Deep Vein Thrombosis: Diagnosis and Management

Key points

• NICE NG158: two-level DVT Wells score first — DVT likely ≥ 2 points, unlikely ≤ 1. A Wells score alone cannot exclude DVT.
• Wells items (1 pt each): active cancer · paralysis/plaster · bedridden ≥ 3 days or major surgery < 12 weeks · deep-vein tenderness · entire leg swollen · calf ≥ 3 cm difference · pitting oedema · collateral superficial veins · previous DVT · minus 2 if an alternative diagnosis is at least as likely.
• DVT likely → proximal leg vein ultrasound within 4 hours; if the scan cannot be done in that time, take a D-dimer and give interim anticoagulation while waiting. DVT unlikely → D-dimer first.
• Treatment: offer apixaban or rivaroxaban first-line for confirmed proximal DVT or PE · if neither is suitable, LMWH for at least 5 days followed by dabigatran or edoxaban, or LMWH with a vitamin K antagonist until INR ≥ 2.0 on two consecutive readings.
• Duration: at least 3 months · provoked with a resolved risk factor, usually stop at 3 months · unprovoked, consider continuing after weighing recurrence against bleeding risk.
• Cancer-associated VTE: NICE NG158 says CONSIDER a DOAC — taking account of tumour site, bleeding risk and drug interactions · this replaced the older blanket recommendation of LMWH for 6 months, but NICE's wording is 'consider', not a blanket first-line rule.

Decision points in this pathway

• Wells ≥ 2 points (DVT likely)?
• Ultrasound positive?
• D-dimer raised?

The full step-by-step algorithm, including what to do at each branch, opens in the app for approved members.