Which patients with a new diagnosis of DVT need an evaluation for PE?
This has come up for me in clinic a few times recently, so I thought to review the literature for updated guidance. My general practice pattern has been to pursue diagnostic imaging for PE in patients with new DVT if (a) they are at high risk (e.g. malignancy, pregnancy, etc.) or (b) of course if they have symptoms concerning for PE.
I thought this would be a relatively easy query, but somewhat surprisingly to me, there's not a great answer. The 2012 Chest Guidelines don't address this issue; neither do either of the subsequent updates. But, I'm linking them here because they are a good review and cover other important stuff we should know.
There are several studies on the incidence of DVT in patients diagnosed with a PE, ranging from 44% to 71% (Reference 1, Reference 2, Reference 3).
Literature the other way around is limited. In patients with a DVT of the calf, up to 6.2% had PE in one study but only 1.5% in another. One hospital looked at patients with distal DVT and found that 7% developed proximal DVT or PE overall; patients who were inpatient or older than 60 years were at the highest risk, and the risk for outpatients was less than 4%. The one full paper I'm attaching is from the PREPIC study group which observed that 2% of patients with DVT on A/C were found to have a PE at three months.
In a group of high-risk trauma patients, 17% of those with DVT were found to have a PE. But, another paper from the trauma literature found no relationship between DVT and PE in this patient population.
My take-home is that in outpatients with DVT, risk of (asymptomatic) concurrent PE is low, and I can probably continue my practice pattern of deferring a chest CT unless the patient is symptomatic or high-risk.
Allen CJ, Murray CR, Meizoso JP, et al. Surveillance and Early Management of Deep Vein Thrombosis Decreases Rate of Pulmonary Embolism in High-Risk Trauma Patients. Journal of the American College of Surgeons. 2016;222(1):65-72.
Aziz HA, Hileman BM, Chance EA. No correlation between lower extremity deep vein thrombosis and pulmonary embolism proportions in trauma: a systematic literature review. European Journal of Trauma and Emergency Surgery. 2018;44(6):843-850.
Brateanu A, Patel K, Chagin K, et al. Probability of developing proximal deep-vein thrombosis and/or pulmonary embolism after distal deep-vein thrombosis. Thrombosis and Haemostasis. 2016;115(03):608-614.
Garry J, Duke A, Labropoulos N. Systematic review of the complications following isolated calf deep vein thrombosis. British Journal of Surgery. 2016;103(7):789-796.
Girard P, Decousus M, Laporte S, et al. Diagnosis of Pulmonary Embolism in Patients with Proximal Deep Vein Thrombosis. American Journal of Respiratory and Critical Care Medicine. 2001;164(6):1033-1037.
Hirmerova J, Seidlerova J, Chudacek Z. The Prevalence of Concomitant Deep Vein Thrombosis, Symptomatic or Asymptomatic, Proximal or Distal, in Patients With Symptomatic Pulmonary Embolism. Clinical and Applied Thrombosis/Hemostasis. 2018;24(8):1352-1357.
Kearon C, Akl EA, Ornelas J, et al. Antithrombotic Therapy for VTE Disease. Chest. 2016;149(2):315-352.
Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e419Se496S.
Stevens SM, Woller SC, Baumann Kreuziger L, et al. Antithrombotic therapy for VTE disease: second update of the CHEST guideline and expert panel report – executive summary. Chest. 2021;160(6).
Quezada CA, Bikdeli B, Barrios D, et al. Assessment of coexisting deep vein thrombosis for risk stratification of acute pulmonary embolism. Thrombosis Research. 2018;164:40-44.
Wu AR, Garry J, Labropoulos N. Incidence of pulmonary embolism in patients with isolated calf deep vein thrombosis. Journal of Vascular Surgery: Venous and Lymphatic Disorders. 2017;5(2):274-279.
Yamaki T, Nozaki M, Sakurai H, Takeuchi M, Soejima K, Kono T. Presence of Lower Limb Deep Vein Thrombosis and Prognosis in Patients with Symptomatic Pulmonary Embolism: Preliminary Report. European Journal of Vascular and Endovascular Surgery. 2009;37(2):225-231.
