Society for Vascular Medicine

Five Things Physicians and Patients Should Ques

Released February 21, 2013

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1

Don’t do work up for clotting disorder (order hypercoagulable testing) for patients who develop first episode of deep vein thrombosis (DVT) in the setting of a known cause.

Lab tests to look for a clotting disorder will not alter treatment of a venous blood clot, even if an abnormality is found. DVT is a very common disorder, and recent discoveries of clotting abnormalities have led to increased testing without proven benefit.

2

Don’t reimage DVT in the absence of a clinical change.

Repeat ultrasound images to evaluate “response” of venous clot to therapy does not alter treatment.

3

Avoid cardiovascular testing for patients undergoing low-risk surgery.

Pre-operative stress testing does not alter therapy or decision-making in patients facing low-risk surgery.

4

Refrain from percutaneous or surgical revascularization of peripheral artery stenosis in patients without claudication or critical limb ischemia.

Patients without symptoms will not benefit from attempts to improve circulation. No evidence exists to support improving circulation to prevent progression of disease. There is no proven preventive benefit, only symptomatic benefit.

5

Don’t screen for renal artery stenosis in patients without resistant hypertension and with normal renal function, even if known atherosclerosis is present.

Performing surgery or angioplasty to improve circulation to the kidneys has no proven preventive benefit, and shouldn’t be considered unless there is evidence of symptoms, such as elevated blood pressure or decreased renal function.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

The Society for Vascular Medicine (SVM) is a nonprofit medical society comprised of physicians, surgeons, nurses, physician assistants, nurse practitioners, and vascular interventionists. For nearly 25 years, one of the goals of the Society has been to maintain high standards of clinical vascular medicine. The Society believes that optimal vascular care is best accomplished by the collegial interaction of a community of vascular professionals working with the patient. The Society recognizes the importance of individuals with diverse backgrounds in achieving ideal standards of research and clinical practice. The society believes that partnerships between patients and health care providers are crucial to improving vascular health, achieving better outcomes and lowering health care costs.

For more information, visit www.vascularmed.org.

How this list was created: The Society for Vascular Medicine (SVM) looked to the leadership of its Board of Trustees and input from its members to develop the list of five things physicians and patients should question. Suggestions from SVM members were solicited through an e-mail blast, and a second e-mail was sent to the SVM Board of Trustees seeking volunteers and suggestions.

A committee, consisting of four members of the Board of Trustees, narrowed an initial list down to seven recommendations. The full Board of Trustees voted on the recommendations using the Delphi method of choice, arriving at the five that became SVM’s list as part of the Choosing Wisely® campaign.

SVM’s disclosure and conflict of interest policy can be found at www.vascularmed.org.

Sources

1.

Dalen JE. Should patients with venous thromboembolism be screened for thrombophilia? Am J Med [Internet]. 2008 Jun [cited 2012 Oct 18];121:6;458–463.

Baglin T, Luddington R, Brown K, Baglin C. Incidence of recurrent venous thromboembolism in relation to clinical and thrombophilic risk factors: prospective cohort study. Lancet [Internet]. 2003 Aug 16 [cited 2012 Oct 18];362:523–526.

Ho WK, Hankey GJ, Quinlan DJ, Eikelboom JW. Risk of recurrent venous thromboembolism in patients with common thrombophilia. Arch Intern Med [Internet]. 2006 Apr 10 [cited 2012 Oct 18];166:729–736.

Baglin T, Gray E, Greaves M, Hunt BJ, Keelin D, Machin S, Mackie I, Makris M, Nokes T, Perry D, Tait RC, Walker I, Watson H. Clinical guidelines for testing for heritable thrombophilia; Br J Haematol [Internet]. 2010 Apr [cited 2012 Oct 18];149:209–220.

2.

Bates SM, Jaeschke R, Stevens SM, Goodacre S, Wells PS, Stevenson MD, Kearon C, Schunemann HJ, Crowther M, Pauker SG, Makdissi R, Guyatt GH. Diagnosis of DVT Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines Practice Guidelines. Chest. [Internet]. 2012 Feb [cited 2012 Oct 18];141(2)(Suppl):e351S–e418S.

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Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Antman EM, Buller CE, Creager MA, Ettinger SM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B, Tarkington LG, Yancy CW. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. J Am Coll Cardiol [Internet]. 2007 Oct 23 [cited 2012 Oct 18];50:e159 –241.

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ACC/AHA 2005 practice guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): Executive summary. Circ [Internet]. 2006 Mar 21 [cited 2012 Oct 18]113;1474-1547.

5.

ACC/AHA 2005 practice guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): Executive summary. Circ [Internet]. 2006 Mar 21 [cited 2012 Oct 18]113;1474-1547.