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5 The responsible physician must ensure that all of the following conditions apply: The patient is ambulatory and in stable condition, with normal vital signs There is a low a priori risk of bleeding in the patient Severe renal insufficiency is not present There is a practical system in place for the following: Administration of LMW heparin and/or warfarin with appropriate monitoring, and Surveillance and treatment of recurrent VTE and bleeding complications Minimal requirements for early hospital discharge or outpatient therapy of venous thromboembolic disease VTE: venous thromboembolism; LMW heparin: low molecular weight heparin. Adapted from Hyers, TM, Agnelli, G, Hull, RD, et al. Antithrombotic therapy for venous thromboembolic disease. Chest 2001; 119:176S. (Sixth ACCP Consensus Conference on Antithrombotic Therapy). ©2016 UpToDate®

6 Outpatient therapy is not appropriate in patients with : Massive DVT (eg, iliofemoral DVT, phlegmasia cerulea dolens) Concurrent symptomatic pulmonary embolism High risk of bleeding on anticoagulant therapy Comorbid conditions or other factors that warrant in-hospital care

7 For patients in whom outpatient therapy is selected, we suggest the use of LMW heparin overlapped with warfarin rather than the use of factor Xa or direct thrombin inhibitors. This preference is based upon our clinical experience and data described above that was derived specifically from the outpatient population. Trials that reported efficacy for dabigatran (direct thrombin inhibitor) and edoxaban (factor Xa inhibitor) used a minimum of five days of anticoagulation with LMW heparin or UFH prior to their administration for long-term oral therapy (ie, dual therapy) [50,51]. Consequently, we suggest that dabigatran and edoxaban not be routinely used as a monotherapy for initial anticoagulation in outpatients but can be used in this setting provided they overlap with heparin, similar to the original study protocols that proved their efficacy.

8 In contrast, trials of rivaroxaban and apixaban reported efficacy of both agents as the sole initial anticoagulant (monotherapy). Although short periods (

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10 *2. In patients with DVT of the leg or PE and no cancer, as long-term (first 3 months) anticoagulant therapy, we suggest dabigatran, rivaroxaban, apixaban, or edoxaban over vitamin K antagonist (VKA) therapy (all Grade 2B). For patients with DVT of the leg or PE and no cancer who are not treated with dabigatran, rivaroxaban, apixaban, or edoxaban, we suggest VKA therapy over low-molecular weight heparin (LMWH) (Grade 2C).

11 Arch Intern Med. 2000 Jun 26;160(12):1769-73. Clinical outcome and cost of hospital vs home treatment of proximal deep vein thrombosis with a low-molecular-weight heparin: the Vascular Midi-Pyrenees study. Boccalon H1, Elias A, Chalé JJ, Cadène A, Gabriel S. BACKGROUND: Low-molecular-weight heparins have been shown to be effective and safe in the treatment of deep vein thrombosis. To our knowledge, there have been no direct comparisons of such treatment on an outpatient vs an inpatient basis. OBJECTIVE: To conduct a randomized, comparative, multicenter trial to evaluate the clinical outcomes and treatment costs of deep vein thrombosis in the outpatient and inpatient settings. METHODS: Two hundred one patients presenting with proximal deep vein thrombosis, without known risk factors for pulmonary embolism or hemorrhagic complications, were randomized to receive a low-molecular-weight heparin at the registered dose followed by an oral anticoagulant for up to 6 months, either in the hospital for the first 10 days followed by treatment at home (n=102) or at home from the outset (n=99). The primary clinical outcome was the incidence of venous thromboembolism recurrence, pulmonary embolism, or major bleeding. The economic analysis was performed from the point of view of the health insurance company. Total costs of the 2 management strategies were calculated to compare the cost consequences during the first 10 days. RESULTS: No differences in clinical outcome were detectable between the 2 groups. There was no increase in the rates of primary efficacy outcome in the patients treated at home vs in the hospital (3.0% vs 3.9%), while a cost reduction of 56% was demonstrated for outpatient management. CONCLUSION: For patients with proximal deep vein thrombosis and no symptoms of pulmonary embolism or increased risk of major bleeding, home treatment using a low-molecular-weight heparin is an effective, safe, and cost-saving strategy. Arch Intern Med. 2000 Jun 26;160(12):1769-73. Clinical outcome and cost of hospital vs home treatment of proximal deep vein thrombosis with a low-molecular-weight heparin: the Vascular Midi-Pyrenees study. Boccalon H1, Elias A, Chalé JJ, Cadène A, Gabriel S. BACKGROUND: Low-molecular-weight heparins have been shown to be effective and safe in the treatment of deep vein thrombosis. To our knowledge, there have been no direct comparisons of such treatment on an outpatient vs an inpatient basis. OBJECTIVE: To conduct a randomized, comparative, multicenter trial to evaluate the clinical outcomes and treatment costs of deep vein thrombosis in the outpatient and inpatient settings. METHODS: Two hundred one patients presenting with proximal deep vein thrombosis, without known risk factors for pulmonary embolism or hemorrhagic complications, were randomized to receive a low-molecular-weight heparin at the registered dose followed by an oral anticoagulant for up to 6 months, either in the hospital for the first 10 days followed by treatment at home (n=102) or at home from the outset (n=99). The primary clinical outcome was the incidence of venous thromboembolism recurrence, pulmonary embolism, or major bleeding. The economic analysis was performed from the point of view of the health insurance company. Total costs of the 2 management strategies were calculated to compare the cost consequences during the first 10 days. RESULTS: No differences in clinical outcome were detectable between the 2 groups. There was no increase in the rates of primary efficacy outcome in the patients treated at home vs in the hospital (3.0% vs 3.9%), while a cost reduction of 56% was demonstrated for outpatient management. CONCLUSION: For patients with proximal deep vein thrombosis and no symptoms of pulmonary embolism or increased risk of major bleeding, home treatment using a low-molecular-weight heparin is an effective, safe, and cost-saving strategy.

12 UK patients with deep-vein thrombosis can be safely treated as out-patients. O'Shaughnessy D, Miles J, Wimperis J QJM. 2000;93(10):663. Deep-vein thrombosis (DVT) affects approximately 1:1000 people, approximately 750 cases/year in a Health Authority of average size. Prior to 1992, patients presenting with DVT were usually admitted for treatment with unfractionated heparin (UFH) over a 5-day period, but pressures on medical admissions have prompted many hospitals to review conditions which could be managed at home. Three different pilot studies commenced in 1996 at three centres in the UK. After 6 months, the protocols used were integrated into the normal care plan of the hospital. In total, 5191 patients were assessed, of whom 1347 were either venogram or Doppler ultrasound positive. Overall 1138 (82%) were treated as out-patients, 75% presenting during 'working hours'. Only 12 patients were readmitted, one with a clinically significant PE. Success was attributed to three factors: assignment of a key person as the project co-ordinator; referral of patients directly to permanent, dedicated staff, either on the Medical Admissions Unit (MAU) or the Accident and Emergency (A&E) department; and the introduction of dedicated anticoagulation nurses. In the 6-month period following initial therapy, complications were well below those in previously published studies. Most patients with DVT in the UK can be treated safely and effectively without being admitted to hospital. AD Department of Haematology, St Peter's Hospital, Chertsey, UK.

13 Home treatment of deep venous thrombosis with low molecular weight heparin: Long-term incidence of recurrent venous thromboembolism. Grau E, Tenias JM, Real E, Medrano J, Ferrer R, Pastor E, Selfa S Am J Hematol. 2001;67(1):10. Outpatient treatment of deep venous thrombosis (DVT) with low molecular weight heparin (LMWH) seems as safe and effective as inpatient treatment with unfractionated heparin (UFH). However, most of the randomized trials comparing a LMWH with UFH described clinical outcomes within 3-6 months. The long-term incidence of recurrent VTE after treatment of DVT with LMWH remains to be established. The primary objective of this retrospective study was to document the long-term incidence of recurrent venous thromboembolism (VTE) in patients with DVT treated with a LMWH, nadroparin in an outpatient basis. The patients were evaluated 46 months after inclusion in two cohorts comparing home treatment with nadroparin (n = 130) with in-hospital treatment with intravenous UFH (n = 149). More than 60% of the patients in the nadroparin group could be treated at home, either entirely or after a short stay in hospital. The age-adjusted thrombosis-free survival was not statistically significant between nadroparin and UFH-treated patients (P = 0.084). There was a nonsignificant trend favoring nadroparin as compared with UFH. The hazard ratio (HR) for recurrent VTE in the nadroparin group with respect to the UFH group was 0.44 (95% confidence interval, 0.17-1.12). No significant differences were observed in overall mortality or major hemorrhage between the two treatment groups. Our study suggests that home treatment of DVT with LMWH is at least as effective and safe as in-hospital UFH after a long-term follow-up period. Department of Hematology, Hospital Lluis Alcanyis, Xativa, Spain. [email protected]

14 Outpatient treatment of deep venous thrombosis in diverse inner-city patients. Dunn AS, Schechter C, Gotlin A, Vomvolakis D, Jacobs E, Sacks HS, Coller B Am J Med. 2001;110(6):458. PURPOSE: We sought to describe the development and outcomes of a hospital-based program designed to provide safe and effective outpatient treatment to a diverse group of patients with acute deep venous thrombosis. METHODS: Patients enrolled in the program were usually discharged on the day of or the day after presentation. Low- molecular-weight heparin was administered for a minimum of 5 days and warfarin was given for a minimum of 3 months. The hospital provided low-molecular- weight heparin free of charge to patients. Patients received daily home nursing visits to monitor the prothrombin time, assess compliance, and detect complications. The inpatient and outpatient records of the first 89 consecutive patients enrolled in the program were reviewed. Patients were observed for a 3-month period after enrollment. RESULTS: The median length of stay was 1 day. Low-molecular-weight heparin was administered for a mean (+/- standard deviation [SD]) of 4.7 +/- 2.4 days at home. Recurrent thromboembolism was noted in 1 patient (1%), major bleeding in 2 patients (2%), and minor bleeding in 2 patients (2%). No patients died or developed thrombocytopenia. Assuming that patients would have been hospitalized for the duration of treatment with low-molecular-weight heparin, the program eliminated a mean of 4.7 days of hospitalization, with an estimated reduction of $1,645 in total health care costs per patient. CONCLUSION: This hospital-based program to provide outpatient treatment of deep venous thrombosis to a diverse group of inner-city patients achieved a low incidence of adverse events and substantial health care cost savings. Specific strategies, including providing low-molecular-weight heparin free of charge and daily home nursing visits, can be utilized to facilitate access to outpatient treatment and ensure high-quality care. Department of Medicine, Mount Sinai School of Medicine, New York, NY 10029, USA.

15 Cochrane Database Syst Rev. 2007 Jul 18;(3):CD003076. Home versus in-patient treatment for deep vein thrombosis. Othieno R1, Abu Affan M, Okpo E. BACKGROUND: Deep vein thrombosis (DVT) occurs when a blood clot blocks blood flow through a vein. This can happen after surgery, trauma, or when a person has been immobile. Clots can dislodge and block blood flow to the lungs, causing death. Heparin is a blood-thinning drug used in the first 3-5 days of DVT treatment. Low molecular weight heparins (LMWH) allow people with DVT to receive their initial treatment at home instead of in hospital. OBJECTIVES: To collate randomised controlled trials (RCTs) comparing home (LMWH) versus hospital (LMWH or UH) treatment for DVT, and to compare the safety, efficacy, acceptability and cost implications of home versus hospital treatment. SEARCH STRATEGY: We searched the Cochrane Peripheral Vascular Diseases Group trials register (inception to May 2007) and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (last searched Issue 2, 2007) which includes searches of MEDLINE (January 1966 onwards) and EMBASE (January 1980 onwards). We also handsearched non-listed journals and contacted researchers in the field. SELECTION CRITERIA: RCTs of home versus hospital treatment for DVT in which DVT was clinically confirmed and treated with either LMWH or UH. DATA COLLECTION AND ANALYSIS: One reviewer selected the material for inclusion and another reviewed the literature and selection of trials. Two reviewers independently extracted data. Outcomes included PE, recurrent DVT, gangrene, heparin complications, and death. MAIN RESULTS: Six RCTs involving 1708 participants with comparable treatment arms were included. All six had fundamental problems including high exclusion rates, partial hospital treatment of many in the LMWH arms, and comparison of UH in hospital with LMWH at home. The trials showed that patients treated at home with LMWH are less likely to have recurrence of venous thromboembolism (VTE) compared to hospital treatment with UH or LMWH (fixed effect relative risk (FE RR) 0.61; 95% confidence interval (CI) 0.42 to 0.90). Home treated patients also had lower mortality (FE RR 0.72; 95% CI 0.45 to 1.15) and fewer major bleeding (FE RR 0.67; 95% CI 0.33 to 1.36), but were more likely to have minor bleeding than those in hospital (FE RR 1.29; 95% CI 0.94 to 1.78) though these were not statistically significant. AUTHORS' CONCLUSIONS: The limited evidence suggests that home management is cost effective and preferred by patients. Further large trials comparing these treatments are unlikely to occur. Therefore, home treatment is likely to become the norm; further research will be directed to resolving practical issues.

16 Am J Med. 2015 Jan;128(1):90.e9-15. doi: 10.1016/j.amjmed.2014.08.023. Epub 2014 Sep 19. A prognostic score to identify low-risk outpatients with acute deep vein thrombosis in the lower limbs. Trujillo-Santos J, Lozano F, Lorente MA, Adarraga D, Hirmerova J, Del Toro J, Mazzolai L, Barillari G, Barrón M, Monreal M; RIETE Investigators. Collaborators (125) BACKGROUND: No prior studies have identified which patients with deep vein thrombosis in the lower limbs are at a low risk for adverse events within the first week of therapy. METHODS: We used data from the Registro Informatizado de la Enfermedad TromboEmbólica (RIETE) to identify patients at low risk for the composite outcome of pulmonary embolism, major bleeding, or death within the first week. We built a prognostic score and compared it with the decision to treat patients at home. RESULTS: As of December 2013, 15,280 outpatients with deep vein thrombosis had been enrolled. Overall, 5164 patients (34%) were treated at home. Of these, 12 (0.23%) had pulmonary embolism, 8 (0.15%) bled, and 4 (0.08%) died. On multivariable analysis, chronic heart failure, recent immobility, recent bleeding, cancer, renal insufficiency, and abnormal platelet count independently predicted the risk for the composite outcome. Among 11,430 patients (75%) considered to be at low risk, 15 (0.13%) suffered pulmonary embolism, 22 (0.19%) bled, and 8 (0.07%) died. The C-statistic was 0.61 (95% confidence interval [CI], 0.57-0.65) for the decision to treat patients at home and 0.76 (95% CI, 0.72-0.79) for the score (P =.003). Net reclassification improvement was 41% (P

17 Criterios de exclusión para el tratamiento domiciliario en las trombosis venosas profundas (TVP) según la Michigan Quality Improvement Consortium Guideline Embolia pulmonar Trombosis íleo-femoral extensa Reciente cirugía o traumatismo Hemorragia activa Embarazo Estado conocido de hipercoagulabilidad Catéter asociado a TVP Sospecha de no cumplimiento del tratamiento Aclaramiento de creatinina 2,5 mg/dl Trombocitopenia

18 Criterios de exclusión para el tratamiento domiciliario en las trombosis venosas profundas (TVP) según la British Society for Haematology Coexistencia de otro proceso médico que precise hospitalización Obstrucción venosa grave aguda (flegmasia cerulea dolens) Paciente que requiera analgesia intravenosa Insuficiencia renal (creatinina >200 μmol/l) Alergia conocida a la heparina o trombocitopenia asociada a la heparina Sospecha de falta de adhesión al tratamiento Problemas de comunicación (p. ej., barrera idiomática, domicilio sin teléfono…) Malas condiciones sociales Movilidad limitada Hemorragia activa Importante riesgo hemorrágico Úlcera péptica activa Enfermedad hepática (TP >2 s del intervalo normal) Hipertensión no controlada (diastólica >110 mmHg, sistólica >200 mm) Angiodisplasia Cirugía ocular reciente o del sistema nervioso central (menos de 1 mes) Accidente vascular hemorrágico (menos de 1 mes) Trombocitopenia (plaquetas

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21 Outpatient anticoagulation — In select patients with PE, outpatient therapy can be administered by giving the first dose of anticoagulant in the hospital or urgent care center, with the remaining doses given at home. The decision to treat as an outpatient should be made in the context of the patient’s clinical condition, understanding of the risk-benefit ratio, and their preferences. Although the ideal candidate is poorly defined, several randomized trials and meta-analyses suggest that, in patients with PE, outpatient anticoagulation is safe and effective in those with the all of the following features [5,19-28]: ● Low risk of death – defined as pulmonary embolism severity index (PESI) class I or II (table 5), or simplified PESI (sPESI) score = 0. (see 'Prognostic models' below) ● No requirement for supplemental oxygen ● No requirement for narcotics for pain control ● No respiratory distress ● Normal pulse and blood pressure ● No recent history of bleeding or risk factors for bleeding (table 3) ● No serious comorbid conditions (eg, ischemic heart disease, chronic lung disease, liver or renal failure, thrombocytopenia, or cancer) ● Normal mental status with good understanding of risk and benefits, are not needle averse (if LMWH chosen), and have good home support (eg, do not live alone, have access to a telephone and physician, can return to the hospital quickly if there is clinical deterioration) ● Absence of concomitant deep venous thrombosis (a high clot burden in the lower extremities may increase the risk of death or warrant additional therapy)

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23 Treatment of Acute PE Out of the Hospital *20. In patients with low-risk PE and whose home circumstances are adequate, we suggest treatment at home or early discharge over standard discharge (eg, after the first 5 days of treatment) (Grade 2B).

24 Consistent with AT9, we suggest that patients who satisfy all of the following criteria are suitable for treatment of acute PE out of the hospital: (1)clinically stable with good cardiopulmonary reserve (2) no contraindications such as: recent bleeding severe renal or liver disease severe thrombocytopenia (ie,

25 Whether to Anticoagulate Subsegmental PE *19. In patients with subsegmental PE (no involvement of more proximal pulmonary arteries) and no proximal DVT in the legs who have a (i) low risk for recurrent VTE (see text), we suggest clinical surveillance over anticoagulation (Grade 2C) or (ii) high risk for recurrent VTE (see text), we suggest anticoagulation over clinical surveillance (Grade 2C). Remarks: Ultrasound (US) imaging of the deep veins of both legs should be done to exclude proximal DVT. Clinical surveillance can be supplemented by serial US imaging of the proximal deep veins of both legs to detect evolving DVT (see text). Patients and physicians are more likely to opt for clinical surveillance over anticoagulation if there is good cardiopulmonary reserve or a high risk of bleeding.

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39 SCREENING FOR A HYPERCOAGULABLE STATE Whom to test — There is currently no consensus regarding who to test for inherited thrombophilia. However, the likelihood of identifying an inherited thrombophilia is increased several-fold by screening only patients with one or more of the following: ● Initial thrombosis occurring prior to age 50 without an immediately identified risk factor (ie, idiopathic or unprovoked venous thrombosis) ● A family history of venous thromboembolism (ie, first-degree relatives with VTE prior to age 50) ● Recurrent venous thrombosis ● Thrombosis occurring in unusual vascular beds such as portal, hepatic, mesenteric, or cerebral veins ● A history of warfarin-induced skin necrosis, which suggests protein C deficiency (see "Protein C deficiency: Clinical manifestations and diagnosis")

40 Homocysteine levels and mutational analysis for the responsible gene, methylene tetrahydrofolate reductase (MTHFR), should NOT be performed. Although elevated levels of homocysteine can be found in patients with thrombosis, the causal role of hyperhomocysteinemia in thrombosis is unclear. In addition, lowering homocysteine levels with folic acid, pyridoxine, and vitamin B12 does not appear to reduce the rate of VTE in patients with hyperhomocysteinemia. Homocisteína: qué gran invento

41 EVALUATION FOR OCCULT MALIGNANCY — In general, other than age-appropriate cancer screening, routine evaluation for occult malignancy in unselected patients with a diagnosis of venous thromboembolism (VTE) is not warranted. However, we perform additional testing in patients in populations who are thought to be at high risk of having a malignancy (eg, a first episode of uncomplicated unprovoked VTE, recurrent thrombosis on anticoagulation). Although testing leads to the increased identification of cancer, no convincing survival advantage due to any testing strategy has been shown in patients who present with VTE. Thus, the major purpose of evaluating this population for malignancy is the early identification of cancer, rather than the prevention of cancer-related death. In unselected patients presenting with VTE, the reported incidence of a subsequent diagnosis of malignancy varies from 2 to 25 percent (on average 10 percent) with the highest risk in the first six months following the initial diagnosis [45-53]. The most common cancers that are found include hematologic malignancies and occult cancers of the ovary, pancreas, liver, kidney, and lung. Studies that report an increased incidence of cancer in unselected patients who present with VTE include the following: ● A meta-analysis of 40 reports published between 1982 and 2007 found a threefold excess risk of occult cancer in patients with unselected VTE compared with individuals without VTE (relative risk [RR] 3.2; 95% CI 2.4-4.5) [46]. ● A retrospective study of 1383 patients with deep venous thrombosis (DVT) reported that, compared with patients without DVT, a higher incidence of subsequent malignancy was observed in patients with thrombosis (11 versus 7.5 percent) [47]. ● A nested case-control study of patients with cancer reported that, compared with those who did not have VTE, patients with VTE had a higher risk of developing a second cancer (RR 1.3; 95% CI 1.1-1.4) [54]. The risk of developing a second cancer was greatest in patients who had VTE one year or more after their first cancer was diagnosed (RR 1.4).

42 Cochrane Database Syst Rev. 2015 Mar 6;3:CD010837. doi: 10.1002/14651858.CD010837.pub2. Effect of testing for cancer on cancer- and venous thromboembolism (VTE)-related mortality and morbidity in patients with unprovoked VTE. Robertson L1, Yeoh SE, Stansby G, Agarwal R. BACKGROUND: Venous thromboembolism (VTE) is a collective term for two conditions: deep vein thrombosis (DVT) and pulmonary embolism (PE). A proportion of patients with VTE have no underlying or immediately predisposing risk factors and the VTE is referred to as unprovoked. Unprovoked VTE can often be the first clinical manifestation of an underlying malignancy. This has raised the question of whether patients with an unprovoked VTE should be investigated for an underlying cancer. Treatment for VTE is different in cancer and non-cancer patients and a correct diagnosis would ensure that patients received the optimal treatment for VTE to prevent recurrence and further morbidity. Furthermore, an appropriate cancer diagnosis at an earlier, potentially curative stage could avoid the risk of cancer progression and thus lead to improvements in cancer-related mortality and morbidity. OBJECTIVES: To determine whether testing for undiagnosed cancer in patients with a first episode of unprovoked VTE (DVT or PE) is effective in reducing cancer and VTE-related mortality and morbidity and to establish which tests for cancer are most useful. SEARCH METHODS: The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched January 2015) and the Cochrane Register of Studies (CRS) (2014, Issue 12). Clinical trials databases were searched. The reference lists of relevant articles were also checked. SELECTION CRITERIA: Randomised and quasi-randomised trials in which patients with an unprovoked VTE were allocated to receive specific tests for cancer or clinically indicated tests only were eligible for inclusion in this review. Primary outcomes included all-cause mortality, cancer-related mortality and VTE-related mortality. DATA COLLECTION AND ANALYSIS: Selection of the studies, quality assessment and data extraction were completed independently by two review authors. Any disagreements were resolved by discussion. MAIN RESULTS: Two studies with a combined total of 396 patients met the inclusion criteria for this review. Both studies assessed the effect of testing for cancer versus clinically indicated tests only in patients with an unprovoked VTE. The quality of the evidence was moderate because although the studies were judged to be at low or unclear risk of bias, there was concern that the studies were small as reflected in the wide confidence intervals (CIs). Pooled analysis showed that testing for cancer was consistent with either a benefit or no benefit on cancer-related mortality (odds ratio (OR) 0.49, 95% CI 0.15 to 1.67, P = 0.26). One study showed that, overall, malignancies were less advanced in patients belonging to the extensive screening group than in patients of the control group (64% versus 20%, P = 0.047) and that tested patients were diagnosed earlier than untested patients (mean 1 month versus 11.6 months to cancer diagnosis from the time of diagnosis of VTE). Standard deviations were not provided for time to diagnosis, so it was not possible to perform an independent statistical analysis on this association. Neither study measured all-cause mortality, VTE-related morbidity and mortality, side effects of anticoagulation, side effects of cancer tests or patient satisfaction. AUTHORS' CONCLUSIONS: Testing for cancer in patients with idiopathic VTE leads to earlier diagnosis of cancer at an earlier stage of the disease. However, there is currently insufficient evidence to draw definitive conclusions concerning the effectiveness of testing for undiagnosed cancer in patients with a first episode of unprovoked VTE (DVT or PE) in reducing cancer and VTE- related morbidity and mortality. The results are imprecise and could be consistent with either harm or benefit. Further good-quality large-scale randomised controlled trials are required before firm conclusions can be made.

43 First episode of uncomplicated unprovoked VTE We believe that an evaluation for cancer in patients with a first unprovoked (idiopathic) episode of VTE should be limited to a complete history and examination, basic laboratory testing, routine age-appropriate cancer screening, and a chest radiograph. Any abnormality observed on initial testing should then be investigated. Age-appropriate cancer screening tests and the components of a limited testing strategy are discussed separately

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46 Screening for Occult Cancer in Unprovoked Venous Thromboembolism En base a las Recomendaciones de la Canadian Task Force on Preventive Health Care y la U:S: Preventive Services Task Force, se realizó un screening sexo- específico si no se había realizado en el año previo que consistía en: – Examen mamario o mamografía o ambas en mujeres mayores de 50 años. – Papanicolau y examen pélvico en mujeres entre 17 y 70 años si habían tenido vida sexual activa. – Examen prostático o PSA o ambas en hombres mayores de 40 años

47 Nos vemos en el episodio IV Gracias