Grant M Greenberg MD MA MHSA Overview Identify the challenges in diagnosis of Venous Thromboembolic Disease Diagram current protocolspathways for evaluation and treatment of VTE Review current anticoagulation ID: 683712
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Venous Thromboembolic Disease: The Role of Novel Anticoagulants
Grant M. Greenberg MD, MA, MHSASlide2
Overview
Identify the challenges in diagnosis of Venous Thromboembolic Disease
Diagram current protocols/pathways for
evaluation
and treatment of VTE
Review current anticoagulation
options
and their benefits/trade offsSlide3
Diagnosing VTE can be tricky
Diagnosis can be challenging and uncertain
Risk factors are non-specific
Clinical findings alone are not adequate
Imaging Modalities need to be put into context of pre-study probability
Labs such as D-Dimer only helpful if negativeSlide4
Diagnostic Approach to VTE
DVT
Presentation
No “typical” story makes dx challenging
Risk Factors
To apply pre-test probability
Testing
Imaging
Laboratory
PE
Presentation
Can be used to assess pre-test probability
Risk Factors
Same as for DVT
Testing
Imaging
LaboratorySlide5
VTE Selected Risk Factors
Prior VTE
Advanced age (>70)
Malignancies
Surgery
Trauma
Pregnancy
Hormonal agents containing estrogen
ObesityImmobilization
Inherited ThrombophiliaCHFPolycythemia vera
Nephrotic syndrome
Inflammatory Bowel DiseaseSlide6
Wells Criteria for Likelihood Estimation of DVTSlide7
Finding a LE DVT: the challenge of the clinical scenario
Calf swelling or tenderness (50% of cases)
Leg Pain
Palpable Cord may or may not be present
Tissue Erythema
Superficial Thrombophlebitis has similar S/SxSlide8
LE DVT: Diagnostic Modalities
Low Pre-test Probability
Exclude dx with neg hsD-Dimer (NPV 99.5%)
If D-Dimer positive, proceed with Duplex US (NPV > 99.5%)
Moderate Pre-test Probability
Whole leg Duplex positive, proceed to treatment
High Pre-test Probability
Whole leg Duplex positive, proceed to treatmentSlide9
PE: Associated Clinical FindingsSlide10
Modified Wells’ Criteria for Assessment of Pretest Probability for Pulmonary Embolism
Criteria
Points
Clinical signs and symptoms of DVT
(objectively measured calf swelling and pain with palpation in the deep vein region)
3.0
An alternative diagnosis is less likely than PE
3.0
Heart rate >100 beats per minute
1.5
Immobilization or surgery in the previous four weeks
1.5
Previous DVT or PE
1.5
Hemoptysis
1.0
Malignancy (on treatment, treated in the past six months, or palliative care)
1.0
Score
Mean Probability
Risk
<2 points
3.6
Low
2 to 6 points20.5Intermediate>6 points66.7High
From Wells et al., Ann Int Med 2001;135:98-107.Slide11
PE: Diagnosis
Low Clinical Likelihood
hs D-Dimer, if negative, no further testing (NPV 99%)
hs D-Dimer positive, proceed with imaging
Intermediate or High Clinical Likelihood
Direct to imaging Slide12
PE Imaging Modalities
CT Angiography (Pulmonary Angiography)
Requires IV Contrast
CT Venography (Pelvic Venography)
V/Q (Ventilation/Perfusion Scan)
Still useful if no infiltrate/effusion and CTA contraindicated
A positive LE Duplex US in the setting of High Clinical Likelihood can establish the
diagnosis
without additional imagingSlide13
Managing CTA results by pre-test probability still important…
Further
investigation is required
if:
Low clinical likelihood and CTA positive
for sub- or segmental
embolism
a
high or intermediate clinical likelihood, but negative CTA resultsV/Q scanning may be helpful or Pulmonary angiography may be required in some
casesavoid the risk of
missing
PE or
unnecessary long-term anticoagulationSlide14
VTE Treatment: Oral Anticoagulants
** not FDA approved for VTE as of 5/2014Slide15
Novel Oral Anticoagulants (NOACs)
PRO
Do not require monitoring blood work
Lower bleeding risks
“Non-inferior” to standard therapy
Bridging with heparin (LMWH) not required
CON
No
reversal
agents yet
No clear advantage for compliance
$$$$$ (non-generic)Slide16
NOACs and Compliance
Chatterjee
S,
Sardar
P,
Giri
J,
Ghoshi
J, Mukherjee D. Treatment
discontinuations with new oral agents for long-term anticoagulation: insights from a meta-analysis of 18 randomized trials including 101,801 patients
Mayo
Clinic Proceedings
.
89.7 (July 2014): p896Slide17
Duration of Therapy
3 months
Indefinite
Other
Calf Vein DVT w/
reversible cause
x
Idiopathic
VTE
x
Proximal DVT, no prior event, with reversible
cause
x
Proximal DVT or PE, no prior event, without reversible
cause
x
VTE and
active cancer
x
Thrombophilia:
heterozygous factor V Leiden, first VTE,
x
recurrent VTE, +/- thrombophilia with affected first deg relatives, protein c, protein S, antiphospholipid syndrome
xVTE in PregnancyxAnd for at least 6 weeks PPSlide18
Managing Anticoagulation: There’s a website for that….
http://anticoagulationtoolkit.org/