ACUTE DVT MANAGEMENT Richard J. DeMasi, MD April 26, 2014

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1 ACUTE DVT MANAGEMENT Richard J. DeMasi, MD April 26, 2014

2 Thromboembolism epidemiology 5 million DVT s 900,000 PE s 290,000 fatalities Heit J. Blood. 2005;106: VTE events Since this talk began

3 DVT Treatment Goals Anticoagulation

4 DVT TREATMENT GOALS Primary : PREVENTION OF PE Prevention of CVI Secondary : Prevent progression Treat symptoms

5 In the beginning, there was heparin.

6 MARIA M.W. KOOPMAN, M.D. et al THE NEW ENGLAND JOURNAL OF MEDICINE March 14, 1996 Conclusions. In patients with proximal DVT, treatment with low-molecular-weight heparin at home is feasible, effective, and safe. (N Engl J Med 1996;334: ) 1996, Massachusetts Medical Society.

7 Levine et al: New England Journal of Medicine 1996; 334 (11): Patients given LMWH primarily at home had no clear difference in: recurrent thromboembolism, major bleed or death Patients given LMWH spent about 5 days less in hospital than those given standard heparin.

8 Outpatient Management of DVT Reduce Hospital Admissions Less Expensive Patient preference

9 DVT Diagnosis Unilateral Leg Pain Swelling Cyanosis Risk Factor

10 Diagnosis: Guidelines for referral of patients to the acute treatment program will use clinical criteria (The Wells DVT score) and laboratory assay with D- dimer if and when available. Active Cancer (Treatment ongoing, within the previous 6 months, or palliative). 1 Paralysis, paresis, or recent cluster immobilization of the lower extremities. 1 Recently bedridden greater than three days or major surgery within 12 weeks requiring general or regional anesthesia 1 Localized tenderness along the distribution of the deep system 1 Entire leg swollen 1 Calf swelling 3.0 cm larger than asymptomatic side measured 10.0 cm below the tibial tuberosity. 1 Pitting edema combined to the symptomatic leg. 1 Collateral, superficial veins, nonvaricose. 1 Alternative diagnosis at least as likely as deep venous thrombosis -2 High risk = 3 or greater Moderate risk = 1-2 Low risk = less than or equal to 0.

11 Ultrasound: Sens/Spec

12 DVT Diagnosis Hx/PE Prediction Tool (Wells) Sensitive Test (D-Dimer) Sensitive confirmatory test (U/S) Excellent diagnostic accuracy

13 DVT Stratify Severity Anatomic Factors How Proximal is DVT? Patient Factors Pain, edema, other medical problems, social circumstances

14 DVT Location Matters Current terminology Iliofemoral Fempopliteal Calf Vein Proximal vs Distal Common femoral vein and above Common femoral vein and below

15 Ambulatory? Outpatient vs Inpatient Pain controlled on PO Meds? High Risk for Bleeding? Other medical conditions Pregnancy, Hx HIT, GFR <30, liver disease Social situation

16 Treatment 2012

17 Treatment Calf Vein DVT ( mild DVT ) Asyx or min sx Duplex U/S in 1 week If no progression No anticoagulation Sx or progression (or high risk of progression) Anticoagulation x 3 months All can be managed outpatient

18 Treatment Fempop DVT ( Moderate DVT ) Anticoagulation x 3 months Most can be managed outpatient

19 Proximal DVT Ileofemoral DVT Fempop DVT with recalcitrant sx despite usual therapy. Inpatient management with LMWH, UFH, Arixstra Vascular consultation for consideration of Lytic Therapy

20 Warfarin Ecstatic or Dead

21 Which Anticoagulant? LMWH (Lovenox etc) x 5 days while simultaneous Warfarin Fondaparinux (Arixtra) x 5 days while simultaneous Warfarin Factor Xa inhibitors? Xarelto Above regimens contraindicated in pts with renal insufficiency - cr cl < 30

22 Rivaroxaban (Xarellto) in Acute DVT and PE A. DVT study [Bueller H et al. NEJM 2010;363: ] B. PE study [Bueller H et al. NEJM 2012;366: ]

23 ACCP 2012 Guidelines: Highlights Treatment beyond Acute Period Surgery-associated DVT/PE: recommend 3 months. (1B) Non-surgical transient risk factor: recommend 3 months over 6 or more months. (1B) Unprovoked DVT/PE and low/intermediate risk for bleeding: suggest extended anticoagulation (2B). High bleeding risk: 3 months (1B). Cancer patient with DVT/PE: recommend/suggest extended therapy. LMWH rather than VKA (2C). [Kearon C et al. Chest 2012;141(2)(Suppl):e419S-e494S]

24 SMG: ACUTE DVT TREATMENT PROGRAM Purpose: To standardize the management of deep vein thrombosis across the Sentara System in accordance with evidencebased practice guidelines. To stratify treatment in accordance with severity of DVT

25

26

27 DVT Treatment Protocol A smartset with the PVL orders and a few common diagnosis codes for you to use, along with instructions on what to do if the PVL comes back POSITIVE. The PVL orders also have information within them for the PVL techs as well.

28

29 SUMMARY Suspected DVT should be diagnosed with Duplex Ultrasound (PVL) DVT categorized according to severity Treatment with anticoagulation is standard Outpatient management can be achieved in most cases

30 Extra slides

31 The 2 Major Developments in 2012 I Publication of ACCP Guidelines 2012 II Approval of Rivaroxaban (Xarelto)for VTE

32 DVT Nuances Poor candidate for anticoagulation (active bleeding, major surgery within 24 hrs or anticipated within 14 days, noncompliance, fall risk, CNS Lesion, etc.) - referral to VTS practitioner for consideration for IVC Filter. Cancer patients LMWH 3 months Convert to VKA until Ca risk eliminated Upper extremity

33 Exclusion Criteria Co- existent serious medical pathology Severe acute venous obstruction Patients in significant pain Renal impairment creatinine > 200 µmol/l Liver disease Communication problems Poor social background Limited mobility Active bleeding

34 Exclusion Criteria High risk of bleeding Active peptic ulcer Uncontrolled hypertension ( diastolic> 110mmHg, systolic >200mmHg) Angiodysplasia Recent CNS or eye surgery Recent hemorrhagic stroke Thrombocytopenia ( plts < 100 X10 9 / L)

35 Treatment of VTE with dabigatran or rivaroxaban, in addition to being less burdensome to patients, may prove to be associated with better clinical outcomes than VKA and LMWH therapy. When these guide- lines were being prepared (October 2011), postmar- keting studies of safety were not available. Given the paucity of currently available data and that new data are rapidly emerging, we give a weak recommenda- tion in favor of VKA and LMWH therapy over dab- igatran and rivaroxaban, and we have not made any recommendations in favor of one of the new agents over the other.

36 DVT Severity Increased Severity Decreased Severity Proximal Iliofemoral Occlusive Distal Femoropoliteal Tibial Nonocclusive

37 Anatomical DVT Locations Goldhaber, Samuel Z. A Prospective Registry of 5,451 Patients With Ultrasound-Confirmed Deep Vein Thrombosis, Am. J. Cardiol,

38 For Rx

39

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