3 July 2012

Patients with Blood Clots Should be Treated Within 4 hours, Says NICE

People who present to hospital with blood clots in the legs or lungs should be offered treatment within 4 hours and have their investigative tests including scans within 24 hours, according to latest guidelines.

Those aged 40 and over who develop a blood clot should also be tested to see whether they have an underlying cancer.

Currently, some patients encounter delays as tests and scans are unavailable at hospitals over the weekend or out-of-hours. During this time, the risk of developing a potentially fatal pulmonary embolism (PE) increases significantly.

The opportunity to check for cancer is also being missed, despite estimates suggesting that one in 10 people with a blood clot have an underlying cancer.

Around a 1,000 people are diagnosed every week with a blood clot in the legs or lungs, and nearly 17,000 deaths were recorded in England and Wales in 2007 as a result of deep vein thrombosis (DVT) or PE.

NICE recommends in its new guidance on venousthromboembolic diseases that health professionals make a diagnosis using the Wells score which has two versions, one for suspected DVT and one for PE.

Health professionals should take a history, chest x-ray and blood tests when patients, aged 40 and over, present for the first time with deep vein thrombosis (DVT) or PE for which there is no obvious cause, and who are not already known to have a cancer.

If this suggests a cancer, they should then consider further investigations with an abdomino-pelvic CT scan or a mammogram for women.

The guidance also sets out new recommendations for treating blood clots among cancer patients who benefit from the use of different blood thinners.

Patients with cancer should be treated with low weight molecular heparin given as an injection once a day for six months. This reduces the risk of the blood clot coming back compared to treating patients who don't have cancer for approximately three months with warfarin.

Gerrard Stansby, Professor of Vascular Surgery and Chair of the Guideline Development Group for the VTE diseases guidance, said: “The launch of this guidance is a completion of the circle and compliments the existing NICE recommendations on VTE prevention to provide a complete care package for the NHS.

“It looks specifically at trying to improve the diagnosis and speed of investigation by recommending two separate algorithms both based on the Wells score.

“Tests should be made available within 4 hours. This will be a challenge for some NHS trusts but it is appropriate to do so to stop patients suffering delays in treatment.”

“Trusts will not need to buy any new equipment to support the guidance so we think that it will be cost effective," added Professor Stansby.

Dr Roshan Agarwal, a Consultant Medical Oncologist who was also involved in developing the guidance, said: “This new guideline represents an important milestone in improving the quality of care received by patients with cancer associated blood clots.

“It clarifies the differences in the best treatment options for cancer and non-cancer patients, and critically for the first time sets clear standards for the investigation of underlying cancer in patients with a blood clot.”

Hayley Flavell, an Anticoagulant and Thrombosis Consultant Nurse, said: “This new guideline provides clinicians with a pathway for the safe and effective investigation and management of patients with blood clots.

“It will provide clear comprehensive standards of care that ensure patients are managed according to best evidence.”

Dr Roshan Agarwal, a member of the Guideline Development Group, discusses the venous thromboembolic diseases guidance and the link between VTE and cancer.