Venous thromboembolic diseases

Question 1

What are provoked and unprovoked DVTs?

Answer 1

• Provoked DVT: associated with a transient risk factor, which can be removed to reduce risk of recurrence.
• Unprovoked DVT: absence of a transient risk factor, person is at increased risk of recurrence.

Question 2

Name four continuous or intrinsic risk factors for DVT

Answer 2

• Previous DVT
• Cancer
• Age over 60
• Overweight; obesity
• Male
• Heart failure
• Acquired/familial thrombophilia
• Inflammatory disorders: ^eg. vasculitis; IBD
• Varicose veins
• Smoking

Question 3

Name four transient risk factors for DVT

Answer 3

• Recent major surgery; hospitilisation; trauma
• Chemotherapy
• Significant immobility
• Prolonged travel (>4h)
• Significant trauma; direct trauma to vein
• COCP; HRT
• Pregnancy; postpartum period
• Dehydration

Question 4

Name two complications of deep venous thrombosis

Answer 4

• Pulmonary embolism
• Post-thrombotic syndrome
• Bleeding associated with anticoagulation treatment
• Heparin-induced thrombocytopenia

Question 5

What is post-thrombotic syndrome?

Answer 5

DVT complication affecting up to 50% (within two years)

• Chronic venous HTN, causing:
  
  • Limb pain; swelling
  • Hyperpigmentation; dermatitis
  • Ulcers
  • Venous gangrene
  • Lipodermatosclerosis

Question 6

Name three differential diagnoses for DVT

Answer 6

• Physical trauma
• Cardiovascular disorders:
  
  • Superficial thrombophlebitis
  • Post-thrombotic syndrome
  • Venous obstruction; insufficiency
• Ruptured baker’s cyst
• Cellulitis
• Dependent oedema
• Nephrotic syndrome; cirrhosis
• Compartment syndrome

Question 7

List four presenting features of a DVT

Answer 7

• Unilateral swollen leg (esp >3cm difference)
• Localised pain: typically throbbing
• Tender
• Oedematous; erythematous; warm
• Vein distension

Question 8

What scoring system is used to assess DVT risk?

Answer 8

Two-level DVT Wells score

Question 9

Outline the initial investigation of patients with likely DVT (2+ Wells score)

Answer 9

• Proximal leg vein USS within 4h
  
  • D-dimer if scan result is negative
  • Repeat scan if D-dimer positive
• If unable to obtain scan within 4h:
  
  • D-dimer test
  • Interim 24h treatment-dose LMWH
  • Proximal leg USS within 24h

Question 10

Outline the initial investigation of patients with unlikely DVT (<2 Wells score)?

Answer 10

D-dimer test:

• If +ve: proximal leg vein USS within 4h
• If -ve: consider alternative diagnosis

Question 11

What investigations should be offered in unprovoked DVT?

Answer 11

• Investigations for possible malignancy
  
  • CT abdomen and pelvis
• Thrombophilia testing

Question 12

Give three ECG findings in pulmonary embolism

Answer 12

• Sinus tachycardia
• RV strain: T wave inversion in V1-4
• RBBB
• Dominant R wave in V1
• S₁Q₃T₃: non-specific
  
  • -S wave in lead I
  • -Q wave in lead III
  • -T wave inversion in lead III

Question 13

What scoring system is used to assess PE risk?

Answer 13

PE Wells score - original or simplified

Question 14

Outline the initial investigation of patients with likely PE (>4 Wells score)

Answer 14

• CTPA immediately
• V/Q SPECT scan if:
  
  • Allergy to contrast media
  • Severe renal impairment (eGFR <30ml/min)
  • High risk from irradiation
• If either is delayed, offer interim anticoagulation
  
  • ^eg. apixaban; rivaroxaban

Question 15

Outline the initial investigation of patients with unlikely PE (4 or less Wells score)

Answer 15

D-dimer test, results within 4h

• If +ve: investigate as likely PE
  
  • CTPA or V/Q SPECT scan, ± interim anticoagulation
• If -ve: consider alternative Dx

Question 16

Outline the anticoagulation treatment for confirmed DVT/PE

Answer 16

• Apixaban or rivaroxaban
  
  • Consider LMWH/VKA if renal impairment or APLS
• Duration before reassessing to continue, stop, or change
  
  • Provoked: 3+ months
  • Unprovoked: 6+ months
  • Active cancer: 3-6+ months

Question 17

Name two contraindications for DVT maintenance treatment with oral anticoagulation therapy

Answer 17

• Cancer
• Pregnancy

Question 18

Differentiate venous and arterial insufficiency

Answer 18

• Venous:
  
  • Heavy, aching
  • Swelling esp around ulcers, and end of day
  • Worsens on standing; improves with elevation/activity
  • Pulses present
• Arterial:
  
  • Sharp cramping pain; tired leg/hip muscles
  • Swelling is rare
  • Worsens with activity; improves with rest
  • Pulses absent or diminished

Question 19

What investigations are for determining which anticoagulation to give for confirmed DVT/PE?

Answer 19

• FBC
• U+E
• LFTs
• Clotting

Renal impairment, active cancer, and antiphospholipid syndrome require modifications to choice of anticoagulation