1. Treatment of deep venous thrombosis and pulmonary embolism Anders Waage

2. Arterial thrombosis: anti platelet agents Venous thrombosis: agents affecting the coagulation system

3. Anticoagulation/Trombolytic treatment Heparin Marevan (warfarin) Local vs systemic thrombolysis New agents Stockings Other

4. Deep venous thrombosis, LE Treament of acute DVT Duration of treatment Prophylactic treatment

5. What is the purpose of the treatment ?

6. Treatment schedule Heparin Marevan INR 2-3 6 months5 days, at least

7. Start concomitant with heparin and warfarin. Heparin has effect after 30 min, warfarin after 5 days Stop heparin when INR >2, but not before 5 days

8. Therapeutical range of INR INR = 2-3: DVT, LE, atrial fibrillation, other conditions INR 2,5-3,5: mechanical heart valve

9. Genetic variation in degradation of warfarin (CYP 2C9) Dose of Marevan ½-7 tablets/day

10. Duration of treatment

11. Thrombolytic treatment DVT with great risk of serious post thrombotic syndrome DVT v. femoralis, iliaca, cava Serious LE

12. Thrombolytic therapy Systemic: iv infusion continually for 3 days Local: delivered locally by a catheter Presumably less side effects by local therapy, but not well documented

14. Side effect thrombolytic treatment Serious bleeding: 0,5 % Serious bleeding lmw. heparin: 0,1 %

15. Choice of treatment

16. Prophylactic treatment Consider: Number of thrombosis Idiopatic, temporary, permanent cause What is the risk of new thrombosis What is the consequence of new thrombosis What is the risk of bleeding on anticoagulation

17. Prophylactic situations Relapsing DVT, LE Surgery Atrial fibrillation Mechanical heart valve Other situations

18. Risk factors Genetic: Deficiency of protein s, protein c, antithrombin III, Factor V Leiden (APC resistance) Aquired: Age, surgery, immobilisation, oestrogen ++

19. Prophylaxis Orthopedic surgery (hip, knee) Abdominal, gynecological surgery Moderate risk: 30-120 min duration High risk: >2 hours Age, weight, malignancy, oestrogen, p-pill, history of thrombosis

20. Moderat risk: Fragmin/Klexane 2500 U/ 20 mg High risk: Fragmin/Klexane 5000U/40 mg Start6 hours after surgery Stopwhen mobilised

21. DVT and pregnancy Risk 0,5-3/1000 pregnancies (x6 compared to normal) Use lmw heparin, never Marevan (Teratogenecity) After delivery: Marevan, continue for 6 weeks

22. Heparin do not pass placenta Marevan and breast-feeding

23. Prophylaxis in pregnancy DVT in previous pregnancy: 10 % risk for new DVT Prophylaxis with lmw heparin

24. DVT and cancer Post mortem studies: up to 50 % with thrombosis Clinical thrombosis in cancer patients: up to 30 %

25. Stockings after DVT Reduces risk of post-thrombotic syndrome Usefor 6 months Compression stocking up to the knee