Practical manual

Scores and Algorithms

in Haemostasis
and Thrombosis

José A. Páramo (coordinator)

Henri Bounameaux
Marcel Levi
Gregory YH Lip
Pascual Marco
Joan Carles Reverter
Alberto Tosetto
© Text: the authors
© Edition: Grupo Acción Médica. Madrid, 2014
Email: publicaciones@accionmedica.com

This work is subject to copyright. All rights, be they related to all or part of the material,
specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting,
reproduction on microfilm or in any other way, and storage in data banks reserved.

ISBN: 978-84-15226-29-1 • Legal Deposit: M-13411-2014

Scientific board

Henri Bounameaux
Division of Angiology and Haemostasis
University Hospital of Geneva, Switzerland

Marcel Levi
Academic Medical Center, University of Amsterdam
Amsterdam, The Netherlands

Gregory YH Lip
Centre for Cardiovascular Sciences - City Hospital
University of Birmingham, United Kingdom

Pascual Marco
Hematology Service
University General Hospital of Alicante, Spain

José A. Páramo
Hematology Service
University Hospital of Navarra - Pamplona, Spain

Joan Carles Reverter

Hemotherapy and Hemostasis Service. CDB
Hospital Clínic of Barcelona, Spain

Alberto Tosetto
Hemophilia and Thrombosis Center
Hematology Department
San Bortolo Hospital, Vicenza, Italy

3
Summary

Prologue  ..............................................................................................................  7

Deep Vein Thrombosis and Pulmonary Embolism 

Clinical probability model for deep vein thrombosis  ......................................... 9
Clinical probability models for Pulmonary Embolism  ....................................... 10
Diagnostic algorithm for deep vein Thrombosis and Pulmonary Embolism  .... 12
Prognostic scores in pulmonary embolism  ...................................................... 14
Prediction of recurrent deep vein thrombosis or Pulmonary Embolism  ......... 17
Outpatient versus inpatient care in venous thromboembolism  ....................... 19
Assessment of post-thrombotic syndrome  ..................................................... 21

Pregnancy 
Diagnostic algorithm in suspected deep vein thrombosis during pregnancy  . 22
Diagnostic algorithm in suspected pulmonary embolism during pregnancy  ... 23

Atrial Fibrillation 
Prediction of stroke risk in patients with atrial fibrillation  ................................ 25
Bleeding risk in anticoagulated patients with atrial fibrillation  ......................... 28
Predicting the likelihood of achieving good anticoagulation control in a newly
diagnosed non-anticoagulated patient with atrial fibrillation  ........................... 30

Other thrombotic conditions 

Cancer
Risk of Venous thromboembolism in Cancer Patients  .................................... 32
Medical patients
Risk assessment models in hospitalized Medical Patients  .............................. 35
Antiphospholipid syndrome
Diagnosis of the antiphospholipid syndrome  ................................................... 38
Diagnosis of Disseminated Intravascular Coagulation  .................................... 40
Others
Diagnosis of Thrombotic Thrombocytopenic Purpura (TTP)  ............................ 43
Acute Intestinal Ischemia / Thrombosis  ........................................................... 44

5
Summary

Bleeding 
ISTH bleeding assessment tool for the evaluation of bleeding severity  .......... 46
Pediatric bleeding assessment tool for the evaluation of bleeding
severity in children  ........................................................................................... 50
Bleeding assessment tool for the evaluation of bleeding severity
in immune thrombocytopenia: the SMOG system  ........................................... 53

Anticoagulant therapy 
Diagnostic and therapeutic algorithm of Heparin-Induced
Thrombocytopenia (HIT syndrome)  ................................................................. 59
Bridging strategies in patients on anticoagulants who need
to undergo invasive procedures  ....................................................................... 61

6
Prologue

Evidence-based medicine provides guidelines to physicians aimed at improving

efficacy and safety of patient management. This approach is to a great extent
based on the use of clinical scores and diagnosis algorithms that, in combination
with patient clinical examination and laboratory tests, improve diagnosis accuracy
and patient stratification. This approach also offers a better standardization of patient
management across centres and improves patient care reliability.

For doctors who see patients with thrombotic and bleeding problems, or whose clinical
workload makes it difficult to keep up with developments in the field of haemostasis,
it is hoped that this algorithm booklet may be of some help in the management
of such cases.

The use of score calculators and algorithms can facilitate decision making in
both diagnosis and treatment of thrombotic and bleeding problems. However,
considering the multiplicity of these tools in recent years, it becomes necessary to
use a comprehensive manual, without referring to the original sources in every case.
An international expert panel has developed a booklet that compiles, in a clear and
simple way, most recognized and useful clinical scores and diagnosis algorithms in the
field of thrombosis and haemostasis: deep venous thrombosis, pulmonary embolism,
pregnancy, cancer, DIC, antiphospholipid syndrome, atrial fibrillation, and bleeding
risk. Each algorithm includes the indication and a brief interpretation emphasising
the most relevant aspects of each one followed by some representative references.

We hope this algorithm booklet may guide the clinician in the most appropriate
diagnostic and therapeutic strategy, answering some of the questions that may arise
when treating thrombotic and bleeding problems.

The authors

7
 Deep Vein Thrombosis and Pulmonary Embolism
Clinical probability model for deep vein thrombosis

Indication
Clinically suspected deep vein thrombosis (DVT)

Wells’ score
Feature Score
Active cancer (treatment ongoing, within previous 6 months, or palliative) 1
Paralysis, paresis, or recent plaster immobilization of the lower extremities 1
Recently bedridden ≥ 3 days or major surgery
1
(within the previous 12 weeks requiring general or regional anesthesia)
Localized tenderness along the distribution of the deep venous system 1
Entire leg swollen 1
Calf swelling by ≥ 3 cm than that on the asymptomatic leg
1
(measured 10 cm below tibial tuberosity)
Pitting oedema* (confined to the symptomatic leg) 1
Collateral superficial veins (non-varicose) 1
Previously documented DVT 1
Alternative diagnosis at least as likely as DVT –2
Clinical probability
Low probability (unlikely) ≤1
Intermediate/high probability (likely) ≥2
* The most symptomatic extremity is used in patients with symptoms in both legs.

Interpretation
Useful clinical decision rule if incorporated into the algorithm. Combined with a
D-dimer test result below a validated threshold and/or a negative ultrasound, a
low clinical probability can safely exclude the presence of DVT.

References
•  W ells PS. Integrated strategies for the diagnosis of venous thromboembolism.
J Thromb Haemost. 2007;5(Suppl 1):41-50.
•  Wells PS, Anderson DR, Bormanis J, et al. Value of assessment of pretest probability
of deep-vein thrombosis in clinical management. Lancet. 1997;350:1795-8.

9
Deep Vein Thrombosis and Pulmonary Embolism

Clinical probability models for Pulmonary Embolism

Indication
Clinically suspected Pulmonary Embolism (PE).

Wells’ score
Feature Score
Previous DVT or PE 1.5
Heart rate > 100 bpm 1.5
Surgery or bedridden < 4 weeks 1.5
Hemoptysis 1
Active malignancy 1
Clinical symptoms of DVT 3
Alternative diagnosis less likely than PE 3
Clinical probability
PE unlikely ≤4
PE likely >4

10
 Deep Vein Thrombosis and Pulmonary Embolism
Geneva scores

Points Points
Feature
(revised dichotomized score) (simplified score)

Previous DVT or PE 3 1
Heart rate:
75-94 bpm 3 1
≥ 95 bpm 5 2
Surgery or fracture < 1 month 2 1
Hemoptysis 2 1
Active malignancy 2 1
Unilateral lower limb pain 3 1
Pain on lower limb deep venous palpation
4 1
or unilateral oedema
Age > 65 1 1
Clinical probability
PE unlikely ≤5 ≤2
PE likely >5 >2

Interpretation
These models are very useful when incorporated into algorithms, to optimize
patient management in clinically suspected PE. Combined with a D-dimer
test result below a validated threshold and/or an objective imaging test, a low
clinical probability can safely rule out the presence of PE.

References
•  C eriani E, Combescure C, Le Gal G, et al. Clinical prediction rules for pulmonary
embolism: a systematic review and meta-analysis. J Thromb Haemost. 2010;8:957-70.
•  Klok FA, Mos IC, Nijkeuter M, et al. Simplification of the revised Geneva score
for assessing clinical probability of pulmonary embolism. Arch Intern Med.
2008;168:2131-6.
•  Le Gal G, Righini M, Roy PM, et al. Prediction of Pulmonary Embolism in the Emergency
Department: The Revised Geneva Score. Ann Intern Med. 2006;144:165-71.
•  Lucassen W, Geersing GJ, Erkens PM, et al. Clinical decision rules for excluding
pulmonary embolism: a meta-analysis. Ann Int Med. 2011;155:448-60.
•  Wells PS, Anderson DR, Rodger M, et al. Derivation of a simple clinical model to
categorize patients probability of pulmonary embolism: increasing the models utility
with the SimpliRED D-dimer. Thromb Haemost. 2000;83:416-20.

11
Deep Vein Thrombosis and Pulmonary Embolism

Diagnostic algorithm of deep vein Thrombosis

and Pulmonary Embolism

Indication
Clinically suspected deep vein thrombosis (DVT) or non-massive Pulmonary
Embolism (PE), to decide therapeutic approach.

Clinical probability

Unlikely Likely

D-dimer

Below cut-off Above cut-off

CUS or MDCTA

Negative Positive

No anticoagulant therapy Anticoagulant therapy

12
 Deep Vein Thrombosis and Pulmonary Embolism
Interpretation
Clinical decision rule with sequential diagnostic steps in clinically suspected
DVT or PE, based on the clinical probability, assessed by the diagnostic
scores (see corresponding chapters), DD (D-dimer measurement) and
imaging (CUS: compression ultrasonography in suspected DVT, MDCTA:
multidetector CT angiography in suspected PE). When using highly sensitive
DD assays, the cut-off is usually set at 500 ng/mL. Recently, the utility of the
DD step was shown to be greatly improved by using an age-adjusted cut-off,
defined as patient’s age times 10 in patients aged 50 years or more.

References
•  A dam SS, Key NS, Greenberg CS. D-dimer antigen: current concepts and future
prospects. Blood. 2009;113:2878-87.
•  Agnelli G, Becattini C. Acute pulmonary embolism. N Engl J Med. 2010;363: 
266-74.
•  Aguilar C, del Villar V. Combined D-dimer and clinical probability are useful for
exclusion of recurrent deep venous thrombosis. Am J Hematol. 2007;82:41-4.
•  Goldhaber SZ, Bounameaux H. Pulmonary embolism and deep vein thrombosis.
Lancet. 2012;379:1835-6.
•  Hogg K, Wells PS, Gandara E. The diagnosis of venous thromboembolism. Semin
Thromb Hemost. 2012;38:691-701.
•  Prisco D, Grifoni E. The role of D-dimer testing in patients with suspected venous
thromboembolism. Semin Thromb Hemost. 2009;35:50-9.
•  Righini M, van Es J, Den Exter PL, et al. Age-adjusted D-dimer cut-off levels to
rule out pulmonary embolism: a prospective outcome study: the ADJUST-PE study.
JAMA. 2014;111:1117-24.
•  Schutgens RE, Ackermark P, Hass FJ, et al. Combination of a normal D-dimer
concentration and non-high pretest probability score is a safe strategy to exclude
deep venous thrombosis. Circulation. 2003;107:593-7.
•  Wells PS, Anderson DR, Rodger M, et al. Evaluation of D-dimer in the diagnosis of
suspected deep-vein thrombosis. N Engl J Med. 2003;349:1227-35.

13
Deep Vein Thrombosis and Pulmonary Embolism

Prognostic scores in pulmonary embolism

Indication
Predictive scoring system for patients with pulmonary embolism (PE) using
PESI (the Pulmonary Embolism Severity Index) and Geneva score calculators.

PESI
Points
Features
Original version Simplified version
Age Years > 80 =1
Male +10
History of cancer +30 1
History of heart failure +10
History of chronic lung disease +10 } 1a
Pulse ≥ 110 bpm +20 1
Systolic BP < 100 mmHg +30 1
Respiratory rate ≥ 30/min +20
Temperature < 36 ºC +20
Altered mental status +60
Arterial oxygen saturation < 90% +20 1
Risk evaluation
Class I (very low) ≤ 65 points
Class II (low) 66-85 points
Class III (intermediate) 86-105 points Low: 0
High: ≥ 1
Class IV (high) 106-125 points
Class V (very high) > 125 points
a
Variables combined into a single category of chronic cardiopulmonary disease

Interpretation
The PESI score includes 11 clinical features and provides an estimation of the
risk of mortality at 30 days after hospitalization in patients with PE. A significant
proportion of low-risk patients (negative predictive value 99%) are identified as
potential candidates for ambulatory treatment. The simplified version includes

14
 Deep Vein Thrombosis and Pulmonary Embolism
6 features with a similar validity. The RIETE study shows that mortality was
1% amongst 36% of the classified low-risk patients, against 10.9% in high-risk
patients. The PESI has been used to identify patients that may be treated in an
outpatient setting.

Geneva prognostic score

Feature Points
History of cancer 2
History of heart failure 1
Previous DVT 1
DVT on ultrasound 1
PAS < 100 mmHg 2
PaO2 < 8 kPa 1

Clinical probability
Low risk ≤2
High risk ≥2

Interpretation
Predictive risk value of low-mortality-risk patients, recurrent VTE or increasing
bleeding at 3 months. Patients with ≤ 2 points are considered low-level risk
patients. This stratification might help identifying patients who could be treated
in an outpatient setting.

15
Deep Vein Thrombosis and Pulmonary Embolism

References
•  A ujesky D, Obrosky DS, Stone RA, et al. Derivation and validation of a prognostic
model for pulmonary embolism. Am J Respir Crit Care Med. 2005;172:1041-6.
•  Aujesky D, Roy PM, Verschuren F, et al. Outpatient versus inpatient treatment for
patients with acute pulmonary embolism: an international, open-label, randomised,
non-inferiority trial. Lancet. 2011;378:41-8.
•  Donzé J, Le Gal G, Fine MJ, et al. Prospective validation of the Pulmonary Embolism
Severity Index. A clinical prognostic model for pulmonary embolism. Thromb Haemost.
2008;100:943-8.
•  Jiménez D, Aujesky D, Moores L, et al. RIETE Investigators. Simplification of the
pulmonary embolism severity index for prognostication in patients with acute
symptomatic pulmonary embolism. Arch Intern Med. 2010;170:1383-9.
•  Wicki J, Perrier A, Perneger TV, et al. Predicting adverse outcome in patients with
acute pulmonary embolism: a risk score. Thromb Haemost. 2000;84:548-52.

16
 Deep Vein Thrombosis and Pulmonary Embolism
Prediction of recurrent deep vein Thrombosis
or Pulmonary Embolism

Indication
Assessment of risk of recurrence after a first DVT or PE. Presentation of two
methods: the Vienna nomogram and the DASH score.

Vienna Nomogram
Points
0 10 20 30 40 50 60 70 80 90 100

Male
Gender
Female

Proximal DVT
Location
Distal DVT PE

D-dimer
(ng/mL) 100 150 200 250 400 500 750 1.000 1.500 2.000

Total points
0 50 100 150 200 250 300 350

1 year cumulative
recurrence rate 0.02 0.04 0.06 0.08 0.1 0.12 0.15

5 year cumulative
recurrence rate 0.1 0.2 0.3 0.4 0.5

Interpretation
The nomogram aims at estimating the recurrence risk following DVT or PE.
Clinical (type of thrombosis and gender) and analytical (D-dimer measured at the
time of the suspension of anticoagulation) variables are taken into consideration.
In practice, a line has to be drawn perpendicular to the top row (called points)
that cuts the value of each of the three considered features (gender, location
and D-dimer). The sum of the three responses is born on a line called Total, from

17
Deep Vein Thrombosis and Pulmonary Embolism

which a perpendicular line is drawn to this value, which gives the cumulated risk
at one year and, by drawing another perpendicular line, the cumulative risk at
five years. For example: A man with a proximal DVT and a D-dimer of 400 μg/L
will score 60 points for gender, 70 for proximal thrombosis and 46 points for
D-dimer, totalizing 176 points, which corresponds to a probability of recurrence
of 5.1% and 18.5%, at one and five years, respectively.

DASH score
Feature Score
Abnormal D-dimer
+2
(measured one month after stopping anticoagulation)
Age ≤ 50 +1
Male +1
Hormonal therapy at onset of VTE (among women) –2
Probability
Low ≤1
High >1
DASH: D-dimer, Age, Sex, Hormones

Interpretation
This model classifies DVT or PE recurrence risk as low (annual incidence
around 3%) if the score is 0 or 1, or high (annual incidence around 9%) if it is
higher than 1. Of note, D-dimer measurement is performed after withdrawal of
anticoagulation (≅ 30 days).

References
•  E ichinger S, Heinze G, Jandeck LM, et al. Risk assessment of recurrence in
patients with unprovoked deep-vein thrombosis or pulmonary embolism: the
Vienna prediction model. Circulation. 2010;121:1630-6.
•  Tosetto A, Iorio A, Marcucci M, et al. Predicting disease recurrence in patients
with previous unprovoked venous thromboembolism: a proposed prediction score
(DASH). J Thromb Haemost. 2012;10:1019-25.

18
 Deep Vein Thrombosis and Pulmonary Embolism
Outpatient versus inpatient care in venous
thromboembolism

Indication
To identify patients with VTE that can safely be treated as outpatients.

Hestia criteria

yes
Is the patient hemodynamically unstable?*
no
yes
Is thrombolysis or embolectomy necessary?
no
yes
Active bleeding or high risk for bleeding?**
no
yes
More than 24 hours of oxygen supply to maintain oxygen saturation > 90%?
no
yes
Is pulmonary embolism diagnosed during anticoagulant treatment?
no
yes
Severe pain needing intravenous pain medication for more than 24 hours?
no
Medical or social reason for treatment in the hospital for more than 24 hours yes
(infection, malignancy, no support system, etc.)? no
yes
Does the patient have a creatinine clearance of less than 30 mL/min?***
no
yes
Does the patient have severe liver impairment?****
no
yes
Is the patient pregnant?
no
Does the patient have a documented history of heparin-induced yes
thrombocytopenia (HIT)? no
* Systolic arterial pressure (SAP) < 100 mmHg; pulse > 100 bpm; Intensive Care Unit admission required
** Gastrointestinal bleeding in the previous 14 days, recent ictus (< 4 weeks), recent surgery (> 2 weeks),
bleeding diathesis or thrombocytopenia (< 75.000/mm3), uncontrolled hypertension (SAP > 180 or
diastolic arterial pressure [DAP] > 110 mmHg)
*** Calculated applying Cockcroft-Gault formula
**** As per medical assessment

19
Deep Vein Thrombosis and Pulmonary Embolism

Interpretation
Answering yes to any of the questions means that the patient should probably
be hospitalized for treatment. Of note, the PESI and the Geneva Prognostic
Score (see corresponding chapters) that stratify patients in low and high
risk of mortality or adverse outcome, respectively, have also been used for
that purpose.

References
•  Z ondag W, Hiddinga BI, Crobach MJ, et al.; Hestia Study Investigators. Hestia criteria
can discriminate high from low risk patients with pulmonary embolism. Eur Respir J.
2013;41:588-92.
•  Zondag W, Mos IC, Creemers-Schild D, et al.; Hestia Study Investigators. Outpatient
treatment in patients with acute pulmonary embolism: the Hestia Study. J Thromb
Haemost. 2011;9:1500-7.

20
 Deep Vein Thrombosis and Pulmonary Embolism
Assessment of post-thrombotic syndrome

Indication
Score of post-thrombotic syndrome (PTS) severity

Villalta score
None Light Moderate Severe
Symptoms
• Pain 0 1 2 3
• Cramps 0 1 2 3
• Heaviness 0 1 2 3
• Paresthesia 0 1 2 3
• Itching 0 1 2 3
Signs
• Pretibial oedema 0 1 2 3
• Skin induration 0 1 2 3
• Hyperpigmentation 0 1 2 3
• Redness 0 1 2 3
• Venous ectasia 0 1 2 3
• Calf pain 0 1 2 3
on pressure
Venous ulcer Absence Presence

Interpretation
The diagnosis of PTS is established when total score (ranking 0-33) is ≥ 5.
Patients with venous ulcer are scored with 15. PTS is stratified in three levels:
• Light: 5-9
• Moderate: 10-14
• Severe ≥ 15

References
•  K ahn SR, Partsch H, Vedantham S, et al.; Subcommittee on Control of Anticoagulation
of the Scientific and Standardization Committee of the International Society on
Thrombosis and Haemostasis. Definition of post-thrombotic syndrome of the leg
for use in clinical investigations: a recommendation for standardization. J Thromb
Haemost. 2009;7:879-83.
•  Prandoni P, Villalta S, Polistena P, et al. Symptomatic deep-vein thrombosis and the
post-thrombotic syndrome. Haematologica. 1995;80(Suppl 2):42-8.
•  Villalta S, Bagatella P, Piccioli A, et al. Assessment of validity and reproducibility of a
clinical scale for the post-thrombotic syndrome. Haemostasis. 1994;24(suppl 1):158a.

21
Pregnancy

Diagnostic algorithm in suspected deep vein

thrombosis during pregnancy

Indication
Clinically suspected DVT during pregnancy.

Clinically suspected DVT

Serial compression ultrasound

DVT no confirmed DVT confirmed

Clinically suspected iliac DVT* Start treatment

No Yes

Serial compression
ultrasound after 1 week Duplex Doppler

Normal Abnormal Flow absent Flow present

DVT excluded DVT confirmed Consider magnetic

resonance image

Start treatment

* The clinical suspicion of iliac vein thrombosis is based on pain located at the back of the thigh or
buttocks and swelling in the upper part of the lower extremity.

Interpretation
Clinical decision rule using sequential steps in clinically suspected DVT in
a pregnant woman. D-dimer measurement is usually skipped due to lack of
specificity in this condition, though a value below the threshold allows ruling out
the condition.

22
 Pregnancy
Diagnostic algorithm in suspected pulmonary
embolism during pregnancy

Indication
Clinically suspected PE during pregnancy.

Clinically suspected PE

Symptomatic DVT

No Yes

Serial compression
ultrasound

DVT no DVT confirmed

confirmed

Start treatment

Ventilation/ Computed tomography

perfusion scan

Normal High Non- PE PE Non-

probability diagnostic excluded confirmed diagnostic

PE PE Computed Start treatment Ventilation/

excluded confirmed tomography perfusion scan

Start treatment

23
Pregnancy

Interpretation
Clinical decision rule using sequential steps in clinically suspected PE in a
pregnant woman. Again, D-dimer measurement is usually skipped during
pregnancy, though a value below the threshold allows ruling out the condition.
In case of detecting a symptomatic DVT, anticoagulation therapy should be
started without additional imaging tests.

References
•  C han WS, Ginsberg JS. Diagnosis of deep-vein thrombosis and pulmonary
embolism in pregnancy. Thromb Res. 2002;107:85-91.
•  Le Gal G, Kercret G, Ben Yahmed K, et al. Diagnostic value of single complete
compression ultrasonography in pregnant and postpartum women with suspected
deep vein thrombosis: prospective study. BMJ. 2012;344:e2635.
•  Tan M, Huisman MV. The diagnostic management of acute venous
thromboembolism during pregnancy: recent advancements and unresolved
issues. Thromb Res. 2011;127:S13-6.

24
 Atrial Fibrillation
Prediction of stroke risk in patients
with atrial fibrillation

Indication
Atrial fibrillation (AF) is the most common arrhythmia in the population, and is a
major cause of stroke and systemic thromboembolism. Whilst the risk of stroke
in AF is increased 5-fold, stroke risk in AF is not homogeneous.

The CHADS2 and CHA2DS2-VASc stroke risk score calculators have been
used to aid risk stratifying of patients, and to help decision making for
thromboprophylaxis. The CHA2DS2-VASc score is now recommended by
many international guidelines, including those from the ESC, AHA/ACC/HRS,
APHRS, SIGN and NICE guidelines.

CHADS2 risk score

Risk factor Score
Congestive heart failure 1
Hypertension 1
Age ≥ 75 years 1
Diabetes mellitus 1
Prior Stroke or TIA or Thromboembolism 2

Interpretation
Low risk = 0
Moderate risk = 1
High risk ≥ 2

The CHADS2 score has been replaced by the CHA2DS2-VASc score in the
latest guidelines from the ESC, AHA/ACC/HRS, NICE, etc. Older guidelines
(e.g. the 2006 ACC/AHA/ESC guidelines) recommended the following:

CHADS2 score Antithrombotic therapy recommendation

>1 OAC (vitamin K antagonist or dabigatran)
1 OAC or ASA 75-325 mg/day
0 ASA
OAC: oral anticoagulant; NOAC: Non-VKA Oral AntiCoagulants (previously called New or novel OACs);
ASA: Acetylsalicylic Acid

25
Atrial Fibrillation

CHA2DS2-VASc risk score

Risk factor Score
Congestive heart failure 1
Hypertension 1
Age ≥ 75 years 2
Diabetes 1
Prior Stroke or TIA or Thromboembolism 2
Vascular disease 1
(peripheral artery disease, myocardial infarction, aortic plaque)
Age between 65 and 74 years 1
Sex category (i.e. female gender) 1
Maximum score 9

Interpretation
Low risk = 0 (males) or 1 (females)
Moderate risk = 1 (males)
High risk ≥ 2

The ESC guidelines de-emphasises the ‘traditional’ (but artificial) low,

moderate and high risk stratification and recommends a risk factor-based
approach using the ‘CHA2DS2-VASc’ score.

The initial focus is now on identification of ‘truly low-risk’ patients with AF,
that is, those ‘age < 65 and lone AF (irrespective of gender)’ – which is
essentially a CHA2DS2-VASc score = 0 (males) or 1 (females). Such ‘low
risk’ patients do not need any antithrombotic therapy.

After this initial decision step, patients with AF and ≥ 1 stroke risk factors can
be offered effective stroke prevention, which is oral anticoagulation (OAC).
The latter can be delivered either as well controlled VKA (as reflected by
average Time in Therapeutic Range [TTR] ≥ 70%) or one of the NOACs.

26
 Atrial Fibrillation
References
•  C amm AJ, Lip GY, De Caterina R, et al. 2012 focused update of the ESC Guidelines
for the management of atrial fibrillation: An update of the 2010 ESC Guidelines for
the management of atrial fibrillation. Eur Heart J. 2012;33:2719-47.
•  De Caterina R, Husted S, Wallentin L, et al. Vitamin K antagonists in heart
disease: Current status and perspectives (section III). Position paper of the esc
working group on thrombosis - task force on anticoagulants in heart disease.
Thromb Haemost. 2013;110:1087-107.
•  Lip GY. Stroke and bleeding risk assessment in atrial fibrillation: When, how, and
why? Eur Heart J. 2013;34:1041-9.
•  Lip GY, Nieuwlaat R, Pisters R, et al. Refining clinical risk stratification for predicting
stroke and thromboembolism in atrial fibrillation using a novel risk factor-based
approach: the euro heart survey on atrial fibrillation. Chest. 2010;137:263-72.
•  Pisters R, Lane DA, Marin F, et al. Stroke and thromboembolism in atrial fibrillation.
Circ J. 2012;76:2289-304.

27
Atrial Fibrillation

Bleeding risk in anticoagulated patients

with atrial fibrillation

Indication
Major complication in anticoagulated patients is bleeding, intracranial
haemorrhage being the most severe manifestation (0.8-1%/patients/year).

In the ESC guidelines, bleeding risk assessment is also recommended using

the HAS-BLED score. The HAS-BLED score is validated for VKA and non-VKA
anticoagulants, and is the only bleeding risk score predictive for intracranial
haemorrhage. Other studies have validated HAS-BLED in atrial fibrillation (AF)
and non-AF patients, those undergoing bridging therapy, and in bleeding related
to PCI/stenting.

HAS-BLED score
HAS-BLED Score
Hypertension i.e. uncontrolled Blood Pressure 1
Abnormal renal/liver function 1 or 2
Stroke 1
Bleeding tendency or predisposition 1
Labile INR 1
Elderly (e.g., > 65, frail condition) 1
Drugs (e.g. concomitant aspirin or NSAIDs) or alcohol excess or abuse 1
9

Interpretation
A high HAS-BLED score (≥ 3) should not be used as a reason for withholding
OAC but is indicative of the need for regular review and follow-up. A high
HAS-BLED score also makes us consider the potentially reversible risk
factors for bleeding, for example, the H in HAS-BLED stands for uncontrolled
blood pressure (so to reduce risk, BP should be controlled), the L stands for
labile INRs, and D for concomitant use of aspirin/NSAIDs in anticoagulated
patients, etc. Those patients with a high HAS-BLED score derive a higher net
clinical benefit when balancing ischaemic stroke and intracranial bleeding.

28
 Atrial Fibrillation
References
•  F riberg L, Rosenqvist M, Lip G. Net clinical benefit of warfarin in patients with
atrial fibrillation: A report from the Swedish atrial fibrillation cohort study.
Circulation. 2012;125:2298-307.
•  Lip GY, Andreotti F, Fauchier L, et al.; European Heart Rhythm Association.
Bleeding risk assessment and management in atrial fibrillation patients. Executive
Summary of a Position Document from the European Heart Rhythm Association
[EHRA], endorsed by the European Society of Cardiology [ESC] Working Group on
Thrombosis. Thromb Haemost. 2011;106:997-1011.
•  Pisters R, Lane DA, Nieuwlaat R, et al. A novel user-friendly score (has-bled) to
assess 1-year risk of major bleeding in patients with atrial fibrillation: The Euro
Heart Survey. Chest. 2010;138:1093-100.

29
Atrial Fibrillation

Predicting the likelihood of achieving good

anticoagulation control in a newly diagnosed
non-anticoagulated patient with atrial fibrillation

Indication
A clinical management dilemma is how to predict those newly diagnosed
non-anticoagulated AF patients who are likely to do well on warfarin with
high TTR, especially since costs of NOACs are high, and since the relative
benefits of NOACs over the VKAs may be small in those who achieve
good-quality anticoagulation control, with high TTRs (> 70%).

An ESC Working Group on Thrombosis Anticoagulation Task Force Position

paper recommends that the use of the new SAMe-TT2R2 score should be
considered to aid decision making when assessing such patients. This is a
user-friendly validated score based on simple clinical variables.

Definition of the SAMe-TT2R2 score

Acronym Definitions Score
S Sex (female) 1
A Age (less than 60 years) 1
Me Medical history* 1
Treatment 1
T (interacting Rx e.g., amiodarone for rhythm control)
T Tobacco use (within 2 years) 2
R Race (non-Caucasian) 2
Maximum points 8

Definition of the SAMe-TT2R2 score

* 2 of the following: hypertension, diabetes melitus, coronary artery disease /
myocardial infraction, PAD, coronary heart failure, previous stroke, pulmonary
disease, hepatic or renal disease.

30
 Atrial Fibrillation
Interpretation
This score identifies those Atrial Fibrillation patients likely to do well on warfarin
(SAMe-TT2R2 score 0-1) or those more likely to have poor anticoagulation
control (SAMe-TT2R2 score > 2).

If the SAMe-TT2R2 score is > 2, such patients could be better off being started
on NOACs as initial therapy, or having more aggressive efforts to improve
anticoagulation control.

References
•  A
 postolakis S, Sullivan RM, Olshansky B, et al. Factors affecting quality of
anticoagulation control among patients with atrial fibrillation on warfarin: The
SAME-TT2R2 score. Chest. 2013;144:1555-63.
•  Boriani G. Predicting the quality of anticoagulation during warfarin therapy: the
basis for an individualized approach. Chest. 2013;144:1437-8.
•  De Caterina R, Husted S, Wallentin L, et al. Vitamin K antagonists in heart
disease: Current status and perspectives (section III). Position paper of the ESC
working group on thrombosis - task force on anticoagulants in heart disease.
Thromb Haemost. 2013;110:1087-107.
•  Lip GY, Haguenoer K, Saint-Etienne C, Fauchier L. Relationship of the SAME-
TT2R2 score to poor quality anticoagulation, stroke, clinically relevant bleeding
and mortality in patients with atrial fibrillation. Chest. 2014 Apr 10. doi: 10.1378/
chest.13-2976. [Epub ahead of print].

31
Other thrombotic conditions

Risk of venous thromboembolism in cancer Patients

Indication
Assessing the risk of DVT or PE in outpatients with cancer on chemotherapy
(Khorana model), the prediction of recurrence (Ay and Ottawa models) and
the risk of DVT in patients with multiple myeloma treated with thalidomide or
lenalidomide.

Khorana model: for outpatients with cancer on chemotherapy

Feature Points
Site of cancer (origin)
• High risk (pancreas, stomach) 2
• Low risk (lung, lymphoma, gynaecologic, bladder, testicular) 1
Platelet count ≥ 350 × 109/L 1
Haemoglobin level < 100 g/L or use of red cell growth factor 1
Leukocyte count > 11 × 109/L 1
BMI ≥ 35 kg/m2 1
Probability
• Low risk 0
• Intermediate risk 1-2
• High risk >3

Interpretation
The risk of thrombosis was 0.3-0.8% for low-risk patients; 1.8-2.0% for
intermediate-risk patients and 6.7-7.1% for high-risk patients; in the latter
thromboprophylaxis should be considered.

32
 Other thrombotic conditions
Vienna score (Ay Model): DVT or PE risk scoring
Feature Points
Khorana Model scoring (0 to 6)
D-dimer ≥ 1.44 μg/mL 1
P-selectin ≥ 53.1 mg/mL 1
Probability
Low risk 0
Intermediate risk 1-2
High risk ≥3

Interpretation
The risk of DVT or PE at 6 months was 17.7% in high-risk patients, 9.6% in
intermediate-risk patients and 3.8% in low-risk patients.

Ottawa score
Recurrence risk in patients with thrombosis associated with neoplasia
Feature Points
Female 1
Lung Cancer 1
Breast Cancer –1
Status (TNM*) –2
Previous DVT or PE 1
Probability
Low risk ≤0
High risk ≥1
* TNM: Tumor-Node-Metastasis level

Interpretation
The DVT or PE recurrence risk was ≤ 4.5% for low-risk patients and ≥ 19% for
high-risk patients.

33
Other thrombotic conditions

DVT risk scoring in patients with myeloma treated

with thalidomide or lenalidomide
DVT risk Category Prophylaxis
factors
Individual and •  BMI ≥ 30 kg/m2 ≤ 1 risk factor:
myeloma-related •  Previous DVT or PTE • Aspirin
factors • Central venous catheter or pacemaker (80-300 mg/d)
• Concomitant disease (cardiac, chronic
renal, diabetes, acute infection, ≥ 2 factors:
immobilization) • LMWH (equivalent
•  Medications (EPO) to enoxaparin
•  Clotting disorders 40 mg/d) or
•  Hyperviscosity •  VKA (INR = 2-3)
Myeloma High dose of dexamethasone, HBPM (e.g., enoxaparin
therapy doxorubicin, polychemotherapy 40 mg/d) or VKA
(INR = 2-3)
BMI: Body Mass Index; EPO: Erythropoietin; LMWH: Low-Molecular-Weight Heparin; INR: International
Normalized Ratio; VKA: Vitamin K antagnonists

Interpretation
The risk of thrombosis is high in patients with multiple myeloma, especially in those
receiving thalidomide or lenalidomide combined with dexamethasone. In these
patients antithrombotic prophylaxis should be considered, according to the risk.

References
•  A
 y C, Dunkler D, Marosi C, et al. Prediction of venous thromboembolism in cancer
patients. Blood. 2010;116:5377-82.
•  F arge D, Debourdeau P, Beckers M, et al. International clinical practice guidelines for
the treatment and prophylaxis of venous thromboembolism in patients with cancer.
J Thromb Haemost. 2013;11:56-70.
•  Khorana AA, Kuderer NM, Culakova E, et al. Development and validation of a predictive
model for chemotherapy-associated thrombosis. Blood. 2008;111:4902-7.
•  Louzada ML, Carrier M, Lazo-Langner A, et al. Development of a clinical prediction rule
for risk stratification of recurrent venous thromboembolism in patients with cancer:
Associated Venous Thromboembolism. Circulation. 2012;126:448-54.
•  P alumbo A, Rajkumar SV, Dimopoulos MA, et al.; International Myeloma Working
Group. Prevention of thalidomide- and lenalidomide-associated thrombosis in
myeloma. Leukemia. 2008;22:414-23.

34
 Other thrombotic conditions
Risk assessment models
in hospitalized Medical Patients

Indication
Risk Assessment Model (RAM) for DVT or PE in patients hospitalized for
medical conditions.

Padua prediction score

Feature Points
Active cancer* 3
Previous DVT or PE (excluding superficial vein thrombosis) 3
Reduced mobility** 3
Already-known thrombophilic condition*** 3
Recent (≤ 1 month) trauma and/or surgery 2
Age ≥ 70 years 1
Heart and/or respiratory failure 1
Acute myocardial infarction or ischemic stroke 1
Acute infection and/or rheumatologic disorder 1
Obesity (BMI ≥ 30 kg/m2) 1
Ongoing hormonal treatment**** 1
Probability
High >4
* Patients with local or distant metastases and/or in whom chemotherapy or radiotherapy have been
given in the previous 6 months
** Bed rest for at least 3 days
*** Carrier status for antithrombin or protein C or S defects, factor V Leiden, prothrombin gene
mutation, antiphospholipid syndrome
**** Hormone replacement therapy or oral contraceptives

Interpretation
Among patients who did not receive prophylaxis, VTE occurred in 11% of the
high-risk group against 0.3% in the low-risk group. The prevalence of DVT and
PE were 6.7% and 3.9% respectively in the high-risk group.

35
Other thrombotic conditions

References
•  B arbar S, Noventa F, Rossetto V, et al. A risk assessment model for the identification
of hospitalized medical patients at risk for venous thromboembolism: the Padua
Prediction Score. J Thromb Haemost. 2010;8:2450-7.
•  Kahn SR, Lim W, Dunn AS, et al.; American College of Chest Physicians.
Prevention of VTE in non surgical patients: Antithrombotic Therapy and Prevention
of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based
Clinical Practice Guidelines. Chest. 2012;141(Suppl 2):e195S-226.

Geneva prediction score

Feature Points
Cardiac failure 2
Respiratory failure 2
Recent stroke 2
Recent myocardial infarction 2
Acute infectious disease 2
Acute rheumatic disease 2
Malignancy 2
Myeloproliferative syndrome 2
Nephrotic syndrome 2
History of VTE 2
Known hypercoagulability state 2
Immobilisation 1
Travel > 6hs 1
Age > 60 1
Obesity (BMI > 30) 1
Chronic venous insufficiency 1
Pregnancy 1
Hormonal therapy 1
Dehydration 1

Interpretation
Indication for thromboprophylaxis if the score is ≥ 3.

36
 Other thrombotic conditions
References
•  C hopard P, Spirk D, Bounameaux H. Identifying acutely ill medical patients
requiring thromboprophylaxis. J Thromb Haemost. 2006;4:915-6.
•  Nendaz M, Spirk D, Kucher N, et al. Multicenter validation of the Geneva risk
score for hospitalized medical patients at risk of venous thromboembolism.
Explicit ASsessment of Thromboembolic risk and prophylaxis for Medical Patients
in Switzerland (ESTIMATE). Thromb Haemost. 2014;111:531-8.

37
Other thrombotic conditions

Diagnosis of the antiphospholipid syndrome

Indication
According to the 2006 Sydney criteria, both clinical and biological features
should be associated in the diagnosis of the antiphospholipid antibody syndrome
(APS).

Diagnostic criteria for APS

Clinical featuresa
One or more episodes of venous
or arterial thrombosis
• Presence of small-vein thrombosis
in any organ system
• Confirmed by imaging tests
(such as ultrasound or Doppler)
• Histopathology confirmation: to exclude
in case of inflammation
• Superficial venous thrombosis excluded
Pregnancy-related complications
• One or more unexplained deaths of a
morphologically normal foetus at or after
10 weeks of gestation, evidenced by
ultrasound or direct examination of the
foetus
• One or more premature births of
morphologically normal neonate(s) at or
before 34 weeks gestation associated
with severe preeclampsia or eclampsia or
severe placenta insufficiency
• Three or more unexplained consecutive
miscarriages at or before 10 weeks
gestation, with anatomic, genetic and
hormonal causes excluded
a
APS diagnosis criteria: both clinical and laboratory criteria are required
b
Biological tests should be confirmed at two occasions separated at least by 12 weeks
Haemostasis laboratory criteriab
1) Lupus anticoagulant:
• Prolonged result of a phospholipid-
dependent clotting assay (e.g., aPTT,
dRVVT)
• Mixing study: evidence of the LA
inhibitory effect
• Evidence of phospholipid
dependency: Correction by adding
phospholipids into coagulation assay
(exclusion of specific inhibitors against a
coagulation factor)
2) Anticardiolipin antibodies:
• Normalised ELISA system
• Titre > 40 UGPL/UMPL or > 99th
percentile. IgG and IgM antibodies
3) Anti-β2 glycoprotein I antibodies:
• Normalised ELISA system
• Titre > 99th percentile. IgG and IgM
antibodies

38
 Other thrombotic conditions
Recommendations for the determination of Lupus Anticoagulant

1) Preanalytical
• Sodium citrate tube containing 0.109 mol/L citrate, proportion 9 blood to 1 citrate
(vol/vol)
• Double-spinning centrifuge. Freeze promptly < –70 ºC
• Fast defrosting in a water bath at 37 ºC and mix gently by repeated inversion before
using
• DO NOT work with filtrated plasma

2) Process: Detection, Mixture, Confirmation

• Detection tests
– Two tests based on different principles: dRVVT and aPTT
– Contact activation system. Recommended activator: Silicium-based;
NOT Recommended: Kaolin or Ellagic acid
– Set up a cut off value by 99th percentile. Avoid average ± 2 SD
• Mixing study
– Use a 1:1 proportion between the patient plasma and the normal plasma (pool
or commercially certified plasma). NO pre-incubation of sample and activator. If
using pool plasma, make sure that the platelet count is lower than 10,000/μL.
Cut off value by 99th percentile or Rosner Index
• Confirmation tests: Addition of phospholipids
– In dRVVT: generics. In Staclot-LA: hexagonal structure

References
•  D evreese K, Hoylaerts MF. Laboratory diagnosis of the antiphospholipid syndrome:
a plethora of obstacles to overcome. Eur J Haematol. 2009;83:1-16.
•  Miyakis S, Lockshin MD, Atsumi T, et al. International consensus statement on an
update of the classification criteria for definite antiphospholipid syndrome (APS).
J Thromb Haemost. 2006;4:295-306.
•  Pengo V, Tripodi A, Reber G, et al.; Subcommittee on Lupus Anticoagulant/
Antiphospholipid Antibody of the Scientific and Standardisation Committee of the
International Society on Thrombosis and Haemostasis.Update of the guidelines
for lupus anticoagulant detection. Subcommittee on Lupus Anticoagulant/
Antiphospholipid Antibody of the Scientific and Standardisation Committee of
the International Society on Thrombosis and Haemostasis. J Thromb Haemost.
2009;7:1737-40.

39
Other thrombotic conditions

Diagnosis of Disseminated Intravascular Coagulation

Indication
Disseminated intravascular coagulation (DIC) is a clinical syndrome
characterized by the intravascular activation of coagulation, of diverse etiology,
involving fibrin generation in the microcirculation and organ failure.

Scoring system of the International Society of Thrombosis and

Haemostasis (ISTH)

1) Clinical risk assessment

Does the patient have a disease known
to be associated with DIC? (see table on p. 42)

Continue the algorithm only

if the answer is yes

2) Perform a global coagulation evaluation

Score global coagulation test results

• platelet count (> 100 × 109/L = 0; < 100 × 109/L = 1; < 50 × 109/L = 2)
• elevated fibrin-related marker (e.g., fibrin degradation products or D-dimer)
(no increase: 0; moderate increase: 2; strong increase: 3)
• prolonged prothrombin time
(< 3 sec. = 0; > 3 but < 6 sec. = 1; > 6 sec. = 2)*
• fibrinogen level (> 1.0 g/L = 0; < 1.0 g/L = 1)

Calculate score
The scoring system can only be used if an underlying disorder, known to be
associated with DIC, has been diagnosed. The cut-off values for the fibrin-related
marker are dependent on the test used. A moderate increase was defined as
above the upper limit of normal and a strong increase as above 5 times the
upper limit of normal. A total score of ≥ 5 is compatible with DIC.

40
 Other thrombotic conditions
Template for scoring system for non-overt DIC

1. Risk assessment: Does the patient have an underlying disorder known to be

associated with DIC (see table on page 42)?
yes = 2, no = 0 score

2. Major criteria
platelet > 100 × 109/L = 0 < 100 × 109/L = 1 rising = –1 stable = 0 falling = 1
count +

PT < 3 sec = 0 > 3 sec = 1 falling = –1 stable = 0 rising = 1

prolongation* +

soluble fibrin normal raised falling = –1 stable = 0 rising = 1

or FDP’s +

3. Specific criteria
antithrombin normal = –1 low = 1

protein C normal = –1 low = 1

4. Calculate score

A score of 5 or higher is compatibe with non-overt DIC.

The score should be repeated daily.

41
Other thrombotic conditions

Table of diseases known to be associated with DIC

• sepsis/severe infection (any micro-organism)

• trauma (e.g., polytrauma, neurotrauma, fat embolism)
• organ destruction (e.g., severe pancreatitis)
• malignancy
– solid tumors
– myeloproliferative/lymphoproliferative malignancies
• obstetrical calamities
– amniotic fluid embolism
– abruptio placentae
• vascular abnormalities
– Kasabach-Merrit syndrome
– large vascular aneurysms
• severe hepatic failure
• severe toxic or immunologic reactions
– snake bites
– recreational drugs
– transfusion reactions
– transplant rejection

References
• Levi M. Disseminated intravascular coagulation. Crit Care Med. 2007;35:2191-5.
• Páramo JA. Coagulación intravascular diseminada. Med Clin (Barc). 2006;127:785-9.
• Taylor FB Jr, Toh CH, Hoots WK, et al.; Scientific Subcommittee on Disseminated
Intravascular Coagulation (DIC) of the International Society on Thrombosis and
Haemostasis (ISTH). Towards definition, clinical and laboratory criteria, and a
scoring system for disseminated intravascular coagulation. Thromb Haemost.
2001;86:1327-30.
• Toh CH, Downey C. Performance and prognostic importance of a new clinical and
laboratory scoring system for identifying non-overt disseminated intravascular
coagulation. Blood Coagul Fibrinolysis. 2005;16:69-74.

42
 Other thrombotic conditions
Diagnosis of Thrombotic Thrombocytopenic Purpura (TTP)

Indication
TTP is an acute, rare life-threatening thrombotic microangiopathy that requires
rapid diagnosis and treatment.

Diagnostic features of thrombotic microangiopathies

1.  Thrombocytopenia
2.  Hemolytic anemia
3.  Renal insufficiency
4.  Cerebral symptoms
5.  Fever

ADAMTS13-related parameters in TMAs

Congenital TTP Acquired TTP Other TMAs

Antigen Very low or absent Low or variable Normal or moderately decreased
Activity ≤ 5% ≤ 5% or variable 30-100%
Inhibitor No Mostly yes No

Interpretation
TTP results from a deficiency of ADAMTS-13, a serine metalloproteinase
required for the cleavage of von Willebrand factor.

Reference
•  Shenkman B, Einav Y. Thrombotic thrombocytopenic purpura and other thrombotic
microangiopathic hemolytic anemias: Diagnosis and classification. Autoimmun
Rev. 2014;13:584-6.

43
Other thrombotic conditions

Acute Intestinal Ischemia / Thrombosis

Management of suspected mesenteric ischemia

Suspected mesenteric ischemia (arterial)

Peritonitis No peritonitis

Laparotomy CT/CT angiography

Remaining Remaining Central Peripheral Suspected

intestine intestine NOMI
too short sufficient

No resection Resection Interventional Surgery Interventional Interventional

radiology radiology radiology

Catheter Embolectomy Lysis, Vasodilation

embolectomy vasodilation (also
and lysis, postsurgery
possibly stent following
recection)

44
 Other thrombotic conditions
Management of patients
with occlusion of the superior mesenteric artery

CT-verified acute SMA occlusion

No peritonitis Peritonitis

Embolus Thrombosis Exploratory

laparotomy

Stenting

Embolus Thrombosis
No contraindication Contraindication
to thrombolysis to thrombolysis
Open Stenting +
embolectomy + damage
Aspiration ± Aspiration ± Open completion control surgery
pharmacological endovascular embolectomy + angiography +
thrombolysis ± mechanical completion damage
endovascular embolectomy angiography control surgery
mechanical
embolectomy

References
• Acosta S, Björck M. Modern treatment of acute mesenteric ischaemia. Br J Surg.
2014;101:e100-8.
• Sise MJ. Acute mesenteric ischemia. Surg Clin North Am. 2014;94:165-81.

45
Bleeding

ISTH bleeding assessment tool for the evaluation

of bleeding severity

Indication
Quantitative assessment of the severity of bleeding symptoms in patients referred
for the evaluation of a suspected congenital bleeding disorder. Correlation of
clinical symptoms with biological parameters for research purposes.

The Bleeding Assessment Tool (BAT) is formed by two components:

1. Bleeding questionnaire: a detailed bleeding questionnaire has been

endorsed by the International Society of Haemostasis and Thrombosis as the
result of experts’ consensus. The bleeding questionnaire allows to accurately
record the worst-ever presentation for each bleeding symptom. The bleeding
questionnaire is available at:
http://www.isth.org/resource/resmgr/ssc/isth-ssc_bleeding_assessment.pdf
A Web-based version of the questionnaire (ISTH-BATR) has been developed
together by ISTH and the Rockefeller University, and it is accessible at:
https://bh.rockefeller.edu/bat/
Users willing to keep their patients’ information stored in the ISTH-BATR are
strongly encouraged to join the ISTH-BATR initiative, which is provided as a
freely available service for the scientific community.
Please visit http://www.isth.org/members/group.aspx?id=100549 or
https://bh.rockefeller.edu/ISTH-BATR/ for full information on how to join the
initiative.

2. Bleeding score: The severity of symptoms collected with the bleeding

questionnaire is scored and all obtained values are summed together. The final
result is the Bleeding Score, an index of the overall severity of the bleeding
phenotype.

46
 Bleeding Assessment Tool
Symptoms Score
(up to the time of diagnosis)
0 1 2 3 4
Epistaxis No / trivial • > 5/year or Consultation only Packing or cauterization Blood transfusion or replacement therapy
• more than or antifibrinolytic (use of hemostatic blood components
10 minutes and rFVIIa) or desmopressin
Cutaneous No / trivial For bruises 5 Consultation only Extensive Spontaneous hematoma requiring blood
or more (> 1 cm) transfusion
in exposed areas
Bleeding from minor No / trivial • > 5/year or Consultation only Surgical haemostasis Blood transfusion, replacement therapy,
wounds • more than or desmopressin
10 minutes
Oral cavity No / trivial Present Consultation only Surgical haemostasis Blood transfusion, replacement therapy
or antifibrinolytic or desmopressin
Gastrointestinal No / trivial Present Consultation only Surgical haemostasis, Blood transfusion, replacement therapy

47
bleeding (not associated antifibrinolytic or desmopressin
with ulcer, portal
hypertension,
hemorrhoids,
angiodysplasia)
Hematuria No / trivial Present Consultation only Surgical haemostasis, Blood transfusion, replacement therapy
(macroscopic) iron therapy or desmopressin
Tooth extraction No / trivial Reported in ≤ 25% Reported in > 25% Resuturing or packing Blood transfusion, replacement therapy
or none of all procedures, of all procedures, or desmopressin
done no intervention no intervention
Surgery No / trivial Reported in ≤ 25% Reported in > 25% Surgical haemostasis Blood transfusion, replacement therapy
or none of all procedures, of all procedures, or antifibrinolytic or desmopressin
done no intervention no intervention

Bleeding
 Bleeding

Bleeding Assessment Tool (cont.)

Symptoms Score
(up to the time of diagnosis)
0 1 2 3 4
Menorrhagia No / trivial Consultation • Time off work/school > • Requiring combined • Acute menorrhagia requiring hospital
only or 2/year or treatment with admission and emergency treatment or
• Changing pads •R  equiring antifibrinolytics and requiring blood transfusion, replacement
more frequently antifibrinolytics or hormonal therapy or therapy, desmopressin, or
than every 2 hormonal or iron • Present since • Requiring dilatation & curretage or
hours or therapy menarche and > 12 endometrial ablation or hysterectomy
•C  lot and flooding months
or
•P  BAC score >
100
Post-partum No / trivial Consultation • Iron therapy or Requiring blood Any procedure requiring critical care

48
hemorrhage or no only or •A ntifibrinolytics transfusion, replacement or surgical intervention
deliveries •U  se of syntocin or therapy, desmopressin (e.g., hysterectomy, internal iliac artery legation,
• L ochia > 6 weeks or requiring examination uterine artery embolization, uterine brace sutures)
under anaesthesia and/or
the use of uterin balloon/
package to tamponade
the uterus
Muscle hematomas Never Post trauma, Spontaneous, Spontaneous or Spontaneous or traumatic, requiring surgical
no therapy no therapy traumatic, requiring intervention or blood transfusion
desmopressin
or replacement therapy
Hemarthrosis Never Post trauma, Spontaneous, Spontaneous or Spontaneous or traumatic, requiring surgical
no therapy no therapy traumatic, requiring intervention or blood transfusion
desmopressin
or replacement therapy
CNS bleeding Never Subdural, any intervention Intracerebral, any intervention
Other bleedings No / trivial Present Consultation only Surgical haemostasis, Blood transfusion or replacement therapy
antifibrinolytics or desmopressin
 Bleeding
Interpretation
A bleeding score > 3 is considered suggestive for the presence of a bleeding
disorder, warranting a detailed laboratory investigation, whereas a bleeding
score ≤ 3 has negative predictive value of 99.2% in excluding a congenital
bleeding disorder. In a multicentre study using a very similar quantitation of
bleeding symptoms, a bleeding score > 3 in males or > 5 in females showed
a sensitivity and specificity for the diagnosis of von Willebrand’s disease of
64.2% and 99.1%, respectively.

References
•  R odeghiero F, Castaman G, Tosetto A, et al. The discriminant power of bleeding
history for the diagnosis of type 1 von Willebrand disease: an international,
multicenter study. J Thromb Haemost. 2005;3:2619-26.
•  Rodeghiero F, Tosetto A, Abshire T, et al. ISTH/SSC bleeding assessment tool: a
standardized questionnaire and a proposal for a new bleeding score for inherited
bleeding disorders. J Thromb Haemost. 2010;8:2063-5.
•  Tosetto A, Castaman G, Plug I, et al. Prospective evaluation of the clinical utility
of quantitative bleeding severity assessment in patients referred for hemostatic
evaluation. J Thromb Haemost. 2011;9:1143-8.

49
Bleeding

Pediatric bleeding assessment tool for the evaluation

of bleeding severity in children

Indication
Quantitative assessment of the severity of bleeding symptoms in young patients
referred for the evaluation of a suspected congenital bleeding disorder.

The Pediatric Bleeding Assessment is formed by two components: the Pediatric

Bleeding Questionnaire (PBQ) and the Bleeding Score, essentially derived from
the one used by the European Study on type 1 VWD. The Pediatric Bleeding
Assessment tool was originally developed to evaluate address pediatric-specific
bleeding symptoms, and all its items in the questionnaire are now represented
also in the ISTH Bleeding Assessment Tool. The PBQ is however presented
since many studies in children used this score.

1. Pediatric Bleeding Questionnaire (PBQ): The bleeding questionnaire

allows to accurately record the worst-ever presentation for each bleeding
symptom. The bleeding questionnaire is publicly available at:
http://onlinelibrary.wiley.com/doi/10.1111/j.1538-7836.2009.03499.x/full
There is no electronic version of the questionnaire available so far.

2. Bleeding Score: The severity of symptoms collected with the PBBQ is

scored according to the following table and all obtained values are summed
together. The final result is the Pediatric Bleeding Score, an index of the overall
severity of the bleeding phenotype in children.

Interpretation (see tables on p. 51-52)

A Bleeding Score ≥ 2 is considered suggestive for the presence of a bleeding
disorder. The sensitivity, specificity, positive predictive value and negative
predictive value of the PBQ are 83%, 79%, 0.14, and 0.99 respectively for the
diagnosis of von Willebrand’s disease in a secondary care setting. The PBQ is
consistently elevated in children with platelet function disorders.

References
•  B iss TT, Blanchette VS, Clark DS, et al. Quantitation of bleeding symptoms in children
with von Willebrand disease: use of a standardized pediatric bleeding questionnaire.
J Thromb Haemost. 2010;8:950-6.
•  Biss TT, Blanchette VS, Clark DS, et al. Use of a quantitative pediatric bleeding
questionnaire to assess mucocutaneous bleeding symptoms in children with a platelet
function disorder. J Thromb Haemost 2010;8:1416-9.
•  Bowman M, Riddel J, Rand ML, et al. Evaluation of the diagnostic utility for von Willebrand
disease of a pediatric bleeding questionnaire. J Thromb Haemost. 2009;7:1418-21.

50
 Pediatric Bleeding score
Symptoms Score
–1 0 1 2 3 4
Epistaxis No or trivial > 5 per year OR Consultation Packing, cauterization Blood transfusion,
(≤ 5 per year) > 10 minutes only or antifibrinolytics replacement therapy
duration or desmopressin
Cutaneous No or trivial > 1 cm AND Consultation
(≤ 1 cm) no trauma only
Minour wounds No or trivial > 5 per year Consultation Surgical haemostasis Blood transfusion,
(≤ 5 per year) OR > 5 minutes only or or antifibrinolytics replacement therapy
duration Steristreaps or desmopressin
Oral cavity No Reported Consultation Surgical haemostasis Blood transfusion,
at least once only or antifibrinolytics replacement therapy
or desmopressin

51
Gastrointestinal No Identified cause Consultation Surgical haemostasis,
tract or antifibrinolytics, blood
spontaneuous transfusion, replacemente
therapy or demopressin
Tooth extraction No bleeding None Reported, Consultation Resuturing, repacking Blood transfusion,
in at least done or no no consultation only or antifibrinolytics replacement therapy
2 extractions bleeding in or desmopressin
1 extraction
Surgery No bleeding None done Reported, Consultation Surgical haemostasis Blood transfusion,
in at least or no no consultation only or antifibrinolytics replacement therapy
2 surgeries bleeding or desmopressin
in 1 surgery

Bleeding
 Bleeding

Pediatric Bleeding score (cont.)

Symptoms Score
–1 0 1 2 3 4
Menorrhagia No Reported or Antifibronolytics D&C or iron therapy Blood transfusion,
consultation only or contraceptive replacement therapy,
pill use desmopressin
or hysterectomy
Post-partum No bleeding No deliveries Reported or D&C or iron Blood transfusion,
in at least or no consultation only therapy or replacement therapy
2 deliveries bleeding antifibronolytics or desmopressin
in 1 delivery
Muscle Never Post-trauma, Spontaneus, Spontaneus or traumatic, Spontaneus
no therapy no therapy requiring replacement or traumatic, requiring

52
hematoma
therapy or desmopressin surgical intervention
or blood transfusion
Hemarthrosis Never Post-trauma, Spontaneus, Spontaneus or traumatic, Spontaneus
no therapy no therapy requiring replacement or traumatic, requiring
therapy or desmopressin surgical intervention
or blood transfusion
Central nervious Never Subdural, any intervention Intracerebral,
system any intervention

Other No Reported Consultation only Surgical haemostasis, Blood transfusion,

antifibrinolytics or replacement therapy
iron therapy or desmopressin
 Bleeding
Bleeding assessment tool for the evaluation
of bleeding severity in immune thrombocytopenia:
the SMOG system

Indication
Quantitative assessment of the severity of bleeding symptoms in patients with
immune thrombocytopenia (ITP), observed at diagnosis or disease relapse.
Proposed as a clinical guidance to drive need for therapy.

The tool was developed by the International Working Group on ITP to standardize
definitions of bleeding, and to grade symptom-specific and domain-specific
bleedings. Bleeding signs/symptoms are grouped according to three major
domains: skin (S), visible mucosae (M) and organs (Og).

Skin (epidermis, dermis and subcutaneous tissues) includes petechiae,

ecchymosis (purpuric macula, bruise or contusion), subcutaneous hematomas,
bleeding from minor wounds. Visible mucosae include epistaxis, oral cavity (gum
bleeding, hemorrhagic bullae/blisters, bleeding from bites to lips & tongue or after
deciduous teeth loss/extraction), subconjunctival hemorrhage.

Organs include GI bleeding (hematemesis, melena, hematochezia, rectorrhagia),

lung bleeding (hemoptysis), hematuria, menorrhagia, muscle hematoma,
hemarthrosis, ocular bleeding, intracranial (intracerebral, intraventricular,
subarachnoidal, subdural, extradural). Gradation of bleeding severity (SMOG
system): each bleeding manifestation should be assessed at the time of
examination. Its severity is graded from 0 to 4. Appreciation of bleeding based
on history only, without supporting medical documentation, will be given a
grade 1 designation. Within each domain, the same grading is assigned to the
symptoms judged to have similar clinical relevance. For each symptom, the
worst ever episode during the observation period is graded and then the worst
episode within the domain is recorded. For example if the highest grade is 2 for
skin, 3 for mucosae and 2 for organs, SMOG is S2M3O2. The index produced
by summing the worst ever grade in the 3 domains represents the final score for
that particular patient. In the example shown, the final score is 7.

The data collection forms and grading tables are publicly available at:
http://itpbat.fondazioneematologia.it/

Reference
•  Rodeghiero F, Michel M, Gernsheimer T, et al. Standardization of bleeding
assessment in immune thrombocytopenia: report from the International Working
Group. Blood. 2013;121:2596-606.

53
 Bleeding

The SMOG system

Type of bleeding Grades based on the worst incident episode since last visit
SKIN 0 1 2 3 4
Petechiae No • Less than or equal to 10 More than 10 in a patient’s More than 50, if scattered both
(does not include in a patient’s palm-sized palm-sized area or more than above and below the belt
steroid-induced area in the most affected 5 in at least 2 patient’s palm-
or senile purpura) body area sized areas located in at least
• Any number if reported 2 different body areas, one
by the patient above and one below the belt
(in the most affected body areas)
Ecchymoses None or up to 2 • 3 or more in the same body From 1 to 5 larger than a More than 5 larger than a
in the same body area, but all smaller than a patient’s palm-sized area, if: patient’s palm-sized area, if:
area, but smaller patient’s palm-sized area, if: • spontaneous or • spontaneous or
than a patient’s – spontaneous or • disproportionate to trauma/ • disproportionate
palm-sized area, if: – disproportionate to trauma/ constriction with or without to trauma/constriction
• spontaneous or constriction smaller ones
• disproportionate • At least 2 in two different

54
to trauma/ body areas, smaller than a
constriction patient’s palm-sized area, if:
– spontaneous or
– disproportionate to trauma/
constriction
• Any number and size if
reported by the patient
Subcutaneous No • 1 smaller than a patient’s • 2 smaller than a patient’s • More than 2 smaller or at least
hematomas palm-sized area palm-sized area, 1 larger than a patient’s
• Any number and size if spontaneous palm-sized area, spontaneous
reported by the patient • 2 smaller than a patient’s • More than 2 smaller or at least
palm-sized area, 1 larger than a patient’s
disproportionate to trauma palm-sized area,
disproportionate to trauma
Bleeding from minor No • Lasting < 5 min Lasting > 5 min or interfering • Requiring protracted medical
wounds • Any episode if reported by with daily activities observation at the time
the patient of this visit
• Medical report describing
patient’s evaluation
by a physician
 The SMOG system (cont.)
Type of bleeding Grades based on the worst incident episode since last visit
MUCOSAL 0 1 2 3 4
Epistaxis No • Lasting < 5 min Lasting > 5 min or interfering • Packing or cauterization or RBC transfusion or Hb
• Any episode if reported with daily activities in-hospital evaluation drop > 2 g/dL
by the patient at the time of this visit
• Medical report describing
packing or cauterization or
in-hospital evaluation
Oral cavity No • Lasting < 5 min Lasting > 5 min or interfering • Requiring protracted medical
(gum bleeding) • Any episode if reported with daily activities observation at the time of this
by the patient visit
• Medical report describing
patient’s evaluation
by a physician

55
Oral cavity No • Less than 3 From 3 to 10 but no difficulty More than 10 or more than 5 if
(hemorrhagic bullae or blisters) • Any number if reported with mastication difficulty with mastication
by the patient
Oral cavity No • Lasting < 5 min Lasting > 5 min or interfering • Interventions to ensure
(bleeding from bites to lips • Any episode if reported with daily activities haemostasis or in-hospital
& tongue or after deciduous by the patient evaluation at the time
teeth loss) of this visit
• Medical report describing
interventions to ensure
haemostasis or in-hospital
evaluation
Subconjunctival No • Petechiae/hemorrhage Petechiae/hemorrhage Diffuse hemorrhage in both eyes
hemorrhage partially involving one eye partially involving both eyes,
(not due to conjunctival • Any episode if reported or diffuse hemorrhage in
disease) by the patient one eye

Bleeding
 Bleeding

The SMOG system (cont.)

Type of bleeding Grades based on the worst incident episode since last visit
ORGAN
(and internal mucosae)
0 1 2 3 4

Gastrointestinal bleeding No Any episode if reported • Present at this visit • Requiring endoscopy or other RBC transfusion or
not explained by visible mucosal by the patient • Described in a medical therapeutic procedures or in- Hb drop > 2 g/dL
bleeding or lesion: report hospital evaluation at the time
of this visit
• Hematemesis,
• Melena, • Medical report prescribing
• Hematochezia, endoscopy or other therapeutic
• Rectorrhagia procedures or in-hospital
evaluation
Lung bleeding No Any episode if reported • Present at this visit • Requiring bronchoscopy or RBC transfusion or
by the patient • Described in a medical other therapeutic procedures or Hb drop > 2 g/dL
• Hemoptysis
report in-hospital evaluation at the time
• Tracheobronchial bleeding
of this visit

56
Hematuria No • Any episode if reported
by the patient
• Microscopic (lab analysis)
Menorrhagia No • Doubling nr. of pads or
(compared to pre-ITP or to a phase tampons in last cycle
of disease with normal platelet count) compared to pre-ITP or
to a phase of disease
with normal platelet count
• Score > 100 using PBAC
in the last cycle, if normal
score in pre-ITP cycles or
in a phase of disease with
normal platelet count
• Macroscopic
• Described in a medical
report
• Changing pads more
frequently than every 2 hrs.
or clot and flooding
• Requiring combined
treatment with
antifibrinolytics and hormonal
therapy or gynecological
investigation
(either at this visit or described
in a medical report)
• An equivalent episode if
described
in a medical report
• Macroscopic, and requiring RBC transfusion or
cystoscopy or other therapeutic Hb drop > 2 g/dL
procedures or in-hospital
evaluation at the time of this visit
• An equivalent episode if
described
in a medical report
Acute menorrhagia requiring RBC transfusion or
hospital admission Hb drop > 2 g/dL
or endometrial ablation
(either at this visit or described
in a medical report)
 The SMOG system (cont.)
Type of bleeding Grades based on the worst incident episode since last visit
ORGAN
(and internal mucosae)
0 1 2 3 4

Intramuscular hematomas
(only if diagnosed by a physician
with an objective method)
Hemarthrosis
(only if diagnosed by a physician
with an objective method)
No • Post trauma, diagnosed • Spontaneous, diagnosed at • Spontaneous or post trauma RBC transfusion or
at this visit, if judged this visit (if judged disproportionate to trauma) Hb drop > 2 g/dL
disproportionate to trauma • An equivalent episode diagnosed at this visit and
• An equivalent episode if described in a medical requiring hospital admission or
if described in a medical report surgical intervention
report • An equivalent episode if
described in a medical report
No • Post trauma, diagnosed • Spontaneous, diagnosed • Spontaneous or post trauma • Spontaneous or
at this visit, function at this visit, function (if judged disproportionate to post trauma (if judged
conserved or minimally conserved or minimally trauma),diagnosed at this visit disproportionate to trauma)
impaired, if judged impaired and requiring immobilization or diagnosed at this visit

57
disproportionate to trauma
• An equivalent episode if
described in a medical
report
Ocular bleeding No
(only if diagnosed by a physician
with an objective method)
• An equivalent episode if joint aspiration and requiring surgical
described • An equivalent episode if intervention
in a medical report described in a medical report • An equivalent episode if
described in a medical
report
• Any post trauma vitreous • Spontaneous vitreous • Spontaneous vitreous or
or retinal hemorrhage or retinal hemorrhage involving retinal hemorrhage
involving one or both eyes one or both eyes with impaired/ with loss of vision in one
with or without impaired/ blurred vision present at this visit or both eyes present
blurred vision present • An equivalent episode if at this visit
at this visit if judged described in a medical report • An equivalent episode if
disproportionate to trauma described in a medical
• An equivalent episode if report
described in a medical
report

Bleeding
 Bleeding

The SMOG system (cont.)

Type of bleeding Grades based on the worst incident episode since last visit
ORGAN
(and internal mucosae)
0 1 2 3 4

Intracranial bleeding:
intracerebral, intraventricular,
subarachnoidal, subdural, extradural
(only if diagnosed with an objective
method at the visit or described in a
medical report provided by the patient)
No • Any post trauma event Any spontaneous event requiring Any spontaneous event
requiring hospitalization hospitalization in presence requiring hospitalization
of an underlying intracranial lesion without an underlying
intracranial lesion

Other internal bleeding: No Any event requiring hospitalization Any event requiring
hemoperitoneum, hemopericardium, < 48 hrs. hospitalization > 48 hrs.
hemothorax retroperitoneal bleeding, or RBC transfusion
hepatic and splenic peliosis with or Hb drop > 2 g/dL

58
organ rupture retroorbital bleeding,
metrorrhagia, etc.
(only if diagnosed with an objective
method at the visit or described in a
medical report provided by the patient)
 Anticoagulant therapy
Diagnostic and therapeutic algorithm of
Heparin-Induced Thrombocytopenia (HIT syndrome)

Indication
Heparin-Induced Thrombocytopenia (HIT) is a serious complication of
anticoagulant therapy with unfractionated heparin and, less frequently, low
molecular weight heparin, with the formation of abnormal antibodies against
the heparin/platelet factor-4 (PF4) complex. The syndrome is characterized by
the occurrence of a drop in platelet count associated with venous or arterial
thrombotic complications initiated after 5-10 days of treatment with heparin. In
patients that were earlier exposed to heparin the complication may occur in a
shorter time after initiation of heparin treatment.

HIT clinical probability algorithm

4T score Score
Thrombocytopenia
•  Decrease > 50% and platelets nadir ≥ 20 × 109/L 2
•  Decrease 30-50% or platelets nadir = 10-19 × 109/L 1
•  Decrease < 30% or platelets nadir < 10 × 109/L 0
Timing of platelet count fall
• Onset 5-10 days
(or 1 day after previous exposition to heparin in the last month) 2
• Unclear decrease at 5-10 days; onset after day 10 or day 1
after previous exposition to heparin in day 30-100 1
•  Decrease < 4 days with no recent exposition 0
Thrombosis or other sequelae
• New thrombosis (confirmed); cutaneous necrosis; acute systemic
reaction after heparin bolus 2
• Progressive or recurrent thrombosis; non-necrotic cutaneous lesions;
suspicion of thrombosis 1
• None 0
Thrombocytopenia due to other causes
• Apparently none 2
• Possible 1
• Yes 0

59
Anticoagulant therapy

Interpretation
According to the 4T rule, 3 levels of clinical probability can be defined:
• High = 6-8 points
• Intermediate = 4-5 points
• Low = ≤ 3 points
Once the pre-test probabilities are assumed, the HIT diagnostic / therapeutic
algorithm can proceed.

Thrombocytopenia in a patient
receiving heparin or LMWH

Apply clinical scoring system

High clinical suspicion Intermediate (4T’s = 4-5) Low clinical

(4T’s = 6-8) Discontinue heparin: suspicion
Discontinue heparin: start alternative therapy for HIT(4T’s ≤ 3)
start alternative therapy Continue
heparin therapy
Immunoassay
Immunoassay

Positive HIT Negative HIT

Positive HIT Negative HIT possible HIT unlikely
confirmed HIT unlikely (post-test probability (post-test probability
(post-test probability (post-test probability of HIT ~ 60%) of HIT< 0,5%)
of HIT > 95%) of HIT~ 3-16%)

Consider Presence of Presence of

functional high IgG OD/titer low IgG OD/titer
assay and/or platelet or lack platelet
activating antibodies activating antibodies
increase HIT likelihood decrease HIT likelihood
(post-test probability of HIT ~ 65%) (post-test probability of HIT ~ 40%)

References
• Crowther MA, Cook DJ, Albert M, et al.; Canadian Critical Care Trials Group. The
4Ts scoring system for heparin-induced thrombocytopenia in medical-surgical
intensive care unit patients. J Crit Care. 2010;25:287-93.
• Greinacher A. Heparin-induced thrombocytopenia. J Thromb Haemost.
2009;7(Suppl 1):9-12.
• Warkentin TE. How I diagnose and manage HIT. Hematology Am Soc Hematol
Educ Program. 2011:143-9.
• Warkentin TE, Greinacher A, Koster A, et al.; American College of Chest
Physicians. Treatment and prevention of heparin-induced thrombocytopenia:
American College of Chest Physicians Evidence-Based Clinical Practice Guidelines
(8th edition). Chest 2008;133(Suppl 6):340S-380S.

60
 Anticoagulant therapy
Bridging strategies in patients on anticoagulants
who need to undergo invasive procedures

Indication
For patients on vitamin K antagonists requiring a surgical or invasive
procedure, the question of whether or not to bridge and how to bridge is
commonly encountered in clinical practice.

Risk assessment of thrombosis

Arterial thrombosis
High • Atrial fibrillation with CHADS2 score: 4-6
• Atrial fibrillation and rheumatic heart valve disease
• Mechanical mitral valve prosthesis
• Recently inserted heart valve prosthesis
• Heart valve prosthesis plus additional thrombotic risk
• Old type mechanical heart valve (caged ball, tilting disk)
• Intracardial thrombosis
Intermediate • Atrial fibrillation with CHADS2 score: 2-3
• Mechanical aortic heart valve without any other risk
• Recurrent TIA
• Ischemic brain infarct without cardiac embolism
Low • Atrial fibrillation with CHADS2 score: 0-1
• Cerebrovascular disease without recurrent TIA/infarction
Venous thromboembolism
High • Recent (< 3 months) venous thromboembolism
• Thromboembolism with known thrombophilia
• Recurrent idiopathic venous thromboembolism
Intermediate Venous thromboembolism 3-6 months ago
Low Venous thromboembolism > 6 months ago

61
Anticoagulant therapy

Management strategy based on risk assessment

High • Stop treatment with VKA

(warfarin or coumadin 3-4 days,
fenprocoumon 5-7 days)
• Start therapeutic UFH or LMWH
• Stop UFH 3 hours preoperatively or LMWH
24 hours preoperatively
• Restart heparin 12-24 hours postoperatively
Risk of thromboembolism

• Consult with
(if no bleeding)
surgeon or operator
• Restart VKA 1-2 days postoperatively
• Continue VKA
(if no bleeding)
• Monitor INR
• Stop heparin when INR is in therapeutic range
• Target INR 1.5-2.0
Low • Stop treatment with VKA
(warfarin or coumadin 3-4 days,
fenprocoumon 5-7 days)
• Restart VKA 12-24 hours postoperatively
(if no bleeding)
• Usual prophylactic LMWH
(prevention of venous thromboembolism)
Low High
Risk of peri-operative bleeding
VKA: Vitamin K antagonists; UFH: Unfractionated Heparin; LMWH: Low Molecular Weight Heparin;
INR: International Normalized Ratio

Interpretation
Perioperative interruption and bridging strategy based on risk of thromboembolism
and risk of perioperative bleeding. Patients with an intermediate risk of
thromboembolism are treated according to the low risk stratum, although
individual exceptions may be made based on patient characteristics and
preferences of patients and doctors.

References:
• Douketis JD, Johnson JA, Turpie AG. Low-molecular-weight heparin as
bridginganticoagulation during interruption of warfarin: assessment of a
standardized periprocedural anticoagulation regimen. Arch Intern Med.
2004;164:1319-26.
• Levi M, Eerenberg E, Kamphuisen PW. Periprocedural reversal and bridging of
anticoagulant treatment. Neth J Med. 2011;69:268-73.

62
Practical manual
of scores and algorithms in
hemostasis and thrombosis

Diagnostica Stago - 05/2014 - ref.: 28111

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