Evaluating patients with established venous thromboembolism for acquired and inherited risk factors
- Kenneth A Bauer, MD
Kenneth A Bauer, MD
- Professor of Medicine
- Harvard Medical School
- Gregory YH Lip, MD, FRCPE, FESC, FACC
Gregory YH Lip, MD, FRCPE, FESC, FACC
- Professor of Cardiovascular Medicine
- The University of Birmingham, UK
- Section Editors
- Lawrence LK Leung, MD
Lawrence LK Leung, MD
- Editor-in-Chief — Hematology
- Section Editor — Disorders of Hemostasis and Coagulation
- Professor of Medicine
- Stanford University School of Medicine
- Jess Mandel, MD
Jess Mandel, MD
- Section Editor — Pulmonary Vascular Disease
- Professor of Medicine
- University of California, San Diego
The most common presentations of venous thromboembolism (VTE) are deep vein thrombosis (DVT) of the lower extremity and pulmonary embolism (PE). Risk factors for VTE, either acquired or hereditary, can be identified in the majority of patients who present with VTE [1-3].
The evaluation of the adult patient with established VTE for acquired and inherited risk factors is discussed here. Screening for thrombophilia in asymptomatic patients and management of thrombophilic disorders are discussed separately. (See "Screening for inherited thrombophilia in asymptomatic individuals" and "Inherited thrombophilias in pregnancy" and "Screening for inherited thrombophilia in children".)
All patients with established venous thromboembolism (VTE) should undergo a thorough history and physical examination combined with review of diagnostic imaging studies and routine laboratory testing [1-3]. This may reveal an acquired condition (eg, major surgery) predisposing to the thrombotic event (table 1) or provide clues to the presence of inherited thrombophilia (eg, first-degree relatives with VTE at a young age). As venous thrombosis is a multifactorial disorder, some patients will have more than one major risk factor. (See "Overview of the causes of venous thrombosis" and 'Evaluation for occult malignancy' below.)
History and examination — A careful history should evaluate for the following:
●Common risk factors include major surgical procedures or trauma, recent hospitalization (within the previous 90 days), pregnancy, and immobility. The presence or absence of a provoking event should be identified since duration of anticoagulation and the utility of further testing is different in patients with unprovoked compared with provoked VTE. (See "Venous thromboembolism: Anticoagulation after initial management", section on 'Duration of treatment' and 'First episode of uncomplicated unprovoked VTE' below.)
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- INITIAL APPROACH
- History and examination
- Laboratory tests and imaging
- PATIENT SELECTION FOR ADDITIONAL TESTING
- Patients at risk for hypercoagulable disorders
- Patients at risk for an occult malignancy
- EVALUATION FOR HYPERCOAGULABLE DISORDERS
- Patients who may benefit
- - Patients with a family history of VTE
- - Patients without a family history of VTE
- Young patients (<45 years)
- Patients with recurrent thrombosis
- Patients with thrombosis in unusual vascular beds
- Patients with a history of warfarin-induced skin necrosis
- Patients with arterial thrombosis
- Patients who do not benefit
- - First episode unprovoked VTE
- - Upper extremity thrombosis
- Timing of tests and effect of anticoagulants
- Hypercoagulable tests
- - Inheritable thrombophilia panels
- - Tests for antiphospholipid syndrome
- - Other
- EVALUATION FOR OCCULT MALIGNANCY
- First episode of uncomplicated unprovoked VTE
- Other high risk populations
- Testing strategies for occult malignancy
- - Limited
- - Extensive
- Timing of tests
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS