1. Venothrombotic DiseaseDiagnosis and Treatment Jeffrey P Schaefer, MSc, MD, FRCPC January 31, 2006 slides available: www.ucalgary.ca/~jpschaef guidelines available: www.chest.org

2. Objectives • Venothrombotic Disease • diagnosis • therapy / prevention

3. Data Sources - Therapy American College of Chest Physicians CHEST Supplement September 2004 Volume 126(3) **Uptodate & eMedicine are not recent ***

4. full text guidelines available to anyonewww.chest.org  supplements

5. Venothrombotic disease (VTED) • superficial thrombophlebitis • deep vein thrombosis • lower limb • upper limb • pulmonary thromboembolism • post-thrombotic syndrome

6. Superficial Vein Thrombophlebitis

7. Superficial Leg Veins  Saphenous (L & S)

8. Superficial Vein Thrombophlebitis

9. Superficial Thrombophlebitis • Presentation • inflammation along course of vein • complicates 20% of IV infusions

10. Superficial Thrombophlebitis • Conditions Similarly Presenting • DVT • cellulitis • lymphangitis • panniculitis • insect bite • erythema nodosum • cutaneous polyarteritis nodosa (PAN) • sarcoid granuloma • Kaposi's sarcoma

11. Superficial Thrombophlebitis • Diagnosis • risk factor assessment • clinical assessment • inflammation along superficial vein • rule out DVT*** • rule out other conditions

12. Superficial Thrombophlebitis and Deep Vein Thrombosis • 42 leg ST without clinical DVT  • found 4 above knee DVTs and 1 below knee DVT • DVT 12% J Vasc Surg 1990 Jun;11(6):818-23 • 21 ambulatory ST long saphenous vein  • found 7 high probability V/Q scans • PE = 33.3% (95%CI: 15 to 57) • clinical PE present in only one J Vasc Surg 1999 Dec;30(6):1113-5

13. Potentially Lethal Misnomer  SFV = deep

14. Superficial Thrombophlebitis Tx • Complication of Infusion • topical or oral NSAID • warmth / elevation • Spontaneous Superficial Thrombophlebitis • intermediate dosages of UFH or LMWH for at least 4 weeks • JPS  dalteparin 5,000 sq od x 4 wks for most, consider full dose tinzaparin if severe

15. Take-Home-PointsSuperficial Thrombophlebitis (ST) • Exclude DVT among ST patients • Superficial Femoral Vein is a deep vein • Spontaneous ST  heparin • Infusion-related ST  NSAID

16. Deep Vein Thrombosis

17. Incidence of DVT and PE • 117 / 100,000 / year among all • 900 / 100,000 / year among 85 year olds Am Fam Phys 2004;69(12):2829-36 • Alberta 2005 Population (3.2 m) • 3,223,400 x 117 / 100,000 = 3,771 VTEDS/yr • 3,223,400 x $400 = $1,289,360,000

18. Calgary Health RegionJan 1 to June 30, 2001 • 1,400 patients investigated for DVT • 33% inpatient • 40% emergency dept • 27% outpatient • 3,175 patients investigated for PE • 60% inpatient • 25% emergency dept • 15% outpatient QIHI

19. Calgary Health RegionJan 1 to June 30, 2001 • DVT tests • 4,200 leg ultrasounds • 2,500 bilateral • 1,700 unilateral • 95 venograms • PE tests • 1,400 V/Q scans • 130 CT scans • 100 pulmonary angiograms • Estimated cost: $1,500,000QIHI

20. DVT - diagnosis • Clinical Suspicion • D-dimer screen • Compression Ultrasound • Venography • (MRI expensive) • (IPG ‘discredited’)

21. MRI  Positive for DVT • sensitivity 100% & specificity 96% J Vasc Surg 1993 Nov;18(5):734-41

22. DVT - diagnosis • Clinical Suspicion - any one feature performs poorly

23. Well’s DVT Clinical Prediction Rule • Cancer 1 • Paralysis 1 • Bedridden 1 • Tender vein 1 • Leg swollen 1 • Calf swollen 1 • Pitting edema 1 • Collaterals dilated 1 • Alternative dx - 2 • TOTAL: 3 (high 75%), 1-2 (mod 17%), 0 (low 3%) Lancet 1997;350:1795-8

24. Well’s Criteria - study excluded those with previous VTED, needed indefinite anti-coagulation, imminent death

25. D - dimer • D-dimer Assay • D-dimer is breakdown product of fibrinolysis • high sensitivity (98%) & modest specificity (~50%) • useful for excluding DVT and PE • not useful for confirming diagnosis • SHOULD NOT TO BE USED • post-operative patient • pregnant patient • patient with malignancy

26. Duplex Ultrasonography • Duplex US • above knee DVT • Sens = 96% • Spec = 96% Haemostasis 23:61-7 • calf dvt • sens = 80%

27. Venography • Gold standard (sens 100%, spec 100%)

28. CHR Protocol

29. Pulmonary Thromboembolism

30. Pulmonary Thromboembolism • Diagnosis • Clinical • D-dimer • Ventilation - Perfusion Scan (V/Q scan) • Spiral CT Scan • Pulmonary Angiogram

31. PE - clinical diagnosis • Symptoms of PE in 117 previously normal patients • dyspnea 73% • pleuritic pain 66 • cough 37 • leg swelling 28 • leg pain 26 • hemoptysis 13 • palpitations 10 • wheezing 9 • angina-like pain 4 Chest 100:598, 1991

32. PE - clinical diagnosis • Signs of PE in 117 previously normal patients • tachypnea (20/min) 70% • rales (crackles) 51 • tachycardia (>100/min) 30 • fourth heart sound 24 • increased P2 23 • diaphoresis 11 • temperature >38.5°C 7 • wheezes 5 • Homans' sign 4 • right ventricular lift 4 • pleural friction rub 3 • third heart sound 3

34. Well’s PE Clinical Prediction Rule • Signs/Symptoms of DVT 3.0 • measured leg swelling AND • pain with palpation in the deep vein region • Alternative diagnoses less likely than PE 3.0 • history, physical exam, chest X-ray, EKG, lab results • Pulse > 100 beats/min 1.5 • Immobilization 1.5 • bedrest (except access to BR)  3 days OR • surgery in previous 4 weeks • Previous DVT or PE 1.5 • Hemoptysis 1.0 • Malignancy 1.0 • receiving active treatment for cancer OR • have received treatment for cancer within the past 6 months OR • are receiving palliative care for cancer • TOTAL: >6 (high 78%), 2-6 (mod 28%), < 2 (low 3%) Thromb Haemost 2000;83;418

35. D-Dimer • Same as PE

36. PE - diagnosis (V/Q scan) • high probability V/Q scan (2 defects)

37. V/Q scan normal  PE ruled out near normal  PE ruled out low probability  can’t rule in nor out indeterminate  can’t rule in nor out high probability  PE ruled in

38. Most V/Q Scans are non-diagnostic

39. PE - diagnosis (spiral CT scan)

40. Sprial CT Scanning

41. Helical (Spiral) CT Scan • 914 ER pts: chest pain and dyspnea • 858 eligible for study • clinical assessment (Well’s) AND D-dimer • +/- Helical CT • +/- Compression Ultrasound J Emerg Med 2005 Nov;29(4):399-404

42. J Emerg Med 2005 Nov;29(4):399-404

43. 409 with negative CT AND negative US 2 of these were diagnosed with DVT (day 37 & 73)

44. PE - diagnosis Venography - gold standard - (100% / 100%)

45. CHR Protocol

46. Pregnancy • Ionizing Radiation Exposure • first 8 weeks has highest risk for in utero death • most frequent abnormality is microcephaly / mental retardation among term infants • 8 to 15 wk most sensitive period for retardation • risk of severe mental retardation • 4% for 10 rad • 60% for 150 rad • relative risk of childhood leukemia • RR = 1.5 – 2.0 (1 – 2 rad exposure) • 1:3000 (general population)  1:2000 • risk of sib of leukemic child 1:700

49. Take-Home-PointsDiagnosis of DVT and PE • Multimodal approach • Clinical • D-dimer • US / VQ / Spiral CT • Studies exclude those with previous VTED • Fetal risk is low but anxiety may be high (having numbers is helpful)

50. Overview of Prevention / Treatment Patient at Risk DVT PE Death Prevent DVT Treat DVT = Prevent PE Treat PE = Prevent More PE Treat PE