DVT Ix & Mx & Thrombophilia Screening

Question 1

What are the questions in the 2 level DVT Wells Score?

Answer 1

Question 2

What score means a DVT is likely?

Answer 2

2 or more

Question 3

What score means a DVT is unlikely?

Answer 3

1 or less

Question 4

If a DVT is likely (2 or more) what investigations should you do?

Answer 4

• A proximal leg vein ultrasound scan within 4 hours and, if the result is negative, a D-dimer test.
• If a proximal leg vein ultrasound scan cannot be carried out within 4 hours:
  
  • ​D-dimer test should be performed
  • LMWH
  • Proximal leg vein US within 24 hours.

Question 5

If a DVT is unlikely (Score of 1 or less), what investigations should you do?

Answer 5

1. D-Dimer. If Positive:
   
   • A proximal leg vein USS within 4 hours.
   • If cannot, then LMWH and perform within 24 hours.

Question 6

What is the management of a DVT/

Answer 6

• LMWH - continue for 5 days or until INR is >=2.0 for 24 hours.
• Warfarin is given within 24 hours of Diagnosis.

Question 7

How long should Warfarin be given for a DVT?

Answer 7

NICE recommend reassessing at 3 months and then extending if an unprovoked DVT or risk factors and no additional risk of bleeding.

In practice, DVT is given for 6 months if unprovoked DVT.

Question 8

If a cancer patient gets a DVT, what is their treatment?

Answer 8

LMWH for 6 months.

Question 9

What initial investigations should be done in someone has had an unprovoked DVTs (To exclude cancer)?

Answer 9

1. A physical examination
2. CXR
3. Blood tests - FBC, Serum Calcium, Liver Function Tests.
4. Urinalysis.

Question 10

If you do suspect cancer, & the initial investigations are normal, what further investigation should you consider?

REMEMBER >40 years old

Answer 10

Cancer.

Abdominal-Pelvic CT scan

(And a mammogram in women)

Question 11

What 2 conditions should you consider that can cause an unprovoked VTE?

Answer 11

Cancer (If >40 years old)

Thombophilia

Question 12

When should you not offer thrombophilia screening even if you think someone may have an underlying condition?

Answer 12

If they are on lifelong warfarin because it won’t alter management.

Question 13

What are some inherited causes of thrombophilia?

Answer 13

• Factor V Leiden (most common cause of thrombophilia)
• Prothrombin Gene Mutation (Second most common cause)

Rarer (These generally have a higher relative risk of getting DVT)

• Antithrombin III deficiency (Highest risk of DVT)
• Protein C deficiency
• Protein S deficiency

Question 14

What is an aquired cause of thrombophilia?

Answer 14

Antiphospholipid syndrome

Antiphospholipid syndrome is most common secondary to SLE.

Question 15

What drugs can cause thrombophilia?

Answer 15

COCP

Question 16

When should you consider a testing for a hereditary thrombophilia?

Answer 16

If a patient has an unprovoked DVT or PE and who has a first-degree relative who has a DVT or PE.

In this case, refer to haematology to do the thrombophilia screening.

Question 17

What can your “primary care” thrombophilia screen consist of?

Answer 17

• FBC, Clotting screen
• If 1st degree relative also had a VTE test for Anti-Phospholipid Syndrome - Tests are:
  
  • Lupus anticoagulant
  • Anticardiolipin Antibodies
  • Antiphospholipid antibodies.

Question 18

When should you do your thrombophilia screen?

Answer 18

• 4 weeks after completion of anticoagulation
• Should not be on Heparain or Warfarin. Avoid testing in the acute phase of thrombosis as acute phase changes may be present
• Avoid intercurrent severe illness