Treatment of deep venous thrombosis and pulmonary embolism Anders Waage
Arterial thrombosis: anti platelet agents Venous thrombosis: agents affecting the coagulation system
Anticoagulation/Trombolytic treatment Heparin Marevan (warfarin) Local vs systemic thrombolysis New agents Stockings Other
Deep venous thrombosis, LE Treament of acute DVT Duration of treatment Prophylactic treatment
What is the purpose of the treatment ?
Treatment schedule Heparin Marevan INR months5 days, at least
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
Therapeutical range of INR INR = 2-3: DVT, LE, atrial fibrillation, other conditions INR 2,5-3,5: mechanical heart valve
Genetic variation in degradation of warfarin (CYP 2C9) Dose of Marevan ½-7 tablets/day
Duration of treatment
Thrombolytic treatment DVT with great risk of serious post thrombotic syndrome DVT v. femoralis, iliaca, cava Serious LE
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
Side effect thrombolytic treatment Serious bleeding: 0,5 % Serious bleeding lmw. heparin: 0,1 %
Choice of treatment
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
Prophylactic situations Relapsing DVT, LE Surgery Atrial fibrillation Mechanical heart valve Other situations
Risk factors Genetic: Deficiency of protein s, protein c, antithrombin III, Factor V Leiden (APC resistance) Aquired: Age, surgery, immobilisation, oestrogen ++
Prophylaxis Orthopedic surgery (hip, knee) Abdominal, gynecological surgery Moderate risk: min duration High risk: >2 hours Age, weight, malignancy, oestrogen, p-pill, history of thrombosis
Moderat risk: Fragmin/Klexane 2500 U/ 20 mg High risk: Fragmin/Klexane 5000U/40 mg Start6 hours after surgery Stopwhen mobilised
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
Heparin do not pass placenta Marevan and breast-feeding
Prophylaxis in pregnancy DVT in previous pregnancy: 10 % risk for new DVT Prophylaxis with lmw heparin
DVT and cancer Post mortem studies: up to 50 % with thrombosis Clinical thrombosis in cancer patients: up to 30 %
Stockings after DVT Reduces risk of post-thrombotic syndrome Usefor 6 months Compression stocking up to the knee