Venous Thromboembolism (VTE): DVT and PE

Clinic A/P, adults, Clinic A/P, Peds, Hospital A/P, Adults, Hospital A/P, Peds

Diagnosis
H&P
Risk factors?
Provoked vs. Unprovoked PE? –
Massive vs. Sub-massive?
Wells criteria.
Wells Criteria doesn’t work well inpatient.
Complications? –
Differential diagnosis & Etiology.
Diagnostic studies:
Treatment
Outpatient tx vs. Inpatient tx?
-“Most patients with DVT or low-risk PE can be treated in the outpatient setting with LMWH and a vitamin K antagonist (warfarin) or DOACs.
-“Inpatient tx of VTE begins with parenteral agents, preferably LMWH. UFH is preferred over LMWH if a pt is hemodynamically unstable, has severe renal insufficiency, high bleeding risk, or morbid obesity.”
Indication for thrombolysis?
-“Hemodynamically unstable patients with a low bleeding risk may benefit from thrombolytic therapy.”
Activity as tolerated. Early ambulation better than bed rest for DVT. If edema and pain is severe, may delay ambulation.
Both proximal DVT and PE are treated the same way.
Anticoagulation is the mainstay of tx. and is divided into three phases:
-“If warfarin, dabigatran, or edoxaban is used, LMWH or UFH must be administered concomitantly for at least 5 days and, in the case of warfarin, until the INR becomes therapeutic for 24 hours.”
-“Apixaban (Eliquis) and rivaroxaban (Xarelto) do not require concomitant use of heparin at initiation.”
-Active cancer or pregnancy: Use LMWH or UFH long-term.
-“Current guidelines recommend anticoagulation for a minimum of 3 months if there are no contraindications. Anticoagulation beyond 3 months should be individualized based on a risk/benefit analysis.”

—END—

UFH= Unfractionated heparin.

Background
Definition:
-DVT
-PE
Common presentation:

“One-half of patients with DVT will have long-term complications, including postthrombotic syndrome and venous ulcers. One-third of patients with VTE will have a recurrence within 10 years.”

**IVC filters should be avoided in patients with VTE treated with anticoagulation.

– Tx: phase 2 Treatment: Warfarin vs. DOACs
-DOACs may require dose adjustments for patients with kidney disease.
-Only Dabigatran has a commercially available reversal agent. idarucizumab (Praxbind),
-The ACCP recommends the use of DOACs over warfarin for VTE treatment in patients without cancer.

“About one-third of patients with VTE present with PE, and two-thirds present with DVT. Compared with DVT, PE is more often fatal, has a higher recurrence rate, and is associated with more serious long-term complications. Of patients with proximal DVT, 40% have an associated PE, whereas 70% of patients with PE also have DVT” AAFP 2017

“Patients with PE who are hemodynamically unstable (e.g., those with hypotension or evidence of shock) should be admitted to an intensive care unit, and systemic thrombolytic therapy may be considered.”

Isolated distal DVT: Symptomatic distal DVT should be treated with anticoagulation, but asymptomatic patients may be monitored with serial imaging for two weeks and treated only if there is extension.

“Do not treat with an anticoagulant for more than three months in a patient with a first venous thromboembolism occurring in the setting of a major transient risk factor.” American Society of Hematology.

Pulmonary Embolism
DVT

VTE (DVT/PE) Pearls and Important links

References

Am Fam Physician. 2017 Mar 1;95(5):295-302. http://www.aafp.org/afp/2017/0301/p295.html

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