Venous Thromboembolism (VTE) The Patient Journey

Report
Deep Vein Thrombosis
(DVT)
The Patient Journey
Marilyn Rees
Venous Thrombosis Nurse Specialist
Overview
 Diagnosis
 Goals
of DVT
of treatment
 Challenges
 Case
 Quiz
of DVT Treatment
studies
Clinical Diagnosis of DVT
• DVT symptoms can be
nonspecific, making it difficult
to diagnose.
• Presence of DVT risk factors
increase the likelihood of
having the disease
• Objective testing must be used
to confirm or rule out suspicion
Approaches to Diagnosis of DVT
•
•
•
•
•
Patient History
Clinical Symptoms and Signs
Clinical Probability Score
Laboratory Testing
Imaging Testing
Clinical Signs and Symptoms of DVT
(Nonsurgical Patients)
• Leg pain (90%)
• Tenderness (85%)
• Ankle oedema (76%)
• Calf swelling (42%)
• Dilated veins (33%)
• Homan’s sign (33%)
(sharp pain in the calf on dorsiflexion of the
foot)
Reference Haeger K. Problems of acute deep venous thrombosis. I.
The interpretation of signs and symptoms. Angiology. 1969;20:219223.
Clinical Signs and Symptoms of DVT (cont’d)
• DVT cannot be reliably diagnosed on the
basis of history and physical exam, even in
high-risk patients.
• Patients with lower extremity DVT often
do not exhibit erythema, warmth,
swelling, or tenderness
(Symptoms in surgical patients are often masked by
common post- operative pain and limb swelling)
• When present, these findings merit
further evaluation despite lack of
specificity
Diagnostic Algorithms
• Clinical diagnosis of DVT is non-specific
because none of the signs in isolation are
particular to the disease
• In symptomatic patients, clinical pre-test
models can be used to determine
probability of DVT or PE
Wells Scoring System for Diagnosing DVT
Clinical Characteristic
Score*
Active cancer (treatment ongoing, within, 6 months or palliative)
1
Paralysis, paresis, or recent plaster immobilization of the lower extremity
1
Bedridden for >3 days or major surgery with general/regional anaesthesia within
previous 12 weeks
1
Localized tenderness along the distribution of the deep venous system
1
Entire leg swollen
1
Calf swelling 3 cm larger than asymptomatic side (measured 10 cm below tibial
tuberosity)
1
Pitting oedema confined to symptomatic leg
1
Collateral superficial veins (non-varicose)
1
Previous documented DVT
1
Alternative diagnosis at least as likely as DVT e.g
(Popliteal (Baker) cyst, superficial thrombophlebitis, muscle pulls/tears, chronic
venous insufficiency, and others)
-2
Clinical probability simplified score
DVT likely
2 points
or more
DVT unlikely
1 point
or less
Alternative Diagnosis
VTE Investigations
Laboratory
•D Dimer
(degradation product of a crosslinked fibrin blood clot)
D-dimer has a high false-positive rate
Sensitive but nonspecific also increased
in other conditions:
cancer,
inflammation,
postoperatively,
injury,
pregnancy.
Non-invasive testing
Doppler Compression
Ultrasound
Non-invasive, no
contraindications.
High accuracy in
symptomatic patients (91%)
Venous system in lower limbs
PROXIMAL
VEINS
DISTAL VEINS
Suspected Leg Deep Vein Thrombosis
Well’s score UNLIKELY probability
Well’s score LIKELY probability
D-DIMER
-ve
NO DVT
Patient
discharged
back to
referrer
-ve
Full leg Ultrasound
+ve
+ve
NO DVT
Full leg Ultrasound
+ve
-ve
Deep Vein
Thrombosis
Patient
discharged
back to
referrer
What happens next?
Four Goals of VTE Treatment
1.Prevent fatal PE
2.Reduce morbidity associated
with acute leg or lung thrombus
3.Prevent recurrent VTE
4.Prevent long-term sequelae
DVT Confirmed
1.Full medical assessment to consider underlying pathology
including breast examination in women over 30yrs of age and
rectal examination if indicated by symptoms.
2. If pv examination is necessary this will be highlighted in the
discharge letter as the DVT clinic is not a suitable environment for
this to occur.
3. Full blood screen including :
FBC, Ferritin, U+E/ eGFR, LFT, Baseline Coag and INR, Bone
profile, Urine dipstick (and Pregnancy test in women of child
bearing age)
CXR in unprovoked DVT
PSA if required (following PR examination/if prostatic
symptoms)
Tumour markers if abdominal symptoms/signs.
Malignancy

10% Unprovoked DVT / PE present with cancer within 1 year

A Presenting sign in:


Pancreatic cancer

Prostate cancer
Late sign in:

Breast cancer

Lung cancer

Uterine cancer

Brain cancer
Investigations for cancer
Offer all patients diagnosed with unprovoked DVT or PE who are not already
known to have cancer the following investigations for cancer:
a physical examination (guided by the patient's full history)
and
a chest X-ray
and
blood tests (full blood count, serum calcium and liver function tests)
and
urinalysis.
Consider
Further investigations for cancer with an abdomino-pelvic CT scan (and a
mammogram for women) in all patients aged over 40 years with a first
unprovoked DVT or PE who do not have signs or symptoms of cancer based on
initial investigation (see 'Investigations for cancer' above).
Two Phases of VTE Management
Initial Treatment
Long-term treatment
• ≥5 d treatment with SC
• Necessary for patients at
continuous risk for
recurrence
• Duration of treatment is
dependent on underlying
disease and risk factors
• Appropriate treatment can
reduce the risk of
recurrence to
approximately 5% at 3
months
LMWH or IV UFH,
• Discontinue when INR >2.0
for 48 hr
• Initiation of VKA together
with LMWH or UFH on first
treatment day
Or
Initiation with New Oral Anticoagulant (Rivaroxaban)
TIME
1st Precipitated DVT □
1st idiopathic DVT □
Recurrent DVT □
Surgery past 12 weeks
Lower limb fracture
Lower limb in plaster
Pregnant
Post partum up to 12 weeks
(Travel / COCP / HRT)
Distal DVT (below knee)
□
Proximal DVT (above
knee) □
Distal DVT (below
knee) □
Proximal DVT (above
knee) □
Anticoagulate
Anticoagulate
3 months □
3 months □
Refer to ART (if suitable) □
Refer to ART (if suitable) □
If no family history DVT / PE Discharge at end of
treatment □
Thrombosis Clinic
If family history DVT / PE □
Follow up at 3 months □
Traditional approaches of Anticoagulation
Heparin

Minimum of 5 days

Until INR > 2 on at least 2 occasions
Warfarin

PE
minimum 3 months

Idiopathic proximal DVT
minimum 3 months

Idiopathic distal DVT
3 months

Provoked distal DVT
3 months

Recurrent DVT / PE
long term
New approaches to anticoagulation
Vitamin K antagonists (VKAs) and ODIs
VKA
VII
TF
VIIa
Initiation
VKA
X
IX
Propagation
IXa
Xa
VKA
II
RIVAROXABAN
Inactive factor
APIXABAN
Active factor
EDOXABAN
Transformation
IIa
Catalysis
Clot formation
Fibrinogen
DABIGATRAN
Fibrin
OUT-PATIENT TREATMENT OF DVT
Low molecular weight heparin
•Enoxaparin should be continued until the INR has been >2 for 2 consecutive days
and for a minimum of 5 days.
Warfarin
•If the initial PT is <17s (INR <1.3) the patient will receive 5mg of warfarin on the
evenings (17:00 to 19:00) of days 1 and 2.
•The INR is checked on the mornings of day 3 and 4 and the warfarin dose is
adjusted according to the schedule:
If the patient is on an anti-platelet medication a doctor should review whether this is to continue, whilst the
patient is on warfarin.
Indication
Target INR
(+/- 0.5)
Duration
Follow up
1st
idiopathic proximal
DVT
2.5
≥ 3 months
Thrombosis Clinic
1st precipitated proximal
DVT
2.5
3 months
*No follow up
1st idiopathic distal DVT
2.5
3 months
*No follow up
1st
precipitated distal
DVT
2.5
3 months
*No follow up
Recurrent DVT not on
warfarin / subtherapeutic INR
2.5
≥ 3 months
Thrombosis Clinic
Recurrent DVT on
warfarin and therapeutic
INR
3.5
Long-term
Thrombosis Clinic
Day 1 and 2
Warfarin 5mg each day
Day 3
Day 4
INR
Dose
INR
Dose
< 1.5
1.5-2.0
2.1-2.5
2.6-3.0
>3.0
10 mg
5 mg
3 mg
1 mg
0 mg
< 1.6
1.6-1.7
1.8-1.9
2.0-2.3
2.4-2.7
2.8-3.0
3.1-3.5
3.6-4.0
>4.0
10 mg
7 mg
6 mg
5 mg
4 mg
3 mg
2 mg
1 mg
0 mg
Rivaroxaban as an alternative to warfarin
•Patients who have suffered a 1st precipitated DVT and only require 3
months anticoagulation will be offered the option of warfarin or
rivaroxaban
•Patients with a history of excessive alcohol consumption, in whom
warfarin and INR monitoring will be difficult will be offered the option of
LMWH or rivaroxaban
•Patients with poor venous access e.g. history of IVDU will be offered the
option of LMWH or rivaroxaban
First 3 weeks
Subsequent 9 weeks
Rivaroxaban 15mg bd
Rivaroxaban 20mg od
Treatment options for Venous Thromboembolism
in patients with solid tumours

Shared agreement between Bro Taf and Cardiff and Vale

Extended treatment with Dalteparin for up to 6 months

Prescribe Dalteparin at approximately 200 iu/ kg total body weight
subcutaneously once daily for the first 30days

Months 2-6 Dalteparin should be administered at a dose of approxiamtely
150 iu/kg s/c once daily

Recommended treatment is 6 months.

Continuing beyond this period will be evaluated according to individuals
risk/benefits and progression of cancer
Treat for 3 months
and reassess
Isolated distal
DVT
Stop at 3 months
Reversible
provoking factor
Stop at 3 months
Unprovoked
proximal DVT or
PE
Review options
Cancer
Indefinite therapy
or until cancer
inactive
High Bleeding Risk
OR
Prefers to stop
even if D Dimer
positive
Others
Stop and measure
D Dimer at 1
month
Not High Bleeding
Risk and prefers to
stay on even if D
Dimer is negative
Second VTE
Negative D Dimer
Stay off therapy
(Stop at 3 months)
Positive D Dimer
Restart therapy
(Indefinite therapy)
Indefinite therapy
TAKE 100 ASYMPTOMATIC CALF DVT
16%-20% of them become proximal
Half of these will embolise i.e.8%-10%
Half of these will be symptomatic PE ( i.e. 4%-5% or PE’s)
Untreated PE (1.0% of the total) symptomatic and non-fatal –26% (1.0% of
the total) will be fatal PE.
TAKE 100 SYMPTOMATIC CALF DVT
100 symptomatic DVT 21%-36% of them become proximal
Half of these will embolisei.e.8%-18%
Half of these will be symptomatic PE (ie4%-9% or PE’s)
Untreated PE
–26% (1.5% of the total) symptomatic and non-fatal
–26% (1.5% of the total) will be fatal PE.
Cohen AT, JTH 2006
Case History 1
48yr old male
Presenting with 4/52 history of ‘sciatic’ type lower back pain radiating down
left leg.
No past medical history but awaiting private gastro-enterologist review for
‘epigastric’ type pain and MRI for back pain
Wells score – 2 ( Calf >3cms, pitting oedema unilaterally)
• Doppler Ultrasound – Gastrocnemius vein clot (not extending into
popliteal vein)
• Re-scanned in 1/52 – Gastrocnemius clot extended into popliteal ven
• Initial treatment with LMWH whilst awaiting result of MRI
• Urgent CT Chest, abdo and pelvis
• Malignant sacral bone lesion with widespread retroperitoneal and thoracic
small volume tissue deposits
• Plan – Admission – Biopsy
• Management of DVT – insertion of IVC filter
• Anti-coagulation – determined following biopsy result.
Case history 2
63yr old female
Presenting with one day history of calf pain
History of 7hr car journey plus 31/2hr flight
Lower leg feeling ‘itchy’
PMH – Asthma
Wells Score 1
D Dimer +ve
Doppler Ultrasound – Left Tibial DVT
Treatment choice – Rivaroxaban
No follow up
Case history 3
83yr old female
5/52 history of painful/ swollen left leg
Initially treated by GP as cellulitis with antibiotics
No response after 2/52
Doppler ultrasound – Left ileo-femoral DVT
No provoking factors other than age and limited mobility (chronic)
No red flags
Plan
Warfarin/LMWH
Review at 3/12
Clot Quiz
DVT?
Or something else………
One Final Point
Why you should ask about clots
Blood clots can happen to anyone.
If you are in hospital – or have left hospital in the last
three months – you are at greater risk of developing a
clot.
Blood clots are preventable!
Ask your doctor, nurse or healthcare professional to help
you reduce your risk of developing a clot.
Watch the video to find out more
http://www.youtube.com/watch?v=TVKIyy9dcKc
Thank You
The venous return from your leg has now
slowed by 50%.
Please ensure you have re-established
sufficient flow before the next speaker to
reduce your risk of a (potentially fatal) VTE.

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