Presentation on theme: "Deep Vein Thrombosis (DVT) The Patient Journey"— Presentation transcript:
1Deep Vein Thrombosis (DVT) The Patient Journey Marilyn ReesVenous Thrombosis Nurse Specialist
2Overview Diagnosis of DVT Goals of treatment Challenges of DVT TreatmentCase studiesQuiz
3Clinical Diagnosis of DVT DVT symptoms can be nonspecific, making it difficult to diagnose.Presence of DVT risk factors increase the likelihood of having the diseaseObjective testing must be used to confirm or rule out suspicionThe signs and symptoms of both deep vein thrombosis (DVT) and pulmonary embolism (PE) can be nonspecific; as a consequence, many patients who present withleg pain and swelling are evaluated, but do not have DVT or PE.1Risk factors for venous thromboembolism (VTE) have been extensively evaluated in order to provide greater diagnostic specificity. As will be shown in this presentation, specific risk factors have been identified that dramatically increase the diagnostic probability of DVT or PE. However, objective testing must be used to confirm or rule out suspected VTE.
4Approaches to Diagnosis of DVT Patient HistoryClinical Symptoms and SignsClinical Probability ScoreLaboratory TestingImaging Testing
5Clinical Signs and Symptoms of DVT (Nonsurgical Patients) Leg pain (90%)Tenderness (85%)Ankle oedema (76%)Calf swelling (42%)Dilated veins (33%)Homan’s sign (33%)(sharp pain in the calf on dorsiflexion of the foot)Symptoms of DVT occur when large clots partially or totally occlude blood flow in the vein. Clinical signs and symptoms of DVT may include leg pain, tenderness, ankle oedema, calf swelling, dilated veins, and Homan’s sign (a sharp pain in the on dorsiflexion of the foot).Reference Haeger K. Problems of acute deep venous thrombosis. I. The interpretation of signs and symptoms. Angiology. 1969;20:
6Clinical Signs and Symptoms of DVT (cont’d) DVT cannot be reliably diagnosed on the basis of history and physical exam, even in high-risk patients.Patients with lower extremity DVT often do not exhibit erythema, warmth, swelling, or tenderness(Symptoms in surgical patients are often masked by common post- operative pain and limb swelling)When present, these findings merit further evaluation despite lack of specificityAlthough the clinical signs and symptoms of DVT can provide initial evidence to drive further investigation, DVT cannot be reliably diagnosed on the basis of history and physical exam, even in high-risk patients.For example, patients with lower-extremity DVT frequently do not display erythema, warmth, pain, swelling, or tenderness. In clinical studies, sensitivity of calf pain for acute DVT varies from 66% to 91% and specificity ranges from 26% to 74%. Similarly, Homans’sign and swelling of the calf or leg are remarkably inconsistent diagnostic factors.When present, these factors warrant further investigation; however, the clinical diagnosis of DVT in the lower extremities cannot be established with certainty without incorporating objective testing into the diagnosis paradigm.
7Diagnostic Algorithms Clinical diagnosis of DVT is non-specific because none of the signs in isolation are particular to the diseaseIn symptomatic patients, clinical pre-test models can be used to determine probability of DVT or PEVTE cannot be reliably diagnosed on the basis of patient history and clinical examination alone. For this reason, clinical pretest models should be used to determine the probability of DVT or PE.
8Wells Scoring System for Diagnosing DVT Clinical CharacteristicScore*Active cancer (treatment ongoing, within, 6 months or palliative)1Paralysis, paresis, or recent plaster immobilization of the lower extremityBedridden for >3 days or major surgery with general/regional anaesthesia within previous 12 weeksLocalized tenderness along the distribution of the deep venous systemEntire leg swollenCalf swelling 3 cm larger than asymptomatic side (measured 10 cm below tibial tuberosity)Pitting oedema confined to symptomatic legCollateral superficial veins (non-varicose)Previous documented DVTAlternative diagnosis at least as likely as DVT e.g(Popliteal (Baker) cyst, superficial thrombophlebitis, muscle pulls/tears, chronic venous insufficiency, and others)-2Clinical probability simplified scoreDVT likely2 points or moreDVT unlikely1 point or lessThe clinical diagnosis of DVT is nonspecific because none of the signs in isolation are particular to this disease. A clinical prediction rule has been developed that incorporates the signs, symptoms, and risk factors for VTE to categorize patients as having a low,moderate, or high probability of DVT.Multiple studies have demonstrated the reproducibility of this model. Moreover, studies using confirmatory ultrasound have found that patients at low clinical pre-test probability as determined by clinical criteria can have DVT safely excluded based on a negative ultrasound test of the proximal veins.
10VTE Investigations Laboratory D Dimer (degradation product of a cross- linked fibrin blood clot)D-dimer has a high false-positive rateSensitive but nonspecific also increased in other conditions:cancer,inflammation,postoperatively,injury,pregnancy.Laboratory testing for the presence of D-dimer—the breakdown product of a cross-linked fibrin blood clot—can help exclude VTE. However, D-dimer is relatively nonspecific, as levels may be increased in nonthrombotic disorders (eg, recent major surgery, hemorrhage, trauma, malignancy, or sepsis). D-dimer levels may also increase with age. Compression ultrasound is the noninvasive technique of choice in symptomatic patients with DVT. Noncompressibility of a proximal lower limb vein, in the transverse section, has a sensitivity of 91% and a specificity of 99%
15Four Goals of VTE Treatment Prevent fatal PEReduce morbidity associated with acute leg or lung thrombusPrevent recurrent VTEPrevent long-term sequelae
16DVT Confirmed1.Full medical assessment to consider underlying pathology including breast examination in women over 30yrs of age and rectal examination if indicated by symptoms.2. If pv examination is necessary this will be highlighted in the discharge letter as the DVT clinic is not a suitable environment for this to occur.3. Full blood screen including :FBC, Ferritin, U+E/ eGFR, LFT, Baseline Coag and INR, Boneprofile, Urine dipstick (and Pregnancy test in women of child bearing age)CXR in unprovoked DVTPSA if required (following PR examination/if prostatic symptoms)Tumour markers if abdominal symptoms/signs.
17Malignancy 10% Unprovoked DVT / PE present with cancer within 1 year A Presenting sign in:Pancreatic cancerProstate cancerLate sign in:Breast cancerLung cancerUterine cancerBrain cancer
18Investigations for cancer Offer all patients diagnosed with unprovoked DVT or PE who are not already known to have cancer the following investigations for cancer:a physical examination (guided by the patient's full history)anda chest X-rayblood tests (full blood count, serum calcium and liver function tests)urinalysis.ConsiderFurther investigations for cancer with an abdomino-pelvic CT scan (and a mammogram for women) in all patients aged over 40 years with a first unprovoked DVT or PE who do not have signs or symptoms of cancer based on initial investigation (see 'Investigations for cancer' above).
19Two Phases of VTE Management Initial Treatment• ≥5 d treatment with SC LMWH or IV UFH,• Discontinue when INR >2.0 for 48 hr• Initiation of VKA together with LMWH or UFH on first treatment dayOrInitiation with New Oral Anti-coagulant (Rivaroxaban)Long-term treatment• Necessary for patients at continuous risk for recurrence• Duration of treatment is dependent on underlying disease and risk factors• Appropriate treatment can reduce the risk of recurrence to approximately 5% at 3 monthsn patients with objectively confirmed DVT, the guidelines recommend short-term treatment with SC LMWH, IV UFH, monitored SC UFH, fixed dose SC UFH or SC fondaparinux. A vitamin-K antagonist (warfarin) should be initiated with LMWH and UFH or SC fondaparinux on the first treatment day. Treatment with LMWH, UFH, or fondaparinux should be discontinued when the INR is stable and ≥2.0 for 24 hours.As will be summarized in this section, the longer-term duration of treatment is highly dependent on the presence/absence of underlying disease and the presence/absence of risk factors. A treatment regimen of 3-6 months of oral anticoagulant therapy following 5-10 days of heparin therapy reduces the risk for short-term thromboembolic complications to 5% or less.TIME
201st idiopathic DVT □ Recurrent DVT □ 1st Precipitated DVT □ Surgery past 12 weeksLower limb fractureLower limb in plasterPregnantPost partum up to 12 weeks(Travel / COCP / HRT)Distal DVT (below knee) □Proximal DVT (above knee) □Distal DVT (below knee) □Proximal DVT (above knee) □Anticoagulate3 months □Anticoagulate3 months □Refer to ART (if suitable) □Refer to ART (if suitable) □If no family history DVT / PE Discharge at end of treatment □Thrombosis ClinicFollow up at 3 months □If family history DVT / PE □
21Traditional approaches of Anticoagulation HeparinMinimum of 5 daysUntil INR > 2 on at least 2 occasionsWarfarinPE minimum 3 monthsIdiopathic proximal DVT minimum 3 monthsIdiopathic distal DVT 3 monthsProvoked distal DVT 3 monthsRecurrent DVT / PE long term21
22New approaches to anticoagulation Vitamin K antagonists (VKAs) and ODIs VIIVKATFVIIaInitiationVKAXIXPropagationXaIXaIIVKAThis slide shows a simplified model of the coagulation pathway.Different anticoagulants target different point in the coagulation pathway.VKAs such as warfarin inhibit the vitamin-K-dependent synthesis of Factors II, VII, IX and X as well as numerous other proteins.RIVAROXABANAPIXABANEDOXABANInactive factorActive factorTransformationIIaDABIGATRANCatalysisClot formationFibrinogenFibrin222222
24OUT-PATIENT TREATMENT OF DVT Low molecular weight heparinEnoxaparin should be continued until the INR has been >2 for 2 consecutive days and for a minimum of 5 days.WarfarinIf the initial PT is <17s (INR <1.3) the patient will receive 5mg of warfarin on the evenings (17:00 to 19:00) of days 1 and 2.The INR is checked on the mornings of day 3 and 4 and the warfarin dose is adjusted according to the schedule:If the patient is on an anti-platelet medication a doctor should review whether this is to continue, whilst the patient is on warfarin.IndicationTarget INR (+/- 0.5)DurationFollow up1st idiopathic proximal DVT2.5≥ 3 monthsThrombosis Clinic1st precipitated proximal DVT3 months*No follow up1st idiopathic distal DVT1st precipitated distal DVTRecurrent DVT not on warfarin / sub- therapeutic INRRecurrent DVT on warfarin and therapeutic INR3.5Long-termDay 1 and 2Day 3Day 4INR DoseINR DoseWarfarin 5mg each day< mgmgmgmg> mg< mgmgmgmgmgmgmgmg> mg
25Rivaroxaban as an alternative to warfarin Patients who have suffered a 1st precipitated DVT and only require 3 months anticoagulation will be offered the option of warfarin or rivaroxabanPatients with a history of excessive alcohol consumption, in whom warfarin and INR monitoring will be difficult will be offered the option of LMWH or rivaroxabanPatients with poor venous access e.g. history of IVDU will be offered the option of LMWH or rivaroxabanFirst 3 weeksSubsequent 9 weeksRivaroxaban 15mg bdRivaroxaban 20mg od
26Treatment options for Venous Thromboembolism in patients with solid tumours Shared agreement between Bro Taf and Cardiff and ValeExtended treatment with Dalteparin for up to 6 monthsPrescribe Dalteparin at approximately 200 iu/ kg total body weight subcutaneously once daily for the first 30daysMonths 2-6 Dalteparin should be administered at a dose of approxiamtely 150 iu/kg s/c once dailyRecommended treatment is 6 months.Continuing beyond this period will be evaluated according to individuals risk/benefits and progression of cancer
27Treat for 3 months and reassess Isolated distal DVT Stop at 3 months Reversible provoking factorStop at 3 monthsUnprovoked proximal DVT or PEReview optionsCancerIndefinite therapy or until cancer inactiveHigh Bleeding RiskORPrefers to stop even if D Dimer positiveOthersStop and measure D Dimer at 1 monthNot High Bleeding Risk and prefers to stay on even if D Dimer is negativeSecond VTEIndefinite therapyUse of D Dimer testing to guide treatment decisions in patients with a first unprovoked proximal DVT or PE is optional.If D Dimer is not used , the decision is based on risk of bleeding and patient preference (estimated risk of recurrence in the first year of 12% for men 8% for women).Negative D DimerStay off therapy(Stop at 3 months)Positive D DimerRestart therapy(Indefinite therapy)
28TAKE 100 ASYMPTOMATIC CALF DVT %-20% of them become proximal Half of these will embolise i.e.8%-10% Half of these will be symptomatic PE ( i.e. 4%-5% or PE’s) Untreated PE (1.0% of the total) symptomatic and non-fatal –26% (1.0% of the total) will be fatal PE. TAKE 100 SYMPTOMATIC CALF DVT symptomatic DVT 21%-36% of them become proximal Half of these will embolisei.e.8%-18% Half of these will be symptomatic PE (ie4%-9% or PE’s) Untreated PE –26% (1.5% of the total) symptomatic and non-fatal –26% (1.5% of the total) will be fatal PE Cohen AT, JTH 2006
29Case History 1 48yr old male Presenting with 4/52 history of ‘sciatic’ type lower back pain radiating down left leg.No past medical history but awaiting private gastro-enterologist review for ‘epigastric’ type pain and MRI for back painWells score – 2 ( Calf >3cms, pitting oedema unilaterally)Doppler Ultrasound – Gastrocnemius vein clot (not extending into popliteal vein)Re-scanned in 1/52 – Gastrocnemius clot extended into popliteal venInitial treatment with LMWH whilst awaiting result of MRIUrgent CT Chest, abdo and pelvisMalignant sacral bone lesion with widespread retroperitoneal and thoracic small volume tissue depositsPlan – Admission – BiopsyManagement of DVT – insertion of IVC filterAnti-coagulation – determined following biopsy result.
30Case history 2 63yr old female Presenting with one day history of calf painHistory of 7hr car journey plus 31/2hr flightLower leg feeling ‘itchy’PMH – AsthmaWells Score 1D Dimer +veDoppler Ultrasound – Left Tibial DVTTreatment choice – RivaroxabanNo follow up
31Case history 3 83yr old female 5/52 history of painful/ swollen left legInitially treated by GP as cellulitis with antibioticsNo response after 2/52Doppler ultrasound – Left ileo-femoral DVTNo provoking factors other than age and limited mobility (chronic)No red flagsPlanWarfarin/LMWHReview at 3/12
35Hit by a car driven by his girlfriend accidentally’ Sustained fracture tibia, put in plasterReturned 3 days later complainiing of pain and parasthesiae in toes.Diagnosed with compartment syndrome, went to theatre
40One Final Point Why you should ask about clots Blood clots can happen to anyone.If you are in hospital – or have left hospital in the last three months – you are at greater risk of developing a clot.Blood clots are preventable!Ask your doctor, nurse or healthcare professional to help you reduce your risk of developing a clot.Watch the video to find out more