VTE Prevention and Management Flashcards
Management of VTE
- primary prevention (various prophylactic strategy)
- Timely assessment of symptomatic patients (PTP, D-Dimer, CUS/CTPA, Assessment/ancillary of severity of PE)
- Instition of acute treatment (anticoagulation, thromboylysis (only if severe) embolectomy), IVC filter where appropriate)
- Assessment of recurrence risk
- Secondary prevention strategy – chronic anticoagulation, secondary prophylaxis at times of high risk
- Management of chronic complications
- prothrombotic syndrome
- chronic thromboembolic pulmonary hypertension
highest VTE risk
> 40 years and prior VTE or malignancy and major surgery, major elective orthopaedic surgery on lower extremities.
- also in patients with no prior hx of VTE at times of high risk (ex/ major surgery) and in patients with prior VTE who have discontinued anticoagulation reaction (surgery, immobilization)–> there’s an increased risk if about to have surgery, should put them back onto anticoagulants
preventative VTE measures
- mechanical – compression stockings, early ambulation
- pharmacological: low dose UNFRACTIONATED or LMWHEP, warfarin, DOACs.
Mechanical methods for the prevention of VTE are primarily indicated in patients at high risk of bleeding or in whom anticoagulation is contraindicated. When used in these circumstances, transition to a pharmacologic agent should be considered as soon as the bleeding risk becomes
acceptably low or has been reversed.
3 main treatments for acute VTEW
- anticoagulation
- thrombolysis
- inferior vena cava filter
for acute treatment, anticoagulation medication should be initiated with:
an immediate acting agent at therapeutic doses:
LMWH, Unfractionated Hep
- DOACs like rivaroxaban, apixaban
-
T/F Cancer patients and pregnant patients can have apixaban
false. cancer and pregnant patients should be treated with LMWH or heparin
what is thrombolysis and when should you use it
TPA used to rapidly dissolve the clot to open blood vessels. there is a risk for bleeding out, and you should only do it if very serious.
Do it if the pt is hemodynamically unstable due to PE (cariogenic shock, hypotension), or if there’s a limb threatening DVT
what is the inferior vena cava filter
shunt used to strain out clots. captures embolism before it reaches Lungs. it doesn’t prevent the original DVT, just prevents the PE. you still need to do an anticoagulation therapy. IVC filter should be removed afterwards, minimum 3 months.
how long should anticoagulation treatment be for?
- if the VTE risk factor is reversible like the person was on birth control, then it should be 3 month minimum and until the risk factor resolves
if vte risk is idiopathic, anticoagulation therapy should occur for 3 months. During the first event, consider a longer therapy but take into consideration pt preference and recurrence risk
if 2nd idiopathic event, consider long term therapy, but balance the risk and benefit (ex if on chronic anticoagulants, they have a higher bleeding risk doing basic activities)
how to predict the recurrence of VTE after first event
lots of prediction scores; DASH, VIENNA, HERDOO2. there are individuals who are at lower risk who can safely discontinue anticoagulation
DASH score
predicts the recurrence of VTE. takes into account the D-Dimer (if abnormal)= 2 points
age>5- years = 1 pt
male = 1 point
hormone-associated VTE (BC) = -2 points
recurrence risk is 2-20% for score ranging from -2 to 4
VTE treatment recommendations for:
first VTE provoked by TRANSIENT risk factors
first unprovoked episode of VTE
two provoked VTE
a second episode of unprovoked VTE
patients with active cancer and VTE
patients who have been recommended indefinite anticoagulant therapy;
for patients with unprovoked VTE and not continuing on indefinite anticoagulant therapy =
first VTE provoked by TRANSIENT risk factors= 3 months of anticoagulants, mitigate the temporary risk factor.
first unprovoked episode of VTE= 3 months of anticoagulants, predict the recurrence of VTE and consider longer term treatment
two provoked VTE= if both provoked by a transient risk factor which has been resolved, treat for 3 months ,followed by prophylaxis during high risk situations.
a second episode of unprovoked VTE= indefinite anticoagulation with routine check ups unless there is a very high bleeding risk.
patients with active cancer and VTE= indefinite anticoagulant therapy. Cancer patients with potentially curable disease and VTE should be treated for a minimum of 3 months but should continue if they are undergoing chemotherapy until this is completed.
patients who have been recommended indefinite anticoagulant therapy= should be reassessed periodically to re-estimate the VTE vs bleeding risk balance
for patients with unprovoked VTE and not continuing on indefinite anticoagulant therapy = consider long-term low dose aspirin prophylaxis if no contraindications (aspirin has been shown to be effective in reducing the recurrence VTE in patients with previous unprovoked VTE.
anticoagulation options
warfarin: vitamin K antagonist
Direct oral thrombin inhibitor = dabigatran
direct oral XA inhibitor = edoxaban and apixaban
Low molecular weight heparins
unfractionated heparins
fondaparinux.
the risk of bleeding from anticoagulant thromboprophyalxis is increased if:
The risk of bleeding is significantly
increased if the patient has an active gastrointestinal ulcer, previous bleeding (<3 months before hospitalization), known bleeding disorder, advanced age, severe renal failure, hepatic failure, active
cancer, or low platelet count (<50 × 109/L), recent surgery associated with a high bleeding risk.
patients at high risk for thrombosis
undergoing surgery, especially abdominal, pelvic
or orthopedic surgery. Medical patients at high thrombotic risk include those >70 years, previous
VTE, immobility ≥3 days, stroke, active cancer, known thrombophilia (essential thrombocythemia, polycythemia vera), acute inflammatory conditions,
acute infectious disease, recent surgery or trauma <1 month, obesity, pregnancy or hormone therapy.
