Scope of Application
This guideline is intended for physicians working in emergency departments (EDs).

Inclusion Criteria 
This guideline is intended for adult patients presenting to the ED with suspected or known acute venous thromboembolism (ie, PE or DVT).

Exclusion Criteria 
This guideline is not intended to address the care of pediatric patients or those with venous thromboembolism in the setting of cardiac arrest or pregnancy.

Critical Questions

1. In adult patients with suspected acute pulmonary embolism (PE), can a clinical prediction rule be used to identify a group of patients at very low risk for the diagnosis of PE for whom no additional diagnostic workup is required?
   
   Level B Recommendations:
   
   For patients who are at low risk for acute PE, use the Pulmonary Embolism Rule-out Criteria (PERC) to exclude the diagnosis without further diagnostic testing.
   
   
   
2. In adult patients with low to intermediate pretest probability for acute pulmonary embolism (PE), does a negative age-adjusted D-dimer result identify a group of patients at very low risk for the diagnosis of PE for whom no additional diagnostic workup is required?
   
   Level B Recommendations:
   
   In patients older than 50 years deemed to be a low or intermediate risk for acute PE, clinicians may use a negative age-adjusted D-dimer* result to exclude the diagnosis of PE.
   
   *For highly sensitive D-dimer assays using fibrin equivalent units (FEU) use a cutoff of age×10 μg/L; for highly sensitive D-dimer assays using D-dimer units (DDU), use a cutoff of age×5 μg/L.
   
   
   
3. In adult patients with subsegmental pulmonary embolism (PE), is it safe to withhold anticoagulation?
   
   Level C Recommendations:
   
   Given the lack of evidence, anticoagulation treatment decisions for patients with subsegmental PE without associated deep venous thrombosis (DVT) should be guided by individual patient risk profiles and preferences. (Consensus recommendation)
   
   
   
4. In adult patients diagnosed with acute pulmonary embolism (PE), is the initiation of anticoagulation and discharge from the emergency department (ED) safe?
   
   Level C Recommendations:
   
   Selected patients with acute PE who are at low risk for adverse outcomes as determined by Pulmonary Embolism Severity Index (PESI), simplified PESI (sPESI), or the Hestia criteria may be safely discharged from the ED on anticoagulation, with close outpatient follow-up.
   
   
   
5. In adult patients diagnosed with acute lower-extremity deep venous thrombosis (DVT) who are discharged from the emergency department (ED), is treatment with a Non–Vitamin K Antagonist Oral Anticoagulant (NOAC) safe and effective compared with treatment with low-molecular-weight heparin (LMWH) and vitamin K antagonist (VKA)?
   
   Level B Recommendations:
   
   In selected patients diagnosed with acute DVT, a NOAC may be used as a safe and effective treatment alternative to LMWH/VKA.
   
   Level C Recommendations:
   
   Selected patients with acute DVT may be safely treated with a NOAC and directly discharged from the ED.

Disclaimer
Recommendations offered in this policy are not intended to represent the only diagnostic and management options that the emergency physician should consider. ACEP recognizes the importance of the individual physician's judgment and patient preferences.