Pulmonary Embolism DVT Flashcards by Isaac Mammen

FDA approved thrombolytics in Acute PE

AUS-Alteplase,Urokinase,Streptokinase

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Dose of thrombolytics in PE

ALTEPLASE-100 mg ivm over 2 HOURS ( first 10 mg bolus)

UK-4400u/KG over 10 minutes, then 4400/KG/HR for 12 hours

STK—2.5LAKH over 30 mts then 1 LAKH /hr for 24 hrs( In MI unit is in millions but here in lakhs)

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When will u start heparin after thrombolysis

Once APTT is Less than twice upper limit. No bolus..If it is more than 2 times rpt APTT every 4 hours

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—-% of pts with unprovoked proximal VTE develop recurrent VTE with in 1 yr of stopping anticoagulants

Around 10%

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HERDOO2 Predictors of VTE

At 5-12 months of anticoagulation after first proximal DVT..

Hyperpigmentation,Edema,Redness (post-thrombotic signs)
D-dimer 250 ug/L or more( usual cut off value for DVT is 500)
Obesity-BMI of 30 or more
Old age-65 or more

Score of 2 or more is high risk of recurrence

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Conclusion of REVERSE II trial

“Men continue HERDOO2” at 5-12 months after first Proximal DVT

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The ISTH (The International Society of Thrombosis and Hemostasis) suggests that it is safe to stop anticoagulants if risk of recurrent thrombosis at 1 yr off therapy is less than

5% ; given the risk of serious bleeding and a serious bleed is 2-3 times more likely than a VTE to be fatal

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Second most common cardiovascular disorder

Venous thromboembolism

And the 3 Dr common cause of cardiovascular death

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Main criticisms of REVERSE II trial

Only one year follow up. Risk may catch up by 3-4 years as shown in a 2015 French study after PE

2.With NOAC availability is there a big concern on continued anticoagulation

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Target aPTT in PE pts on UFH

1.5-2.5

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Pts on Heparin should be monitored for

Osteoporosis and Thrombocytopenia

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Warfarin target INR in PE

2.5

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May Thurner syndrome is

compression of Left common iliac vein by Right common iliac Artery

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Some common causes of recurrent VTE despite anticoagulation

Malignancy
May Thurner
Anti phospholipid syndrome
Inherited thrombotic disorders

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Should IVC filter be removed

If contraindication for anti coagulation has resolved, remove filter and initiate anticoagulants

Anti coagulation is the optimal therapy for VTE

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If recurrence occurs with adequate anticoagulation inVTE what to do

Change Warf to LMWH/ or increase LMWH/ or add IVC filter

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Early complication of PE is mainly

1-2 weeks- Recurrence. Rpt imaging to be done

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Late complications of PE

Recurrence
CTEPH- chronic thromboembolic PH- suspect with progressive dyspnea Particularly in first 2 years of diagnosis- 5% pts develop

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The NOAC to be taken with food

Rivaroxaban

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Most common cause for PE recurrence

Sub therapeutic anticoagulation

Risk of recurrence of VTE after a first unprovoked episode ( after cessation of anti coagulation)

First yr-10%
First 5 yrs-30%

Anti coagulation reduces recurrence by 90%
Low intensity anti coagulation reduces recurrence by 60%
Aspirin reduces risk by 30%

Max period NOAC used in VTE recurrence prevention

2 years - Rivaroxaban

Safety and efficacy of indefinite anticoagulation in VTE is established in ——————-&—————

UNPROVOKED PROXIMAL dvt
UNPROVOKED SYMPTOMATIC pe

RECURRENT UNprovoked distal dvt/ any VTE also most would suggest indefinite anticoagulants

CI to anti coagulation in Prox DVT

Platelet- Less than 50,000
Past h/o IC bleed
Active bleeding

These are the CONTRAINDICATIONS

The NOAC which showed a higher rate if ACS when given for prevention of recurrent dvt

Dabigatran

Post IVC filter if contraindications for anticoagulants is resolved, what to do

Give full anticoagulation for 3 months | Then consider removal

First unprovoked VTE in high bleeding risk Pt what to do after 3 months

Discontinue-ACCP Guidelines Uptodate 2018

Popliteal vein thrombosis is Proximal or distal

Proximal P=P

Aspirin reduces recurrence of DVT by

1/3rd Anti coagulation reduces risk by 90%

Risk of recurrence after a single provoked DVT

1-5% at 1 year & 3-15% at 5 years

Risk of DVT recurrence after 2 unprovoked DVT

15% at 1 year and 45% at 5 years

In my patient with first provoked (non surgical) PE with low bleeding risk NOAC should be—————after the first 3 months

Not sure. Looks like a weak recommendation to discontinue To confirm

Distal dvt means involvement of “calf veins “ which are

Peroneal, Anterior And Posterior tibial veins and Muscular veins

Late second episode of VTE means

More than 1 year after the first episode

One factor in favor of stopping anticoagulants in DVT is (regarding indefinite anti coagulation

A normal D-dimer within 3 months of anticoagulant withdrawal

One situation where Warfarin is preferred over NOAC in DVT treatment

Creatinine clearence < 30 ml/minute

Rate of bleeding with anticoagulation in VTE in different risk groups in first 3 months

Low- no RF-1.6% Intermediate risk-( One RF)- 3.2% High risk group-(2 RF)- 12.8% Annual Rate of bleeding after first three months is about Half of the above in each group

Initial anti coagulation in VTE means upto

10 days

One of the non hematologic risk with prolonged LMWH

Osteoporosis

Anti coagulation 3 months after surgery provoked VTE

STOP

The relative risk of major bleeding with anti coagulation

2.6 Times roughly

General definition of major blood loss

2gm Hb drop or needing 2 units of blood or in a critical site

Decision of anti coagulation after 3 months is same for Non Surgical provoked VTE and —————-

Unprovoked Distal DVT LOW/ INTERMEDIATE risk- weak recommendation to DIScontinue ( But for unprovoked Prox DVT/PE- weak recommendation to continue) HIGH risk- STOP for both

3 situations where indefinite anti coagulation may benefit in patients in grey zone

Malignancy APLA “High risk” thrombophilias ( def of PC,PS,AT III or Homozygous V,II mutations)

Highest chance of VTE recurrence is ————- after the event

6 months- 1 year after the event

3 major risk factors for VTE

Major surgery >30 mts IMMOBILITY 3 days or more LSCS

Contraindications to anti coagulation in VTE-3

1. Platelet count<50,000 2. Prior ICH 3. Active bleeding. Consider IVC Filter

Progestin only contraception and VTE

Oral prepn are ok in general Injectable depot Medroxy progesterone has increased risk

HRT in VTE

Estradiol by non oral route( patch) appears to be ok