A

Further testing serial U/S or pulmonary angio

PE confirmed

Based on data from JAMA 1990:263:2753: Annob 2001:13S:98

Workup for Idiopathic VTE

• Thrombophilia workup: recurrent or idiopathic DVT/PE » (age <50. © FHx. unusual location, massive); may not predict recurrence. ? utility of w/u (JAMA 2005:293:2352)

• Malignancy workup: 12% pts w/"idiopathic" DVT/PE will have a malignancy; initial screening is adequate: H&P (breast, abd. FOBT. pelvic, rectal), basic labs (CMP. CBC. U/A);CXR. up-to-date mammo.. colonoscopy; avoid extensive w/u (nejm 1998:338:1169) Risk stratification for Pts with PE

• Clinical: hypotension and/or tachycardia ( 30% mortality), hypoxemia

• CTA: RV i LV dimension ratio >0.9 (Ok 20043103276)

• Biomarkers: I troponin (Ore 2002:106:1263).' BNP (Ore 2003:107:1576)

• Echocardiogram: RV dysfxn (2x T mort) Treatment of VTE (CJku 2004:126:401-s)

• Calf-vein DVT: sx. extending to proximal veins or associated PE — anticoagulate

• UE DVT: spontaneous anticoagulate (? catheter-lysis, angioplasty, surgery)

catheter-associated: if sx anticoagulate & ? catheter removal; asx observe

• Acute anticoagulation (inrt/ote immediately if high clinical suspicion!)

IV UFH: 80 U/kg bolus - 18 U/kg/h - titrate to goal PTT 60-85 sec (1.S-2.3 x end), or SC UFH: 333 U/kg X1 250 U/kg bid (jama 2006396935). or

LWMH: enoxaparin 1 mg/kg SC bid or dalteparin 200 lU/kg SC qd (A/moh 1999:130:800) LWMH preferred over UFH except: renal failure (CrCI <25). ? extreme obesity, hemodynamic instability or bleed risk (Chest 2004:126:401s & Coehrone 2004.cd001100) attractive option as outPt bridge to long-term oral anticoagulation Fondaparinux: 5-10 mg SC qd - UFH (matisse, 2003:349.1695). used in HIT © Pts Direct thrombin inhibitors (eg. argatroban. lepirudin) used in HIT <+) Pts

• Thrombolysis (TPA 100 mg over 2 h or 0.6 mg/kg over 3-15 min)

extensive DVT or massive PE causing hemodynamic compromise controversial for RV dysfunction alone as no mort. benefit (nejm 2002:347:1143)

• Thrombectomy: if large, proximal PE ♦ hemodynamic compromise * contra, to lysis;

also consider in experienced ctr if Ig prox. PE • RV dysfxn (/Thome Of Surg 2005:129:1018)

• IVC filter, if anticoagulation contraindication, failure, bleed or I CP reserve; temp, filter if risk time-limited; PE 1 1/2. DVT T 2 x . no mort. drff. (NEJM 1998:338 409: Ore 2005:112.416)

• Long-term anticoagulation

Warfarin: start when PTT therapeutic or after 1w dose of LMWH; overlap x 5 d wI

heparin; goal INR 2-3 (superior to 1.5-2; elatenejm 2003:349631) Reversible or time-limited risk factor: 3-6 mos of warfarin Idiopathic PE/DVT: long-term ( 5 y) superior to 6 mos (prevent, nejm 2003:348:1425) 2nd event, cancer, nonmodifiable risk factor: 12 mos - lifelong (durac ii.n£jm 1997:336:393) Pts w/ cancer: long-term Rx w/ LMWH superior to warfarin (clot, nejm 2003349:146) / head CT if melanoma, renal cell, thyroid, or chorioCA as brain mets tend to bleed

Complications & Prognosis

• Post-thrombotic syndrome (25%): pain, swelling; i with compression stockings x 3 mos

• Recurrent VTE: 1%/y (after V'VTE) to 5%/y (after recurrent VTE)

after only 6 mos of Rx: 5%/y & >10%/y, respectively predictors: D-dimer u:250 after d/c anticoag (jama 2003:290:1071);© U/S after 3 mos of anticoag (anoafc 2002:137:955); thrombin generation >400 nM (jama 2006:296:397)

• Chronic thromboembolic PHT after acute PE 3.8% (nejm 20043S03257)

• Mortality: 17% at 3 mos (PE. cancer, resp. failure); 75% of those die during initial hosp.

Thromboprophylaxis

Risk

Patient & situation

Prophylaxis

VTE « 1%

• minor surgery, age -:40, no RF

early ambulation

Moderate

DVT 2-4% PE 1-2%

• major surgery, age <40. no RF

LDUH 5.000 U q12h

LMWH dalt 2.500 qd or enox 20 mg qd

DVT 4-8% PE 2-4%

■ Ml, CVA. bed rest, chronic illness

LDUH 5,000 U q8h

LMWH dalt 5.000 qd or enox 40 mg qd

DVT 10-20% PE 4-10%

• orthopedic surgery, trauma

• acute spinal cord injury

LMWH dalteparin 5.000 U qd or enoxaparin 30 mg bid fondaparinux 2.5 mg qd

RF risk factor; includes: immobility, varlcosc veins, CHF, malignancy, thrombophilia, prior VTE: ES ^ elastic stockings; IPC = intermittent pneumatic compression; LDUH « low-dose SC UFH (Chest 2004; 126:388-$)

RF risk factor; includes: immobility, varlcosc veins, CHF, malignancy, thrombophilia, prior VTE: ES ^ elastic stockings; IPC = intermittent pneumatic compression; LDUH « low-dose SC UFH (Chest 2004; 126:388-$)

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