Deferring diagnostic evaluation of suspected deep vein thrombosis using direct oral anticoagulant or low-molecular-weight heparin as a single dose anticoagulant: A prospective real-world study in a regionwide care pathway
Inge H.Y. Luu a), Yael Appelboom a), Jeresa I.A. Willems a), Robbert-Jan C.A.M. Gielen a), Marc B.I. Lobbes b), Kemal Külcü b), Hugo ten Cate c), Jos Peeters d), Jan Palmen e), Jacqueline Buijs a), Kon-Siong G. Jie a), Roel J.W. van Kampen a), Guy J.M. Mostard a), Daan J.L. van Twist a)
a-Department of Internal Medicine, Zuyderland Medical Center, Sittard/Heerlen, the Netherlands
b-Department of Medical Imaging, Zuyderland Medical Center, Sittard/Heerlen, the Netherlands
c-Department of Internal Medicine and Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, the Netherlands
d-General practice Overhoven-Hoogveld, Huisartsen Coöperatie Westelijke Mijnstreek, Sittard, the Netherlands
e-General practice Aarveld Medical Center, Huisartsen Oostelijk Zuid-Limburg, Heerlen, the Netherlands
Abstract
Introduction
Patients with suspected deep vein thrombosis (DVT) are typically referred to the emergency department for immediate evaluation. To enhance efficiency, our hospital implemented a regional, general practitioner (GP)-driven DVT care pathway, deferring diagnostic evaluation to a scheduled outpatient DVT clinic appointment the following day. Patients receive a single dose anticoagulant from their GP to prevent thrombosis progression while awaiting diagnostic workup. This prospective study aimed to evaluate the safety and patient preferences regarding the DVT care pathway and the type of single dose anticoagulant (low-molecular-weight heparin (LMWH) vs. direct oral anticoagulant (DOAC)).
Methods
Patients enrolled in the DVT care pathway between June 2021 and July 2023 were eligible. Until July 2022, LMWH was administered, and thereafter, the protocol recommended DOAC as the single dose anticoagulant. Patients completed questionnaires, incorporating patient-reported outcome and experience measures (PROMs/PREMs), during their DVT clinic visit and after five days. The primary endpoint was bleeding events within 72 h of receiving the single dose anticoagulant.
Results
Of 460 included patients, 229 received LMWH and 231 received DOAC as the single dose anticoagulant. DVT was confirmed in 24.8 % of patients. No major or clinically relevant non-major bleeding were reported. LMWH was associated with more minor bleedings (22.3 % vs. DOAC 13.4 %), primarily attributed to injection site hematomas. Patients reported high satisfaction with the DVT care pathway (96.5 %) and generally preferred DOAC over LMWH.
Conclusion
Deferring diagnostic evaluation for DVT using a single dose of either LMWH or DOAC in a real-world population is deemed safe. Considering practical advantages, patient preferences, and fewer skin hematomas, we favor DOACs as the single dose anticoagulant in this care pathway.