VTE Flashcards
Types of VTE
DVT
PE
- due to blood clot which forms in the veins - restricts blood flow
RF
Surgery
Trauma
Significant immobility
Malignancy
Obesity
Pregnancy
Hormonal Therapy (COC or HRT)
DVT
- Blood clot occurs in a deep vein leg or pelvis
- Typically in the calf of one leg.
Symptoms of DVT
- unilateral, localised pain
- swelling/ tenderness
Wells score for DVT
- 2 + = DVT likely
- less than 2 = unlikely
2 + wells score for DVT
- Offer a proximal leg vein ultrasound scan
- If the scan is negative for
DVT, then offer a D-Dimer test
Less than 2 wells score for DVT
- Offer first a D-Dimer test
- If the D-Dimer test confirms that DVT is likely, then offer a proximal leg ultrasound scan
PE
Blood clot detaches and travels to the lungs and blocks the pulmonary artery.
Symptoms of PE
- Chest pain
- Shortness of breath
- Cough
- Coughing blood (Haemoptysis)
Wells score for PE
- 4 + = PE likely
- less than 4 = unlikely
4 + wells score for PE
- computed tomography pulmonary angiogram (CTPA)
- if PE is negative, consider proximal leg ultrasound if DVT is suspected/likely
Less than 4 wells score for PE
- D-dimer test
- if positive = CTPA
Methods of thromboprophylaxis (2)
- Mechanical - graduated compression stockings
- Pharmacological - anticoagulants
How would you reduce risk of VTE in surgical patients?
- LA over GA
In surgical pt - how long is mechanical prophylaxis for VTE sufficient
- until sufficiently mobile
- discharged from hospital, some surgeries require them to be worn for certain amount of days
Surgery - how long do we continue VTE prophylaxis for?
- Continue for at least 7 days post-surgery, or until sufficient mobility has been re-established
- 28 days after major cancer surgery in the abdomen
- 30 days in spinal surgery
Elective hip replacement either
LMWH for 10 days and then 75mg aspirin for 28 days
LMWH for 28 days in + stockings until discharge
Rivaroxaban
Elective knee replacement either:
75mg aspirin for 14 days
LMWH for 14 days in + stockings until discharge
Rivaroxaban
VTE prophylaxis - Pregnancy high risk of VTE
- If risk of VTE that outweighs the risk of bleeding
- LMWH during hospital admission
- Pregnant women: prophylaxis until no risk of VTE or till patient discharged
Women who have given birth, had a miscarriage or termination of pregnancy during the past 6 weeks →
start LMWH 4-8 hours after the event → continue for a minimum of 7 days
unfractionated if patient is at high risk of haemorrhage
Pregnancy - Additional mechanical prophylaxis if immobilised →
until sufficiently mobile or discharged from hospital
Why are Heparins used in pregnancy compared to other pharmacological prophylaxis?
- Heparins do NOT cross the placenta
- They are also cleared rapidly in pregnancy
If a patient has confirmed DVT or PE, What should you offer for treatment?
- Apixaban
OR - Rivaroxaban
What if Apixaban or
Rivaroxaban are unsuitable for a patient with VTE, what should you then offer as an alternative?
- LMWH for at least 5 days followed by Dabigatran or Edoxaban
- LMWH + warfarin for at least 5 days or until the INR is at least 2.0 or above
- Stop heparin and continue on warfarin on its own
When would Heparin (unfractionated) be recommended in the treatment of VTE?
- Not routinely recommended
- only considered in patients with renal impairment
How long should patients be on drug treatment for VTE?
- Distal DVT (calf): 6 Weeks
- Proximal DVT / PE: At least 3 months (3 to 6 months for those with active cancer)
- Provoked DVT / PE: Stop at 3 months if the provoking factor resolved
- Unprovoked DVT / PE: 3 Months +
- Recurrent DVT / PE: Longterm
Review
anually
