final atlantic city dvt pe september 2017 · perc (pulmonary embolism rule out criteria) age
TRANSCRIPT
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James Neuenschwander, MD, FACEPResearch Director Genesis HealthCare Emergency Department. Zanesville, OhioAdjunct Associate Professor The Ohio State University WexnerMedical Center. Columbus, OhioAtlantic City, NJ September 2017
Disclosures � Janssen Consultant and speaker bureau
Tattoo of the Year
Objectives � Identify the causes and risk factors of DVT/PE
� Present clinical work up and evaluation of DVT/PE
� Offer options for treatment and management of DVT/PE
Definitions� Venous Thromboembolism = Deep Venous
Thrombosis (DVT) and Pulmonary Embolism (PE)
Venous Thromboembolism (VTE)
� Unprovoked VTE implies that no identifiable provoking environmental event for VTE is evident
� Provoked VTE is one that is usually caused by a known event (eg, surgery, trauma, significant immobility)
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DVT� Proximal DVT is one that is located in the popliteal,
femoral, or iliac veins
DVT� Distal: does not have proximal component, is located
below the knee, and is confined to the calf veins (perineal, anterior tibial, and muscular veins
Risk Factors� Virchow’s Triad
� Inherited Thrombophilia
� Gender-Related Factors
� Acquired Risk Factors
Virchow’s Triad
� Blood flow alteration
� Vascular injury
� Blood constituent alteration
INHERITED THROMBOPHILIACommon inherited hypercoagulable states
� Factor V Leiden mutation
� Prothrombin gene mutation
� Protein S deficiency
� Protein C deficiency
� Antithrombin deficiency
Risk Factors: Gender� Pregnancy
� Oral Contraceptives: Risk increases within the first 6 to 12 months
� HRT: Approximately twofold increase in VTE risk, greatest in the first year of treatment
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Major Acquired Risk Factors• More than 48
hours of immobility in the preceding month
• Hospital admission in the past three months
Major Acquired Risk Factors
(Pt. 2)• Surgery in the past
three months
• Malignancy in the past three months
• Infection in the past three months
Other Acquired Risk Factors� Trauma
� IV Drug Use
� Glucocorticoids
� Tamoxifen
� Chronic Renal Disease
� Chronic Liver Disease
� Cardiovascular Disease
� Obesity
� Hypertension
� Smoking
� Age
� IBS
Why?� Why do supermarkets make the sick walk all the way
to the back of the store for their prescriptions while healthy people can buy cigarettes at the front?
DVT Presentation� Features are nonspecific and sometimes
asymptomatic.
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DVT Presentation (Symptoms)� Most Common Symptoms
� Leg swelling or edema
� Leg pain
� Leg warmth
DVT Presentation (Physical Exam)� Dilated superficial veins
� Unilateral edema or swelling with a difference in calf or thigh diameters
� Unilateral warmth, tenderness, erythema
� Pain and tenderness along the course of the involved major veins
� Local (eg, inguinal mass) or general signs of malignancy
DVT Presentation (Scoring)� Wells Score
� -2 to 8 Point Scale
� ≤ 0 = Low Probability
� 1-2 = Moderate Probability
� 3-8 = High Probability
DVT Diagnosis (D-Dimer)� Elevated in nearly all patients with acute DVT
(Sensitive)
� Found in many other conditions (Not Specific)
� Negative result (<500 ng/mL) useful for ruling out DVT in the right clinical situation
DVT Diagnosis (Ultrasonography)� Diagnostic test of choice for suspected DVT
DVT Diagnosis - rarely usedCT – Thrombus is usually identified on CT by demonstrating a filling defect with contrast-enhancement.
Venography Expensive, technically difficult to perform and interpret, and can lead to complications
MRI
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Why?� Is the person that invests your money called a broker?
DVT Treatment: Anticoagulation� Anticoagulation is the mainstay therapy
� Benefits vs Risk of bleeding
� Benefits - Prevention clot extension, PE, and improved mortality
� Risk of bleeding.
Traditional Therapy
� Low molecular weight heparin (LMWH) 1 mg/kg bid vs 1.5 mg/kg once daily
� Coumadin (Vitamin K antagonist) with bridging to INR of 2.0 to 3.0
� 3, 6, to 12 months
Cancer Patients and Pregnancy� LMWH
End stage renal disease and
mechanical valves� No DOAC with CrCl < 15 ml/min
� Recommendation vs Indication
� Valvular disease with native valves
Direct Oral AntiCoagulants (DOACS) � Rivaroxaban, Apixaban, Edoxaban Factor Xa inhibitors
� Rivaroxaban and Apixaban do not need LMWH bridging – but Edoxaban does
� Fast onset
� No need for routine monitoring
� Expense of the drug vs in patient stay?
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Doacs continued…� Drug-Drug interactions
� CYP3A4 and P-gp inhibitors. Ketoconazole. Itraconazole. Ritonavir. Clarithromycin.
� CYP3A4 and P-gp inducers. Rifampin. Carbamazepine. Phenytoin. St. John’s Wort.
� CrCl < 30 ml/min
Dabigatran (Thrombin Inhibitor)� LMWH or UFH for transition
DrugsTrade Name
Scientific Name
Bridging Dose Study
Coumadin Warfarin LMWH or UFH
Variable Numerous
Xarelto Rivaroxaban None 15 mg BID x 21 days,20 mg once daily
Einstein
Eliquis Apixaban None 10 mg BID x 7d, 5 mg bid
Amplify
Pradaxa Dabigatran LMWH or UFH
150 mg BID Re-Cover
DVT Treatment: Serial
Ultrasonography� Possible with some distal DVT, can possibly avoid
anticoagulation with serial surveillance
Contraindications to
anticoagulation� Active bleeding
� Severe bleeding diathesis
� Platelet count than 50,oo0 (can be lower based on the strength of the indication)
� Recent planned or emergent high bleeding-risk surgery procedure
� Major trauma
� History of ICH
Relative contraindications
� Recurrent GI bleed
� Intracranial or spinal tumors
� Platelet count less than 100,000
� Large AAA with concurrent HTN
� Stable aortic dissection
� Recent, planned, or emergent low bleeding-risk surgery/procedure
� Frequent falls
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DVT Treatment: Thrombolytic
Therapy/ Thrombectomy� Not usually indicated for DVT –can be used for
extensive ileofemoral. Ekos catheter
� Phlegmasia cerulea dolens: may be important for patients with PCD who have severe venous gangrene
When to stop before a procedure?Many cardiologists say if they will cath on Friday, hold Thursday night dose of DOAC
Roughly 36 to 48 hours based on the procedure
Why?� Didn’t Noah swat those 2 mosquitos?
Reversal � Warfarin
� Vitamin K: oral vs IV
� PCCC (factors II, VII, IX, X) or Recombinant factor VIIa
� FFP (15 ml/kg)
Reversal cont…� Dabigatran
� Idaruczumad (Praxbind)
� IV administration 5 gm
� Widely available?
� Can restart 24 hours after reversal agent
Reversal cont…� Rivaroxaban, Apixaban, Edoxaban, LMWH
� No specific antidote but date set in February 2018 for Portola – Will only be indicated for Rivaroxaban and Apixaban. LMWH?
� Can not use dialysis (protein binding)
� Vitamin K will not work
� Protamine will not work on DOACs but will for LMWH anf UFH
� PCCC (factors II, VII, IX, X)
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Adexanet Alfa� Decoy protein that binds factor Xa inhibitor with
stronger affinity than natural factor Xa
� Decision in Feb. 2018 by FDA
Obese patients� Data still out.
DVT Treatment: Inferior Vena Cava
Filter� Not routinely used
� Used in patients with absolute contraindication to anticoagulation
� Effective?
DVT Disposition� Discharge if:
� Hemodynamically stable
� Low risk of bleeding.
� No renal insuffiency
� Favorable situation (caregiver support, phone, understanding of conditions in which to return if things detoriate)
� NOT FOR: massive DVT to the iliofemoral, phlegmasiacerulean doleans)
Why?� Is the time with the slowest traffic called rush hour?
Pulmonary Embolism� Definition: obstruction of the pulmonary artery or
one of its branches by material (eg, thrombus, tumor, air, or fat) that originated elsewhere in the body
� Acute, Subacute, Chronic
� Massive: Hemodynamically unstable
� Submassive: Right ventricular strain
� Low risk: No right ventricular strain
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PE� Saddle, lobar, segmental, subsegmental
� Bilateral or unilateral
� Symptomatic or asymptomatic
PE Presentation� Wide variety of features (no symptoms to shock or
sudden death)
� Most common presenting symptom is dyspnea followed by chest pain and cough.
PE Presentation (Symptoms)� Most Common Symptoms
� Dyspnea at rest or with exertion (73 percent)
� Pleuritic pain (66 percent)
� Cough (37 percent)
� Orthopnea (28 percent)
� Calf or thigh pain and/or swelling (44 percent)
� Wheezing (21 percent)
� Hemoptysis (13 percent)
PE Presentation (Physical Exam)� Common Physical
Examination Findings
� Tachypnea (54 percent)
� Calf or thigh swelling, erythema, edema, tenderness, palpable cords (47 percent)
� Tachycardia (24 percent)
� Rales (18 percent)
� Decreased breath sounds (17 percent)
� An accentuated pulmonic component of the second heart sound (15 percent)
� Jugular venousdistension (14 percent)
� Fever, mimicking pneumonia (3 percent)
PE Presentation (Scoring)� PERC (Pulmonary Embolism Rule Out Criteria)
� Age <50 years
� Heart rate <100 bpm
� Oxyhemoglobin saturation ≥95%
� No hemoptysis
� No estrogen use
� No prior DVT or PE
� No unilateral leg swelling
� No surgery/trauma requiring hospitalization within the prior four weeks
PE Diagnosis (D-Dimer)� Most useful in excluding PE in low risk patients
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PE Diagnosis (CT)� CTPA scan is the imaging modality of choice for
suspected PE
� Most sensitive and specific modality
PE Diagnosis (VQ Scan)� Modality of choice with patients that should not be
exposed to radiation or dye
� Less conclusive than CT, more inconclusive scans
PE Diagnosis (Radiography)� Not typically used to diagnose
� Hampton’s Hump
� Westmark’s Sign
PE Treatment: Initial Approach� Initial approach for patients with suspected PE should
focus upon stabilization
� Risk stratification is crucial (Hemodynamically stable/unstable)
PE Treatment: Initial Approach if
Unstable� Restore perfusion with IVF and vasopressors
� Stabilize airway
� UFH
PE Treatment: Definitive Approach
for Unstable Patients� Thrombolytic therapy is indicated in most
hemodynamically unstable patients, provided there is no contraindication
� Embolectomy indicated in those for whom thrombolytic therapy is either contraindicated or unsuccessful
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PE Treatment: Definitive Approach
for Stable Patients� If low bleed risks, anticoagulation is indicated
� For those with contraindications or a high bleeding risk, placement of an inferior vena cava (IVC) filter should be performed
DrugsTrade Name
Scientific Name
Bridging Dose Study
Coumadin Warfarin LMWH or UFH
Variable Numerous
Xarelto Rivaroxaban None 15 mg BID x 21 days,20 mg once daily
Einstein
Eliquis Apixaban None 10 mg BID x 7d, 5 mg bid
Amplify
Pradaxa Dabigatran LMWH or UFH
150 mg BID Re-Cover
PE Disposition� Discharge if HESTIA or PESI criteria met?
Weeda et al. on Reduced PE LOS
with rivaroxaban� 624 patients chart review
� Decreased LOS/Cost
� No Readmission Changes
� No Bleeds
Nguyen et al: Observation Not For
Sick People� PE still a serious disease
� According to IMPACT, ~46% of observation stay patients were at higher-risk for early post-PE mortality
Objectives � Identify the causes and risk factors of DVT/PE
� Present clinical work up and evaluation of DVT/PE
� Offer options for treatment and management of DVT/PE
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Questions??? References� UpToDate:� Overview of the causes of venous thrombosis - Authors: Kenneth A
Bauer, MD, Gregory YH Lip, MD, FRCPE, FESC, FACC� Clinical presentation and diagnosis of the nonpregnant adult with
suspected deep vein thrombosis of the lower extremity - Authors: Clive Kearon, MB, MRCP(I), FRCP(C), PhD, Kenneth A Bauer, MD
� Overview of the treatment of lower extremity deep vein thrombosis (DVT) – Authors: Gregory YH Lip, MD, FRCPE, FESC, FACC, Russell D Hull, MBBS, MSc
� Clinical presentation, evaluation, and diagnosis of the nonpregnantadult with suspected acute pulmonary embolism – Authors: B Taylor Thompson, MD, Christopher Kabrhel, MD, MPH
� Treatment, prognosis, and follow-up of acute pulmonary embolism in adults – Author: Victor F Tapson, MD