Continuing Medical Education (CME)

Venous Thromboembolism (VTE)

Introduction to this self-study CME activity

Purpose

Deep venous thrombosis (DVT), along with pulmonary embolism (PE), is one of the most frequent causes of hospitalization for adults, often complicates surgery and childbirth, carries significant risk of death and of long-term sequelae, and is one of the most challenging and often subtle diagnoses in clinical practice.  Improved therapy (LMWH) and diagnostic modalities (duplex Doppler ultrasound for DVT, formal risk scores and D-dimer testing) are available.  This self-study CME activity helps physicians:

(1) Improve the recognition of VTE and selection of appropriate testing. 

(2) Shorten resolution time for clinical symptoms. 

(3) Reduce incidence of pulmonary embolism. 

(4) Reduce mortality. 

(5) Reduce bleeding and other complications. 

(6) Reduce cost of hospitalization. 

 

New information in this update includes:

• CT or V/Q scanning for PE.  CT angiography with or without lower-extremity CT venography is the primary imaging modality for suspected pulmonary embolism.  Ventilation-perfusion scanning remains an appropriate option for patients without confounding pulmonary disease, and is advantageous for patients in whom radiation dose is a concern.
• Investigation of discordant prior probability and imaging findings.  Formal prior-probability estimation is required for suspected pulmonary embolism.  Negative CT angiography in a patient with a high or intermediate prior probability or a segmental or subsegmental finding on CT in a patient at low prior probability require further evaluation.

 

Key aspects of care include:

• Diagnose DVT.  Diagnose DVT with a single duplex color Doppler venous ultrasound scan.
• Diagnose PE.  Formal clinical likelihood estimation is necessary, and should precede imaging by CT or V/Q scanning.
• Alternate for diagnosis exclusion.  Patients with low prior probability on clinical likelihood estimation (Wells criteria scoring) can have high-sensitivity D-dimer testing to exclude DVT or PE without imaging.  D-dimer testing is not indicated for patients at moderate or high prior probability.
• LMWH.  Low molecular weight heparin is generally preferred over unfractionated heparin for both PE and DVT.

Audience

This self-study activity on VTE is appropriate for primary care clinicians and other health care providers who treat adult patients with suspected acute deep venous thrombosis (DVT) of the lower extremity, pulmonary embolus (PE), or both.

Authors

Team Leader
	Lee A. Green, MD, MPH Family Medicine
Team Members
	Kirk A Frey, MD, PhD Nuclear Medicine James B Froehlich, MD, MPH Director, Anticoagulation Services R Van Harrison, PhD Medical Education Mary D Kleaveland, MD General Medicine Steven Kronick, MD Emergency Medicine David M Williams, MD Radiology John G Weg, MD Pulmonary & Critical Care Medicine Thomas W Wakefield, MD Vascular Surgery
Author Disclosures
	Team Member Company Relationship Krik Frey, MD (none)   James Froelich, MD Merck/Schering-Plough, Pfizer, Sanofi-Aventi Speaker’s bureau, consultant   Novartis Research Support Lee Green, MD (none)   Van Harrison, PhD (none)   Mary Kleaveland, MD (none)   Steven Kronick, MD (none)   Thomas Wakefield, MD (none)   John Weg, MD (none)   David Williams, MD (none)

Other Acknowledgements

UMHS Guidelines Oversight Team: William E. Chavey, MD R. Van Harrison, PhD Connie J. Standiford, MD Literature search services: Taubman Medical Library Production of Internet format and web site maintenance: Ellen Patrick-Dunlavey, MA

CME Accreditation and Credit Designation

The University of Michigan Medical School is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

The University of Michigan Medical School designates this educational activity for a maximum of 1 AMA/PRA Category 1 Credits™.  Physicians should only claim credit commensurate with the extent of their participation in the activity.

This CME activity was prepared for release in February 2009. CME credit may be awarded for a maximum of three years from its release date, specifically from February 2009 through January 2012. Continuation of credit from that date depends on a thorough review of the content currency and accuracy.

Method of Participation

1. View the web pages. You may print the self-study text to read off-line.
2. Complete the on-line learning assessment test.  It will be electronically scored and the correct answers returned immediately for your review.
3. Complete the electronic credit request and activity evaluation.  An electronic certificate of participation will be provided immediately.
4. Print the certificate of participation for your personal records.

 

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