Prevention and Treatment of DVT and PE (VTE) · Prevention and Treatment of DVT and PE (VTE) ... Case Study #1 27-year-old woman ... • History of Hypertension and DM type 2

Prevention and Treatment of DVT and PE (VTE)

L. Bernardo Menajovsky, MD, MS. Associate Professor of Medicine Director, Anticoagulation Clinics

Texas A&M Health Sciences Center College of Medicine Scott & White Memorial Hospital and Clinic

Temple, Texas, USA

Need for recommendations - guidelines

•  Most practitioners need to identify the useful and pertinent information for practice

When it comes to anticoagulation management…

ACCP guidelines 2012 AT9

However…

There are several others…

Grade

Meaning (1,2)

Evidence (A,B,C)

1 A Strong

recommendation

High quality

1 B Strong

recommendation

Moderate quality

1 C Strong

recommendation

Low or very low quality

2 A Weak

recommendation

High quality

2 B Weak

recommendation

Moderate quality

2 C Weak

recommendation

Low or very low quality

•  Strong recommendation: 1 Benefits clearly outweigh risk and burdens or vice versa (“we recommend)”

Methodology – grades of recommendation

•  Weak recommendation: 2 Benefits closely balanced with risks and burden (“we suggest”)

9th ACCP, Chest. 2012 Feb;141(2 Suppl):53S-70S.

•  AT9 has many weak recommendations (grade 2) replacing the strong recommendations (grade 1) of AT8...

Main differences from AT8

•  …resulting in many 1A recommendations turning into 2A or, more commonly, 2B

No New Studies Published

Methodology for AT9 •  More rigorous evaluation of studies with standardized

methodology, reviewing the risk of bias, imprecision and inconsistency of results of a RCT

•  Attempt to exclusion of financial and intellectual conflicts of interest •  Authors involved:

•  Editor: Methodologists •  Clinicians with few experience on the subject •  Panelists: the experts (no voting)

•  Caution in interpretation of single studies and recommendations

9th ACCP, Chest. 2012 Feb;141(2 Suppl):53S-70S.

Decrease in 1 A recommendations

2004 123 540 2008 182 901 2012 29 801

1A Pages

Hirsh J, Guyatt G, Lewis SZ. Chest. 2008 Jun;133(6):1293-5. PMID: 18574282 Guyatt GH. Chest. 2012 Feb;141(2 Suppl):48S-52S. PMID: 22315255

•  Apply recommendations to particular clinical scenarios

and check whether these recommendations fit them

•  It is always useful to read the small prints!

Recommendations AT9

Big Change

•  Hard Outcomes = Clinically significant VTE •  Soft Outcomes = Venographic or US VTE

12

Facts

•  50% clinically significant DVT – Asymptomatic

•  60-70% of Fatal PE – Asymptomatic DVT

Heit JA, et al. Arch Intern Med. 1999;159:445.

Application of Guidelines

Real Life Cases

Case Study #1

27-year-old woman, who began having left leg pain 6 days ago, woke up in the morning with the pain. Since the pain did not go away, she then went to the ED. The patient states that she has felt otherwise well. She denies any swelling of the leg or warmth, but she does complain of tenderness to palpation.

Case Study #1 (cont…)

•  PMH: Non-contributory. •  FH: Father prostate cancer. No clotting disorders •  PSH: Repair of septated uterus in 2003. •  SH: No smoking. Occ alcohol. No illicit drug use. •  ALLERGIES: allergic to penicillin. •  ROS: Just back from a non-stop 10 hr. car trip. •  MEDS: OCPs since age 17.

16

Case Study #1 (PE)

•  VS: BP 123/83, HR 88, RR 18, O2 sat on RA 97%. Temp 101.0.

•  GEN: moderate distress (pain). •  HEENT; NECK; CV; LUNGS; ABD; all normal. •  EXTREMITIES: Mod tenderness to palp in left

calf. Leg is warm, 1+ edema and erythema, positive Hommans sign. 2+ pedal pulses.

•  The patient did not ambulate, but states that she has been walking with a limp because of the pain.

17

Case Study #1 (Labs)

•  CBC: WBC 10.3, Hgb 13.1, Hct 38.4, plat 153. •  CMP, and LFTs within normal limits. •  INR 1.2. •  Serum pregnancy test is pending.

18

Q1: What is your diagnosis?

1.  DVT vs. Cellulitis. 2.  Cellulitis vs. DVT. 3.  Other

19

DVTvs.Cellulitis.

Cellulitisvs.D

VT.

Other

33%33%33%

:10

Q2: What is your next step?

1.  Doppler US lower extremity veins.

2.  High sensitivity D- dimer.

3.  Start treatment immediately.

4.  Hypercoagulable panel.

5.  2 and 4

20

DopplerUSlowerextremi..

HighsensitivityD‐dimer.

Starttreatm

entim

media...

Hypercoagulablepanel.

2and4

20% 20%20%20%20%

:15

Q3: Potential contributing factors for this patient’s condition are (except)?

1.  Use of OCPs 2.  Long dist travel. 3.  1 and 2. 4.  Age 5.  None: All are

contributing factors.

23

UseofOCPs

Longdisttravel.

1and2. Ag

e

None:Allarecontributin...

20% 20%20%20%20%

:10

Epidemiology – Incidence 24

Zöller, Circulation 2011

•  Higher risk in females aged 15-35 years  Estrogen containing birth control pill  Pregnancy

Epidemiology of VTE and HT

•  99% of cases occur during the first 2 years •  90% within the first 6 months.

Zöller, Circulation 2011

Long distance travel and VTE

•  Evidence is poor •  Events are unusual •  The majority of patients have other major risk

factors •  Only air travel longer than 6 hours in economy

class has been studied •  Not a single study on land travel.

Case 1 (cont…)

•  All tests you order are pending and you decide to start systemic anticoagulation.

27

Q4: In addition you order the following:

1.  Stop OCPs (particularly estrogen based) immediately and never use them again.

2.  Avoid traveling for at least one year.

3.  Graduated compression stockings, 40 mmHg at level of ankle

4.  Bed rest for at least one week.

5.  1 and 2

28

StopO

CPs(particularly...

Avoidtravelingforatlea..

Graduatedcompression...

Bedrestforatleastone...

1and2

0% 0%0%0%0%

:20

Estrogen-related VTE – Management

•  Attitude towards contraception  Stop the estrogen-containing pill

-  No rush (anticoagulant therapy) -  Refer to the physician in charge of her contraception -  Estrogens should be stopped ideally 6 weeks prior to

anticoagulant discontinuation

 Which contraception after a VTE? -  Mechanical -  Progestin-only pill or levonorgestrel-releasing intra-uterine

device (Mirena®) appear inoffensive, although no RCT is available to support this attitude. Avoid injectable progesterone

-  Never resume an estrogen-containing contraceptive

29

Conard, Contraception 2004

Estrogen-related VTE - Prevention

•  Avoid their use in women with other VTE risk factors  Age > 35 years  Obese  Family hx of VTE, particularly if first degree relatives

with hormone-related thrombosis  Known thrombophilia (but no evidence to support

prior testing)  Current smokers  Hx of diabetes, hypertension, dyslipidemia

30

Case 2 •  42 y/o white man comes to the ED with a 1 day

h/o pain and swelling of the left upper extremity. •  The patient states that he was helping his

brother-in-law moving to his brand new 2nd story apartment over the weekend.

•  PMH: unremarkable. •  PSH: Appendectomy as a child. •  FHx: Parents alive and well; one sister (32) in

good health except for trouble getting pregnant. •  SHx: Accountant; smokes and drinks

occasionally; works out 5 times a week.

Case 2 (PE)

•  Alert, moderate distress from pain on left arm. •  HEENT; Neck; CV; Lungs; Abdomen all normal. •  Left arm swollen and tender with prominence of

superficial venous circulation. •  Pulses and sensation normal.

32

Case 2 (Dx tests)

•  Labs: All normal.

•  Doppler US LUE: Occlusive thrombus on axillary, brachial and basilic veins.

33

Q1: What is your next step?

1.  Start anticoag immediately with a LMWH and Warfarin the same day.

2.  Hypercoagulable panel. 3.  No anticoagulation; arm

elevation and warm compresses + NSAIDs

4.  Consult IR for venography and thrombolysis.

34

Startanticoagimm

ediat...

Hypercoagulablepanel.

Noanticoagulation;arm...

ConsultIRforvenograp..

0% 0%0%0%

:20

Anatomy of Upper Extremity

Types of UEDVT

•  Primary  Unprovoked or without thrombophilia-idiopathic  Effort related– Paget-Schrötter syndrome  Thoracic outlet syndrome (TOS)   Incidence

-  2 per 100,000 person years -  30% of all UEDVTs

Flinterman LE. J Thromb Haemost. 2008;6:1262-1266

Paget-Schrötter Syndrome •  Effort induced thrombosis

  Rapid onset of DVT after strenuous activity   Intimal microtrauma to vessel wall after exertion   Activation of coagulation system

•  Occurs in young, healthy adults; males more often than female

•  Should be treated as an emergency •  Considered venous manifestation of TOS


Thoracic Outlet Syndrome

•  3-10% of TOS cases related to vasculature; venous or arterial

•  Compression of thoracic outlet veins by clavicle and first rib  Rapid occlusion of vein  Typically subclavian vein

•  60% of patients with primary UEDVT have the TOS

Watson HG. J Thromb Haemost. 2008;6:1267-1268

Treatment Recommendations- Paget-Schrötter Syndrome

•  Course of action  Venography  Thrombolysis  Anticoagulation  Surgery


Treatment Recommendations- Paget-Schrötter Syndrome

•  Surgery  Lysis of adhesions around subclavian vein  Resection of part of clavicle and/or first rib  Scalene muscle resection  Subclavian vein patching  Bypass procedures


Case 3

•  52 y/o white man with h/o COPD admitted for exacerbation and IV antibiotics. Right upper extremity PICC placed due to poor IV access.

•  On hospital day # 3, RUE swollen, red and tender.

•  PE: VS normal; Pox 96% on RA ; Lungs with decrease breath sounds, no wheezing.

•  Right arm is slightly swollen and tender. No erythema, good pulses.

•  Doppler US: Occlusive clot on Axillary, brachial, basilic, and cephalic veins.

41

Q1: What is your next step? 1.  Start anticoagulation

immediately with a LMWH and Warfarin the same day. Leave PICC in place.

2.  Request a hypercoagulable panel.

3.  Remove PICC. No anticoagulation; arm elevation and warm compresses

4.  Consult IR for venography and thrombolysis

42

Startanticoagulationi...

Requestahypercoagulab..

RemovePICC.Noanticoa...

ConsultIRforvenograph...

25% 25%25%25%

:20

Types of UEDVT

•  Secondary   Provoked by central venous catheters   Pacemakers   Cancer   IV drug abuse   Coagulation abnormalities

-  Protein C/S deficiency -  Factor V Leiden gene mutation -  Hyperhomocysteinemia -  Antiphospholipid antibody syndrome


Malignancy

•  Related to placement of CVCs   18 fold increase risk of developing UEDVT compared

to patients without active malignancy.

•  Hypercoagulability of malignancy •  Tumor mass compression •  Comprises 24% of UEDVT cases •  Types

  Lymphoma   Lung cancer


Diagnosis

•  Doppler Ultrasound  Disadvantages

-  False negative -  Clavicle may shadow segment of subclavian vein

 Use venography if Doppler is negative and strong clinical suspicion of UEDVT

Gaffar M. Hospital Physician. 2005:29-34

Diagnosis

•  Venography  Gold standard  Contrast dye injected into basilic vein  Defects in intraluminal filling indicate thrombus  Limited use due to complications and invasive nature


Diagnosis

•  Magnetic Resonance Angiography  Higher resolution imaging of thoracic veins compared

to Doppler  Blood flow information and collateral vessel

visualization better  Strong correlation to results of venography

-  Is noninvasive and accurate -  May use if venography is contraindicated


Differential Diagnosis

•  Hematomas •  Muscle contusions or tears •  Cellulitis •  Lymphedema •  Gangrene •  All may present with pain and swelling in upper

extremity


Complications

•  Pulmonary embolism  Occurs in up to 30% of patients  Occurs more frequently if CVC in place  Less common than in patients with LEDVT


Complications

•  Post thrombotic syndrome   Occurs in up to 40% of patients   Results from chronic venous insufficiency from clot   Characteristics

-  Edema -  Pain -  Venous ulcers -  Skin pigmentation changes

  Treatment/prevention


Treatment Recommendations

•  Dependent upon anatomic distribution of thrombus   Subclavian vein

involvement -  Mid-subclavian line and

lateral-conservative treatment

-  Mid-subclavian line and medial-pharmacological management

Treatment Recommendations-Lateral to Mid-Subclavian Line

•  Catheter related UEDVT   Removal of line   Conservative

treatment -  Bed rest -  Local heat -  Limb elevation -  Compression arm

sleeve Venogram demonstrating completely thrombosed right axillary-subclavian vein

Treatment Recommendations-Lateral to Mid-Subclavian Line

•  Catheter related UEDVT  Removal of line not possible

-  Anticoagulate patient for duration of line involvement -  Repeat imaging after line removed

Treatment Recommendations-Medial to Mid-Subclavian Line

•  Catheter Related UEDVT  Removal of line if possible

-  Anticoagulate for total of 12 weeks  Removal of line not possible

-  Anticoagulate patient for duration of line involvement -  Begin 12 weeks of anticoagulation once line is removed

Case 4

•  73 year old man scheduled for elective right total knee replacement surgery

•  History of Hypertension and DM type 2 •  Creatinine clearance: 35 ml/min •  BMI 35 •  Med: metoprolol 50mg, HCTZ 12.5 mg, Lantus 10

55

Q1: What VTE prophylaxis would you recommend?

1.  LMWH S/Q 2.  Heparin (UFH): 5,000 U

S/Q Q8hs 3.  Heparin (UFH): 5,000 U

S/Q Q12 4.  Fondaparinux 2.5 mg. S/

Q daily. 5.  Dabigatran 75 mg PO

every 12 hs 6.  Rivaroxaban 10 mg PO

daily 7.  ASA 325 mg. PO daily

56

LMWH

S/Q

Heparin(UFH):5,000US..

Heparin(UFH):5,000US..

Fondaparinux2.5mg.S/...

Dabigatran75mgPOeve..

Rivaroxaban10m

gPOdaily

ASA325mg.POdaily

14% 14% 14%14%14%14%14%

:25

Q8hr dosing schedule 0700 1500 2300

Methods •  Compare:

  Patients that were prescribed Enoxaparin once daily to   Patients that were prescribed with UFH twice daily or three times daily.

•  Patients enrolled were required to have a hospitalization period > 4 days. •  Followed patients for the duration of their hospitalization. •  Adherence = Number of Doses Administered Number of doses Scheduled for Administration •  We identified all doses that were omitted or late. •  We measure the time interval between:

  Successive administered doses   Time interval between scheduled administration time and dose administration

time.

Fanikos, J. et.al AmJMed Volume 123, Issue 6 , Pages 536-541, June 2010

Results

Outcomes/Compliance

LMWH Once Daily

N=125 UFH BID

N=28 UFH TID

N=97 P-Value Number of scheduled doses 648 204 1195

Number of doses administered 615 177 1049

Number of doses omitted 33 27 146

Adherence 94.9% 86.8% 87.8% <.001

Number of patients that received 100% of doses

77.6% 53.6% 45.4% <.001

Interval between successive administered doses (hours)

24.4±5.1 12.7±2.1 8.7±1.0 <.001

Interval between scheduled dose and administered dose (hours)

0.64±0.26 0.53±0.22 0.64±0.22 0.037

Fanikos, J. et.al AmJMed Volume 123, Issue 6 , Pages 536-541, June 2010

Prevention of VTE in surgical patients What´s new in the 2012 9th ACCP guidelines?

9th ACCP recommendations on prophylaxis after major orthopedic surgery

•  For THR and TKR: LMWH, fondaparinux, apixaban, dabigatran, rivaroxaban, UFH, VKA, aspirin (1B) or IPC (1C) for at least 10-14 days

•  In patients undergoing MOS suggest the use of LMWH in preference to other agents (2B) except VKA or aspirin (2C)

•  For MOS suggest extending thromboprophylaxis for up to 35 days rather than only 10-14 days (2B)

•  In patients undergoing MOS who decline injections, we recommend using apixaban or dabigatran (alternatively rivaroxaban or VKA) (1B)

•  In MOS patients at increased risk of bleeding: IPC or no prophylaxis rather than pharmacological treatment. (2C)

Falck-Ytter Y, et al. Chest. 2012; 141 (2) (Suppl): e278s-e325s

•  Remarks: If started preoperatively, we suggest administering LMWH 12 h before surgery. Patients who place a high value on avoiding the inconvenience of daily injections with LMWH and a low value on the limitations of alternative agents are likely to choose an alternative agent. Limitations of alternative agents include the possibility of increased bleeding (which may occur with fondaparinux, rivaroxaban, and VKA), possible decreased efficacy (LDUH, VKA, aspirin, and IPCD alone), and lack of long-term safety data (apixaban, dabigatran, and rivaroxaban).

Major Orthopedic Surgery: Total Hip Arthroplasty (THA), Total Knee Arthroplasty (TKA), Hip Fracture Surgery

(HFS)

Bleeding and anti-coagulation: to what extent?

The decision to prophylax: The balance of benefits and harms

•  Major orthopedic surgery patients are at high-risk for post-operative venous thromboembolism (VTE)1

•  Risk of major bleeding associated with pharmacological prophylaxis is a concern for orthopedic surgeons2,3

1. Geerts WH, et al. Chest 2008;133:381-453. 2. Schulman S, et al. Chest. 2008;133:257S-298S.

3. Ng JH, Crowther MA. Semin Hematol. 2006;43:S77-S83.

Symptomatic thromboembolic

events

Bleeding

More VTE events

Less VTE events

More bleeding events

Less bleeding events

Agent is non-approvable Necessary to assess

LHH

No brainer Is it relevant to assess LHH?

When to assess benefits versus harms ratio (LHH)?

?

?

A quantitative assessment of the benefits and harms

Clinical benefit = number of patients needed to be treated (NNT)

Clinical harm = number of patients needed to be harmed (NNH)

LHH >1 patients have more benefits than harms related to study treatment

Battaggia and Vaona, Rivista the quality and the qualities in general practice 2006;11: 2-4; www.rivistaqq.it.

Overall balance of benefits and harms = LikeliHood of Helping vs Harming (LHH)

LHH = (1/NNT)/(1/NNH)

A quantitative assessment of the benefits and harms

Clinical benefit = number of patients needed to be treated (NNT) Clinical harm = number of patients

needed to be harmed (NNH)

LHH <1 patients have more harms than benefits related to study treatment

Battaggia and Vaona, Rivista the quality and the qualities in general practice 2006;11: 2-4; www.rivistaqq.it.

Overall balance of benefits and harms = LikeliHood of Helping vs Harming (LHH)

LHH = (1/NNT)/(1/NNH)

Estimation of benefits versus harms ratio (LHH) for fondaparinux

PEGASUS1

PENTATHLON2

EPHESUS3

PENTAMAKS4

NNH

97

125

Heterogeneity p=0.262

52

ARR (%)

- 1.03

- 0.80

- 1.30 77

- 1.94

Favors LMWHcomparator Favors fondaparinux

1. Agnelli G, et al. Br J Surg 2005;92:1212-20. 2. Turpie AG, et al. Lancet. 2002;359:1721-6. 3. Lassen MR, et al. Lancet. 2002;359:1715-20. 4. Bauer KA, et al. N Engl J Med. 2001;345:1305-10.

Major bleeding including surgical site

0.01 1 84.89

Benefits versus harms ratio favors LMWH comparator

(NNT)

(1429)

(125)

129

(588)

0.07

1

0.40

0.13

LHH

Estimation of clinical benefits for rivaroxaban

RECORD 11

RECORD 32

RECORD 43

NNT

435

77

213

Symptomatic VTE

Favors rivaroxaban

Favors rivaroxaban Favors LMWH comparator


1  Eriksson BI, et al. N Engl J Med. 2008;358:2765-2775. 2  Lassen MR, et al. N Engl J Med. 2008;358:2776-2786. 3  Turpie A, et al. Lancet. 2009;373:673-80.

ARR (%)

0.23

1.30

0.47

1 2 0.05

Estimation of benefits versus harms ratio (LHH) for rivaroxaban

0.1 1.9 3.9 1

RECORD 11

RECORD 32

RECORD 43

ARR (%)

- 0.18

- 0.09

- 0.39

NNH

556

256

1111


Major bleeding excluding surgical site

Favors LMWH comparator Favors rivaroxaban

1  Eriksson BI, et al. N Engl J Med. 2008;358:2765-2775. 2  Lassen MR, et al. N Engl J Med. 2008;358:2776-2786. 3  Turpie A et al. Lancet. 2009;373:673-80.

Benefits versus harms ratio favors the study treatment

(NNT)

(435)

(77)

(213)

LHH

1.278

1.202

14.43

0.1 1.9 3.9 1

RECORD 11

RECORD 31

RECORD 41

Major bleeding including surgical site

Favors LMWH comparator Favors rivaroxaban

Estimation of benefits versus harms ratio (LHH) for rivaroxaban

1. FDA regulatory document.

ARR (%)

- 0.33

- 0.35

- 0.70

NNH


303

286

143

(NNT)

(435)

(77)

(213)

LHH

0.697

3.714

0.671

LMWH (489)

Rivaroxaban (559)

P

Return to operating room with wound complications

9 (1.8%) 22 (3.94%) P = 0.04

Rate of deep infection 5 (1%) 14 (2.5%) P = 0.10

Mean time from surgery to reoperation (days, range)

17.2 (8-25)

16.8 (6-30)

P = 0.89

Indication: wound hematoma

0 9 (1.6%) P = 0.03

Return to the OR following THR and TKR, before and after the introduction of rivaroxaban

Jensen CD et al. JBJS (Br) 2011; 93-B: 91-95

“We have discontinued the use of rivaroxaban in our hospital until robust evidence for independent trials become available….”

1.  Ansell J et al. Chest. 2004;126:204S-233S. 2.  Hirsh J et al. J Am Coll Cardiol. 2003;41:1633-1652. 3. Rothberg MB et al. Ann Intern Med. 2005;143:241-250.

Balancing Risks and Benefits of Prophylactic Anticoagulation Therapy

Q2: For how long?

1.  Until discharge from hospital

2.  10 – 14 days. 3.  28 – 35 days. 4.  Until ambulation is

achieved.

75

Untildischargefrom

hosp...

10–14days.

28–35days.

Untilambulationisachi...

25% 25%25%25%

:20

Duration of the risk of postoperative VTE Million-woman study

Sweetland S, et al. Br Med J. 2009;339:b4583.

Rel

ativ

e ris

k, (9

5% C

I)

1 2 3 4 5 6 7 0 8 9 10

40

80

120

160

200

11 12

Weeks since in-patient surgery

PE DVT

Relative risk for time without surgery = 1

Women having surgery were 70 times more likely to be readmitted with VTE up to 12 weeks post-operatively

Time course and clinical presentation of post-operative VTE in RIETE

Arcelus JI, et al. Thromb Haemost. 2008;99:546-51.

19%

77%

53% of VTEs were diagnosed after prophylaxis was

discontinued

PE Distal DVT Proximal DVT

24 hours 48 hours 7 days 15 days 30 days 60 days Clinically overt PE, % 22 (2.8) 41 (5.2) 149 (19) 376 (48) 608 (77) 787

Distal DVT, % 2 (1.1) 5 (2.8) 34 (19) 98 (54) 145 (80) 182

Proximal DVT, % 9 (1.4) 21 (3.3) 91 (14) 248 (39) 432 (68) 633

Days

Cum

ulat

ive

inci

denc

e

5 10 15 20 25 30 35 40 0

45 50 55 60 0

100

200

300

400

500

600

700

800

•  For patients undergoing major orthopedic surgery, we suggest extending thromboprophylaxis in the outpatient period for up to 35 days from the day of surgery rather than for only 10 to 14 days (Grade 2B)

Major Orthopedic Surgery: Total Hip Arthroplasty (THA), Total Knee Arthroplasty (TKA), Hip Fracture Surgery

(HFS)

Back to the Basics

79

Treatment DVT LMWH Vs UFH Meta-analyses

•  Authors  Leizorovicz et al ‘94  Lensing et al ‘95  Siragusa et al ‘96  Gould et al ‘99  Dolovich et al ’00  van den Belt ‘00

•  Outcomes  More or as effective  < Major bleeding  < Thrombocytopenia

Concerns With LMWH Use

•  Obesity •  Renal insufficiency •  Pregnancy •  Adverse effects

 osteoporosis  HIT

HIT = heparin-induced thrombocytopenia

UFH

•  Therapeutic levels -- First 24 hours. •  Otherwise, risk of recurrent VTE -- 15 X

Hull, et al. NEJM 1986; 315, 1109-13 Brandjes DPM et al. NEJM 1992; 327, 1485-90

Treat for at least 5 days with UFH or LMWH, overlapping

oral anticoagulation

Duration of Treatment

General Aspects

•  Short-term treatment associated with 15-50% frequency of extension of thrombus or recurrent disease.

•  Minimum duration 3 months. •  Treatment with VKA is the preferred approach

for long-term treatment.

WHY?

I Know I Don’t Know

Can I fix it?

Yes No

Idiopathic

4 months Indefinite

6 – 12 months vs.

Indefinite

Menajovsky L.B. Am J Med in press

Conclusions

•  Treat acutely with Heparin or LMWH •  Advantages of LMWH •  Either way: Treat for at least 5 days,

overlapping oral anticoagulation •  Thrombolytic therapy and

Thrombectomy for selected patients •  Careful discharge planning

Consequences of VTE

•  Recurrent VTE •  Post-thrombotic syndrome (PTS)1

  Presence of leg symptoms (pain, cramps, heaviness, pruritus, and paresthesia) and signs (pretibial edema, skin induration, hyperpigmentation, new venous ectasia, redness and pain during calf compression)

•  Mortality2

1. Prandoni P et al. Haematologica. 1997;82:423-428. 2. Pengo V et al. N Engl J Med. 2004;350:2257-2264.

Thank you!

Prevention and Treatment of DVT and PE (VTE) · Prevention and Treatment of DVT and PE (VTE) ... Case Study #1 27-year-old woman ... • History of Hypertension and DM type 2

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