Daniel Gilada Prevalence 1 million cases a year Nearly 23 hospitalized Risk factors Hereditary Acquired Reversible Irreversible Diagnosis Duplex ultrasound Sensitivity amp specificity of 95 amp 98 ID: 555328
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Outpatient DVT assessment & treatment
Daniel GiladaSlide2Slide3Slide4
Prevalence
~1 million cases a year
Nearly 2/3 hospitalized
Risk factors
Hereditary
Acquired
Reversible
IrreversibleSlide5
Diagnosis
Duplex ultrasound
Sensitivity & specificity of 95 & 98%
D-Dimer
Contrast
venogramSlide6
Classification
Provoked
UnprovokedSlide7Slide8
Goals of treatment
Prevent recurrence
Embolism
Thrombosis-related deathSlide9
Outpatient treatment
Physician must assess
The patient is ambulatory and in stable condition, with normal vital signs
There is a low a
prior
risk of bleeding in the patient
Severe renal insufficiency is not present
There is a practical system in place for the following:
Administration of LMW heparin and/or warfarin with appropriate monitoring,
and
Surveillance and treatment of recurrent VTE and bleeding complicationsSlide10
Therapies
Warfarin
Low-molecular weight heparin
Fondaparinux
Non-vitamin K antagonist oral anticoagulants (NOACs)Slide11
Warfarin
Vitamin K antagonist
Preferred due to longer clinical experience, available antidotes, and cost
Drawbacks
1.5-2x recurrence of DVT if treatment was 4-6
wks
vs
3-6 monthsSlide12
Low-molecular weight heparin
Indirect
Xa
inhibitor through ATIII
Dosing 1 mg/kg SC BID (ABW)
If Cl
Cr
20-29mL/min, 1mg/kg SC daily
Considerations
Potential benefits compared to warfarinPost-thrombotic syndromeRecanalization of thrombosed
veins
Venous ulcerationSlide13
Fondaparinux
Indirect
Xa
inhibitor through
ATIII
Monitoring not required
Considerations
Like enoxaparin, transition from unfractionated heparin can be immediateSlide14
Factor
Xa
and direct thrombin inhibitors
Avoid in CKD
Patient preference
Considerations
Ileofemoral
DVT
Pregnancy
Active cancerRivaroxaban 15mg BID x 3 weeks; then 20mg daily
Apixaban
10mg BID x 1 week; then 5mg BID
Dabigatran
150mg BID*Slide15
Contraindications
A
ctive bleeding
Severe
bleeding
diathesis
PLT
<
50,000R
ecent, planned, or emergent surgery/procedure, major trauma History of intracranial hemorrhageSlide16
Duration
Unprovoked DVT or symptomatic PE
Indefinitely
Second episode of provoked DVT
Provoked
DVT
with persistent risk factors
APS, malignancySlide17
American College of Chest Physicians (ACCP) Guidelines 2012
Isolated distal DVT
Severe symptoms
Treat
3 months
regardless of etiology (surgery, hospitalization, estrogen therapy,
vs
unprovoked
Mild symptoms
Physician can do serial ultrasound Treat if clot extension presentSlide18
ACCP
Proximal DVT
Traditional treatment
3 months
Surgery
Estrogen therapy
Long-distance travel
Inpatient status
Indefinite
Unprovoked (idiopathic)Slide19
ACCP
Incidental finding
Leg, pelvic, or IVC
Standard therapy
Cancer associated DVT
3 months
Upper extremity DVT
3 months
CatheterSlide20
ACCP
Superficial thrombophlebitis
LMWH or fondaparinux
45 days
IVC filter
Active or high risk bleeding
Slide21
ACCP
Compression stockings
2 years
Slide22Slide23
Other considerations
Recurrent unprovoked VTE
Recurrent provoked VTE
Provoked VTE with persistent risk factors
Indefinite
Depends on risk factorsSlide24
DASH prediction score
Age ≤ 50 +1
Male sex +1
Hormone use at the time of VTE -2
D-dimer
+2
DASH score:
≤ 1 annual VTE recurrence risk 3.1%
≥ 2 annual VTE recurrence risk 6.4% Slide25
Special populations
Pregnancy risk factors
>35
yo
C-section
Pre-
eclampsia
Prior DVT history
LMWH at least 6 weeks post-partumSlide26
IVC filter
High bleeding risk
Active bleeding, major surgery, hemorrhagic strokeSlide27
Other considerations
Malignancy
decision to
anticoagulate
for extended periods, should be balanced against the risk of bleeding, cost of therapy, quality of life, life expectancy, and patient preference.Slide28
ThrombectomySlide29
References
H
opkinsmedicine.org
Uptodate.com
Clevlandclinicmeded.com