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Von Willebrand Disease (VWD)
Part 1: NHLBI Diagnosis Guidelines

Introduction & Clinical Assessment Recommendations



Initial Clinical Evaluation for VWD or Other Bleeding Disorders1

Slide 14

May 2011

This Figure from the NHLBI VWD Guidelines provides an algorithm for initial clinical evaluation for VWD, or other bleeding disorders. Two main scenarios are envisioned: 1) Asymptomatic persons who will undergo a surgical or invasive procedure and who should be assessed for bleeding risk (on the left side of the Figure); or 2) Persons presenting with a personal and/or family history of bleeding symptoms or bleeding disorder, abnormal hemostasis laboratory tests, or concerns about bleeding symptoms.

The left upper box in the Figure provides 3 recommended questions for pre-operative screening of asymptomatic persons for bleeding risks or disorders. "Box 1" at the lower right provides 9 questions (selected for sensitivity and specificity for VWD) that are recommended for further evaluation of persons answering positively to the initial 3 questions, or for evaluation of persons who have specific hemostasis issues. All questions are grade B recommendations based on limited published research, except questions 2 and 3 in the left upper box that reflect expert opinion (grade C). These latter 2 questions provide screening for acquired conditions that can increase bleeding risk, such as cirrhosis or renal failure, or bone marrow or platelet disorders, as well as the use of medications that impair hemostasis such as aspirin and other platelet-inhibitory drugs, or anticoagulants such as warfarin or heparin. Focused physical examination is also recommended (grade C) to detect signs of bleeding (ecchymoses, hematomas, petechiae, or other bleeding) or to detect other causes of bleeding risk such as liver disease (eg, jaundice, splenomegaly), telangiectasia (eg, HHT: hereditary hemorrhagic telangiectasia), joint and skin laxity (eg, Ehlers-Danlos syndrome), signs of anemia, or anatomic lesions on gynecologic examination. If the initial clinical assessment raises significant suspicion or probability that a bleeding disorder may be present, including VWD, then initial laboratory testing may be indicated (lower central box in the Figure). Laboratory testing is discussed in Part 2 of this presentation.

Initial Clinical Evaluation for VWD1

 


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