DVT Flashcards
2 level DVT Wells score
DVT score
1 point :
Cancer
Paralysis
Major surgery 12 weeks
Localized tenderness
Entire leg swollen
Calf swelling 3cm or more
Pitting oedema
Collateral superficial
Previous DVT
Possible alternative diagnosis -2 points
2 or more points - DVT likely
Likely DVT (>=2 p. Wells score)
- DUS within 4 hours.
If negative ->D-Dimer (if d dimer positive stop ANTICOAGULATION, repeat scan in 6-8 days)
If longer than 4 hours-> D-Dimer, ANTICOAGULATION, DUs 24h
If positive
-ANTICOAGULATION (if contraindicated -intervention)
DVT unlikely Wells <1
D-Dimer 4 hours
If not available - ANTICOAGULATION until result available
If positive - DUS
Skala wellsa
Prawdopodobieństwo DVT i PE
Two level PE wells score
More than 4 points - PE likely
DVT 3 points
Alternative diagnosis less likely 3 points
HR > 100 1,5 points
Immobilization for more than 3 days
or surgery in last month 1,5 points
Previous DVT 1,5 points
Haematoptysis 1
Malignancy 1
PE likely in wells score
CTPA
Jeśli ct niedostępne- ANTICOAGULATION
Postępowanie przy potwierdzonym PE
- ANTICOAGULATION
- IF contraindicated - mechanical intervention
- Haemodynamic instability- thrombolytic therapy
PE unlikely - wells score= <4
D dimer if positive CT
Minimal time of ANTICOAGULATION in DVT or PE
3 months
Leki z wyboru w PE i DVT wg NICE
Rivaroxaban
Apixaban
If apixaban and rivaroxaban in PE/DVT are not suitable
LMWH for at least 5 days followed by dabigatran or edoxaban or
• LMWH concurrently with a vitamin K antagonist (VKA) for at least 5 days, or until the INR is at least 2.0 in 2 consecutive readings, followed by a VKA on its own. [2020]
Anticoagulation treatment for DVT or PE in people at extremes of body weight
1.3.11 Consider anticoagulation treatment with regular monitoring of therapeutic levels for people with confirmed proximal DVT or PE who weigh less than 50 kg or more than 120 kg, to ensure effective anticoagulation.
Anticoagulation treatment for PE with haemodynamic instability
For people with confirmed PE and haemodynamic instability, offer continuous
UFH infusion and consider thrombolytic therapy
Leczenie PE/DVT w niewydolności nerek
eGFR 15-50 ml/min
Wszystkie leki jak u zdrowych, w dawkach dostosowanych
eGFR < 15 ml/min
LMWH
UFH
Heparynę łącznie z VKA przez min 5 dni albo do czasu kiedy INR w dwóch kolejnych pomiarach wynosi min 2
ANTICOAGULATION in DVT/PE with active cancer
3-6 months
DOAC/ LMWH/ VKA
Treatment failure
• check adherence to anticoagulation treatment
• address other sources of hypercoagulability
Increase dose or change
Tromboliza w DVT
Catheter directed
• symptoms lasting less than 14 days and
• good functional status and
• a life expectancy of 1 year or more and
• a low risk of bleeding. [2012]
Tromboliza w PE (systemic)
Haemodynamic instability
Inferior vena caval filters in DVT / PE
Anticoagulation is contraindicated or a PE has occurred during anticoagulation reatment
Pończochy w prewencji zespołu pozakrzepowego
Nie
Cancer in unprovoked DVT
Nie szukaj o ile nie mają innych objawow
Thrombophilia testing
Consider testing - for antiphospholypid antibodies- unprovoked DVT- plan to stop ANTICOAGULATION
Do not offer testing for hereditary thrombophilia to people who are continuing anticoagulation treatment.
Unprovoked DVT
ATTRACT trial
pharmacomechanical catheter–directed thrombolysis (PCDT) did not prevent postthrombotic syndrome (PTS) in patients with acute proximal deep vein thrombosis.
In patients with acute iliofemoral deep vein thrombosis, PCDT ….
did not
-influence the occurrence of PTS -recurrent venous thromboembolism.
significantly reduced
-early leg symptoms and,
-over 24 months, reduced PTS severity scores,
-reduced the proportion of patients who developed moderate-or-severe PTS,
-and resulted in greater improvement in venous disease– specific quality of life.
Villata scale
Panel 2: Villalta scale for assessment of post-syndrome (PTS) 15,26
Five patient-rated venous symptoms
• Pain
• Cramps
• Heaviness
• Paraesthesia
• Pruritus
Six clinician-rated signs
• Pretibial oedema
• Skin induration
• Hyperpigmentation
• Pain during calf compression
• Venous ectasia
• Redness
Scoring
Each sign or symptom is rated as 0 (none), 1 (mild), 2 (moderate), or 3 (severe), and summed to produce a total score. A total score of less than 5 indicates no PTS, of 5-14 indicates mild or moderate PTS, and of 15 or more (or presence of venous ulcer) indicates severe PTS.
Hypercoagulable disorders to test for in
VTOS
Inherited
Factor V Leiden/activated protein C resistance
Factor II (prothrombin
G20210) polymorphism
Protein C deficiency
Protein S deficiency
Antithrombin deficiency
Hyperhomocysteinemia
Acquired
Antiphospholipid antibody syndrome
Anticardiolipin antibodies
Anti-beta-2 glycoprotein antibodies
Lupus anticoagulant
