prophylaxis]] ([[Intermittent pneumatic compression]] is preferred)
-** LMWH   PLUS
+* Contraindication to [[LDUH]] or [[Low molecular weight heparin|LMWH]]:
-** Mechanical VTE prophylaxis   (Intermittent pneumatic compression is preferred)
+** Mechanical VTE [[prophylaxis]] ([[Intermittent pneumatic compression|Intermittent pneumatic compression is preferred]])  PLUS
-* Contraindication to LDUH or LMWH:
+** Pharmacological VTE [[prophylaxis]] when the risk of bleeding subsides
-** Mechanical VTE prophylaxis   (Intermittent pneumatic compression is preferred)  PLUS
-** Pharmacological VTE prophylaxis   when the risk of bleeding subsides
 |}<span style="font-size:85%"> '''Abbreviations:''' '''LDUH:''' low dose [[unfractionated heparin]]; '''LMWH:''' low molecular weight heparin; '''VTE:''' Venous thromboembolism </span>
+==References==
 <references />

Venous thromboembolism: Difference between revisions

Latest revision as of 05:48, 10 February 2019

Overiew

Classification

Epidemiology

Prevalence

Incidence

Age

Gender

Race

Hospitalization for VTE

Recurrence of VTE

Complications of VTE

Risk Factors

Diagnosis

Deep Vein Thrombosis

Pulmonary Embolism

Prevention

References

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