venous thromboembolism: diagnosis and managament r. cavalcanti and b. laluck april, 2007
TRANSCRIPT
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Venous Thromboembolism:
Diagnosis and Managament
R. Cavalcanti and B. LaluckApril, 2007
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Learning objectives
• Review factors affecting risk of VTE• Understand an approach to diagnosis
of VTE • Review aspects of treatment of VTE
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Outline
• Cases• Diagnostic algorithm• Prophylaxis • Type and duration of anticoagulation• IVC filters
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Case 1
• 68F Post op day #2 after R TKR• Referred for fever + SOB • PMHx: HTN, osteoporosis, 40pyr
smoker• Meds: Alendronate, Atenolol/HCTZ,
Dalteparin 5000, Moxifloxacin• Over 2 d has needed increasing O2
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Case 1 (cont)
• OE: HR110 RR24 BP90/50 SPO2 90% on 50%FM T 38.5 CVS N hs; JVP 4-5 cm ASA Chest: Fine crackles over bases, long expiratory
time
• Inv: CBC: 98 11.7 318 Lytes 138 104 3.5 26 ABG:7.43 34 65 23 on FiO2 0.5
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CT Angio Chest
• No PE• Diffuse interstitial changes consistent
with pulmonary edema• Left lower lobe opacity
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Case 2
• 23 F presents with shortness of breath
• OCP, smoker and recently flew in from Berlin
• Now requires 2L O2 NP for SpO2 96%
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Case 3
• 83 F presenting with BRBPR C-Scope: large rectal tumour Unilateral R leg swelling
• Doppler US LE: Positive for DVT
• Management?
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Tests for VTE
• Wells score:• D-dimers:• Venous Doppler US• CT Angio Chest• VQ scan• Conventional pulmonary angiography
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Estimating risk
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Risk of DVT
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Wells Prediction Rule for Diagnosing Deep Venous Thrombosis: Clinical Evaluation Table for Predicting Pretest Probability of Deep Vein Thrombosis
Active cancer (treatment ongoing, within previous 6 months, or palliative) 1
Paralysis, paresis, or recent plaster immobilization of the lower extremities1
Recently bedridden >3 days or major surgery within 12 weeks requiring general or regional anesthesia
1Localized tenderness along the distribution of the deep venous system
1Entire leg swollen
1Calf swelling 3 cm larger than asymptomatic side (10 cm below tibial tuberosity) 1Pitting edema confined to the symptomatic leg 1Collateral superficial veins (nonvaricose)
1Alternative diagnosis at least as likely as deep venous thrombosis
–2
Note: Clinical probability: low 0; intermediate 1–2; high 3. In patients with symptoms in both legs, the more symptomatic leg is used.
Reprinted from The Lancet, Vol 350, Wells PS, Anderson DR, Bormanis J, et al. Value of assessment of pretest probability of deep-vein thrombosis in clinical management, pp 1795–1798, Copyright 2002, with permission from Elsevier.
Clinical Characteristic Score
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Adapted from Wells, Thromb Hemost 2000
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Diagnostic approach
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Diagnostic approach
• Assess risk• D-dimer• Lung Imaging
CT angiography of Chest VQ Scan
• Leg imaging CT venography Venous doppler US
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First step
• Assess risk Wells prediction rule
Validated in number of studies (17 DVT / 3 PE)
Induvidual features low predictive value Works best for younger patients without
comorbitidies or a history of VTE Clinical judgement should be used in older
patients with co-morbidities
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D-dimer
• Usefulness depends on number factors Sensitivity (must be high or 3rd generation) Other reason for +
Any trauma, surgery enough to get blood to clot will elevate D-dimer
Probability of disease• When used alone
In patient’s with comorbidity, older age, longer duration of symptoms in low to moderate risk Only 40 – 50% specificities
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Wells + D-dimer
• If you have a patient with low pretest probability of DVT / PE and a HIGH – sensitivity D-dimer is negative 0.5% incidence of in 3 months of DVT
No need for further imaging
• If you have a patient with mod to high pretest probability of DVT / PE and a HIGH – sensitivity D-dimer is negative 3.5% and 21.4% DVT risk within 3 months Further imaging needed
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Leg Ultrasound performance depends on symptoms
• SYMPTOMS PRESENT
• Proximal DVT positive test rules in negative test rules out
sensitivity 90-95% specificity 95%
• Distal DVT positive test rules in negative test DOESN’T
rule out sensitivity 60%; specificity 90-95%
• NO SYMPTOMS• Proximal DVT
positive test rules in negative test
DOESN’T rule-out sensitivity 60% specificity 90-95%
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PIOPED II
• CT Angio chest Sn 83% Sp 96%
• CT Angio chest + CT Venography Sn 90% Sp 95%
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Prevalence of PE by CT Angio Results and Wells
Score
High Interm.
Low Total
CT + 99% 89% 38% 86%
CT - 39% 7% 0.5% 5%
PIOPED II NEJM 06
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Controversy
• Are the next generation multidetector CTs better
• To what level does the study see clots (segmental, subsegmental?)
• What should come first Leg doppler vs CTA?
• In a patient with a high pretest probability for PE Is CTA sufficiently sensitive?
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VTE Prophylaxis
Treating medical and surgical patients at high risk of
developing DVT
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VTE Prophylaxis - non pharmacological
• Mobilization If possible
• Graduated compression stockings (GCS) TEDS
• Intermittent pneumatic compression (IPC) For surgical patients
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VTE Prophylaxis - Rx
• Low dose unfractionated heparin (LDUH) 5000 u sc q12h or q8h
• Low molecular weight heparin intermediate dose (LMWH) Enoxaparin 30 mg bid or 40 mg od Dalteparin 5000 u od
• Fondaparinux 2.5 mg sc od
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VTE Treatment
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VTE Treatment - Rx
• High dose unfractionated heparin (UFH) IV Titrated drip
• Low molecular weight heparin treatment dose (LMWH) Enoxaparin Tinzaparin Dalteparin and others
• Fondaparinux • Coumadin (INR 2 – 3)
With at least 4-5 days of heparin• Direct thrombin inhibitors
For patients with HIT (done via hematology)
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VTE Treatment
• Heparin vs LMWH Safety and efficacy Multiple studies
LMWH superior for treatment • Less mortality and major bleeding• Magnitude not very large
LMWH at least as effective as UFH
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VTE Treatment
• Outpatient vs Inpatient Treatment Number of studies Likely that LMWH at home is as least as
safe as inpatient treatment for DVT In appropriately chosen patients with
required supports in place
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VTE Treatment duration
• If OR is only RF - reversible Recommeded duration 3 months
• If ongoing RF At least 6 months
• For ongoing malignancy LMWH (CLOT trial)
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IVC Filters
• Limited evidence: no RCTs
• Retrievable filters are available Can be removed up to 6 weeks Recent case series: 91% retrievable Risk of migration
• Can be adjunctives in patients with existing recent DVT in which anticoagulation contraindicated