Venous Thromboembolism (VTE) C.L.I.P.S. Definitions Proximal DVT: thrombosis of the popliteal, femoral or iliac veins. Also includes the “superficial femoral” system. Upper Extremity DVTs: ~10% of DVTs. Generally treat like LE DVT. PE: thrombosis originating in venous system and embolizing to pulmonary arterial circulation Clinical Manifestations DVT: calf pain, erythema, warmth swelling, venous distention PE: dyspnea (73%), pleuritic CP (66%), hemoptysis (13%) Diagnostic Workup Wells Criteria: help with pretest probability, along with PERC score “Age adjusted D-Dimer” if >50yo can multiply age x10 mcg/L for cutoff Diagnostic Tests D-Dimer: helps rule out. Use mindfully since poor specificity Compression U/S: 95% sens/spec for symptomatic DVT V/Q Scan: use if pretest prob high, CT not an option CTA: sens ~90%, spec ~95%. Risk Stratification of PE Combo of clinical signs (shock, hypoxia), lab signs (troponins, bnp), and signs of RV strain (RV/LV dimension >1 on CTA, signs on echo). See “PE Severity Index” Boards Q’s What is the most common ECG sign in PE? Sinus tachy What is a more specific ECG sign for PE? SIQIIITIII- a sign of R heart strain Updated 8/16 D. Waldman

Venous Thromboembolism (VTE) C.L.I.P.S. Treatment: immediate and long term Most PE patients get hospitalized, most DVT should not Bridging: LMWH, Heparin, Fonda DOAC’s (like Rivaroxaban/Apixaban) are preferred unless contraindicated. Better bleeding risk profile than Coumadin. Hypercoagulable workup ~12% of idiopathic VTE have malignancy. Age appropriate malignancy screening usually adequate. May consider lab w/u in pts <50 with +FH. Don’t order until >2 week after anticoag finished Hospital VTE Prophylaxis Calculators like Padua can help decision making if not in EMR Systems Issues and Duration of Anticoag UNM trying to decrease unnecessary CT’s see algorithm to the right (from 2015 ACP) Case Managers help w/ bridging meds Trend towards 4 week “superficial” venous thrombosis rx 1st provoked VTE w/ time-limited risk factors: consider only 3 months rx Most PE/DVT rx 6 months, if 2x-->indefinite ASA ↓risk of recurrent VTE. NNT 42/year Circulation 2014; 130(14:1062-1071) What PE patients should be considered for thrombolysis? Patients with hemodynamic compromise What VTE patients should be considered for IVC filters? Anticoag contraindication, failure or bleeding risk.