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Venous Thromboembolism (VTE)

Venous Thromboembolism (VTE). Helbert Rondon, MD, FACP, FASN Assistant Professor of Medicine UNM Health Sciences Center. Outline. Epidemiology of VTE Physiology of Hemostasis Pathogenesis of VTE Risk factors for VTE Prevention of VTE

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Venous Thromboembolism (VTE)

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  1. Venous Thromboembolism(VTE) Helbert Rondon, MD, FACP, FASN Assistant Professor of Medicine UNM Health Sciences Center

  2. Outline • Epidemiology of VTE • Physiology of Hemostasis • Pathogenesis of VTE • Risk factors for VTE • Prevention of VTE • Clinical presentation, Diagnosis and Treatment of DVT and PE • Testing for Thrombophilia • Superficial Vein Thrombosis

  3. Epidemiology of VTE White RH. Circulation. 2003;107:I-4 –I-8

  4. Physiology of Hemostasis

  5. Risk Factors for VTE

  6. Pathogenesis of VTE: Virchow’s Triad

  7. Case #1 • 54 year-old man with PMH Liver cirrhosis is brought to ER c/o AMS and abdominal pain x 2 days • Vitals: BP=90/60, HR=100, R=21, T=38.9 C • Physical exam: • Abdomen: diffuse tenderness, caput medusae, ascites • Rectal : brown stool, negative hemoccult • Neurologic : Confusion, asterixis • Labs: WBC=18K, Hb=13.1, Plat=120K, INR=1.6, ammonia= 98 • Peritoneal fluid: WBC=973, Neutrophils=67%

  8. Which of the following is the most appropriate method of VTE prophylaxis for this patient? • Intermittent pneumatic compression • Graduated compression stockings • Enoxaparin 40 mg subcut BID • Enoxaparin 40 mg subcut daily PLUS Intermittent pneumatic compression • VTE prophylaxis not needed

  9. Prophylaxis for VTE

  10. Assessment of VTE risk Geerts WH et al. Chest 2008; 133:381S–453S

  11. Pharmacologic agents for VTE prophylaxis • LMWH: Enoxaparin 40 mg subcut once daily • UFH: Heparin 5000 units subcut BID or TID • Fondaparinaux 2.5 mg subcut once daily • ASA • Warfarin

  12. Mechanical methods of VTE prophylaxis • Intermittent pneumatic compression • Graduated compression stockings • Venous foot pump

  13. Case # 2 • 65 year-old woman with a long standing history of left knee osteoarthritis comes to your office c/o left calf pain and swelling • Vitals: BP=130/70, HR=100, R=21, T=36.9 ⁰C • Physical exam (see picture): • Left calf edema and tenderness • No erythema or palpable chord • (+) Homan’s sign • Labs: D-dimer = 100 ng/dL

  14. Case # 2 (cont.)

  15. What is the most likely diagnosis in this patient ? • Lymphedema • Ruptured Baker’s cyst • Deep venous thrombosis • Superficial venous thrombosis • Cellulitis

  16. Deep Venous Thrombosis (DVT)

  17. Proximal vs. Distal Lower Extremity DVT

  18. Clinical Manifestations of DVT • Calf swelling • Calf tenderness • Calf asymmetry greater than 1.5 cm • Palpable cord • Dilated superficial veins • Homans’s sign • Skin erythema • Altered skin temperature

  19. Diagnostic Accuracy of Physical Signs for DVT McGee S. Evidence-Based Physical Diagnosis. 2nd ed. Philadelphia, PA: Saunders; 2007: 614-619

  20. Differential Diagnosis of DVT • Muscle strain, tear, or twisting injury to the leg • Leg swelling in a paralyzed limb • Lymphedema • Venous insufficiency • Baker’s cyst • Cellulitis • Internal derangement of knee

  21. Diagnostic Tests for DVT • D-dimer (Very good NPV in the setting of low pretest probability) • Compression ultrasonography (Test of choice) • Impedance plethysmography (indicated in recurrent DVT) • Magnetic resonance venography • Contrast venography (Gold standard)

  22. Complications of DVT • Acute pulmonary embolism • Post-thrombotic syndrome • Phlegmasia cerulea dolens

  23. Assessment of Pretest Probability of DVT Scarvelis D et al. CMAJ 2006;175(9):1087-92

  24. Diagnostic Approach to DVT Scarvelis D et al. CMAJ 2006;175(9):1087-92

  25. Treatment of DVT • LMWH: Enoxaparin 1 mg/kg subcut Q12h • UFH: Heparin 80 units/kg (5,000 units) IV bolus, then heparin 18 units/kg/hour (1,300 units/hour) IV infusion • Fondaparinaux 7.5 mg subcut once daily • Initiate Warfarin together with LMWH, UFH or Fondaparinaux on the 1st treatment day • LMWH, UFH or Fondaparinaux for at least 5 days and until INR ≥ 2.0 for 24 hours

  26. Treatment of DVT (cont.) • Start Warfarin 5 mg PO daily • Target INR = 2.5 (range INR 2.0-3.0) • Duration of Warfarin treatment for 1st episode of unprovoked DVT or DVT due to a transient reversible factor: at least 3 months • Duration of Warfarin treatment for 2nd episode of unprovoked DVT or DVT due to a permanent factor (i.e. APAP): long-term

  27. Indications for Thrombolysis in DVT • Phlegmasia cerulea dolens  catheter-directed thrombolysis or surgical thrombectomy

  28. Indications for IVC filter in DVT • Absolute contraindication to anticoagulation • Recurrent DVT despite adequate anticoagulation

  29. Prevention of Post-thrombotic syndrome • Knee-high graduated compression stockings exerting a pressure of 30 to 40 mmHg at the ankle started ASAP and for at least 2 years

  30. Case # 3 • 35 year-old woman with PMH asthma presents to ER complaining of sudden onset SOB • Vital signs: BP=132/78, HR=90, RR=25, T=36.4 C, O2 sat=89% on RA • Physical exam: • Lungs: absent breath sounds and hyperresonance in right anterior chest • Extremities: no edema or erythema • EKG: normal sinus rhythm • CXR: emphysema, interstitial opacities, cystic airspaces, small right upper lobe pneumothorax • D-dimer: 100 ng/dL

  31. ER physician is concerned about PE. What is the next step in the management of this patient ? • Order a Spiral CT chest with IV contrast • Order a 2D echocardiogram • Order a V/Q scan • Order a Pulmonary angiography • PE has been ruled out, treat pneumothorax

  32. Acute Pulmonary Embolism (PE)

  33. Symptoms of PE • Dyspnea at rest or with exertion (73%) • Pleuritic chest pain (44%) • Cough (34%) • > 2-pillow Orthopnea (28%) • Wheezing (21%) • Hemoptysis (13%) • Symptoms of lower extremity DVT (42%) Stein PD et al. PIOPED II. Am J Med. 2007;120(10):871-9

  34. Diagnostic Accuracy of Physical Signs for PE McGee S. Evidence-Based Physical Diagnosis. 2nd ed. Philadelphia, PA: Saunders; 2007: 365-370

  35. Diagnostic Accuracy of Physical Signs for PE McGee S. Evidence-Based Physical Diagnosis. 2nd ed. Philadelphia, PA: Saunders; 2007: 365-370

  36. Laboratory • ABG: hypoxemia, respiratory alkalosis • High BNP and N-terminal pro-BNP levels • Increased Troponin I

  37. EKG • Non specific ST-segment and T wave changes  most common • Sinus tachycardia • RV strain • New incomplete RBBB • S1Q3T3 pattern

  38. S1Q3T3 pattern

  39. Chest X-ray • Cardiomegaly (24%)  most common • Pleural effusion (23%) • Elevated hemidiaphragm (20%) • Pulmonary artery enlargement or Fleischner’s sign (19%) • Atelectasis (18%) • Parenchymal pulmonary infiltrates (17%) • Westermark’s sign (rare) • Hampton’s hump (rare) Elliot CG et al. ICOPER. Chest. 2000;118(1):33-8

  40. Westermark’s sign

  41. Hampton’s hump

  42. Diagnostic tests for PE • D-dimer  Good NPV • 2D echocardiography • Spiral (Helical) CT chest with IV contrast  test of choice • V/Q scan • Pulmonary angiography (Gold standard)

  43. Spiral CT Chest with IV contrast

  44. V/Q scan

  45. Pulmonary Angiography

  46. Assessment of Pretest Probability of PE Kearon C. CMAJ 2003;168(2):183-94

  47. Diagnostic Approach to PE (Helical CT) Agnelli G et al. N Engl J Med 2010;363:266-74

  48. Diagnostic Approach to PE (V/Q scan)

  49. Treatment of PE • LMWH: Enoxaparin 1 mg/kg subcut Q12h • UFH: Heparin 80 units/kg (5,000 units) IV bolus, then heparin 18 units/kg/hour (1,300 units/hour) IV infusion • Fondaparinaux 7.5 mg subcut once daily • Initiate Warfarin together with LMWH, UFH or Fondaparinaux on the 1st treatment day • LMWH, UFH or Fondaparinaux for at least 5 days and until INR ≥ 2.0 for 24 hours

  50. Treatment of PE (cont.) • Start Warfarin 5 mg PO daily • Target INR = 2.5 (range INR 2.0-3.0) • Duration of Warfarin treatment for 1st episode of unprovoked PE or PE due to a transient reversible factor: at least 3 months • Duration of Warfarin treatment for 2nd episode of unprovoked PE or PE due to a permanent factor (i.e. APAS): long-term

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