Venous Thromboembolism Clinical Policy

In evaluating venous thromboembolism (VTE) in the emergency department, physicians face a challenge. They must carefully consider the risks of untreated pulmonary embolism (PE) and deep venous thrombosis (DVT) but also minimize patient harm from unnecessary testing and treatments. Clinicians use Bayesian decision making and the concept of pretest probability to help guide this work-up and management.

Over the past several years, the management of possible VTE has evolved rapidly. In 2018, the ACEP Board of Directors approved a revised clinical policy on the evaluation and management of adult patients presenting with suspected acute VTE.

Review “ACEP Revises Venous Thromboembolism Clinical Policy” in ACEP Now before you answer the question.

NOTE: This content does not apply to rare cases of coronavirus vaccine-induced thrombotic thrombocytopenia. Learn more about reports of blood clots related to the Johnson & Johnson COVID-19 vaccine.

Which of the following is NOT an accurate portrayal of one of these recommendations regarding PE management?

A) In all adult patients with subsegmental PE (and without associated DVT), it can be judged safe to withhold anticoagulation.

B) In adult patients with a suspected acute PE, the Pulmonary Embolism Rule-out Criteria (PERC) can be used to exclude the diagnosis in patients who are at low risk for acute PE, without further diagnostic testing.

C) In patients older than 50 who have a low or intermediate pretest probability for acute PE, a negative age-adjusted D-dimer test can be used to identify those at very low risk of PE. For them, no additional diagnostic workup is required.

D) The Pulmonary Embolism Severity Index (PESI), the simplified PESI, or the Hestia criteria may be used to identify selected patients with acute PE at low risk for adverse outcomes. These patients may be safely discharged from the emergency department on anticoagulation, with close outpatient follow-up.