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Outpatient DVT assessment & treatment Daniel Gilada
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Prevalence ~1 million cases a year Nearly 2/3 hospitalized Risk factors HereditaryAcquiredReversibleIrreversible
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Diagnosis Duplex ultrasound Sensitivity & specificity of 95 & 98% D-Dimer Contrast venogram
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Classification ProvokedUnprovoked
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Goals of treatment -Prevent recurrence -Embolism -Thrombosis-related death
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Outpatient treatment Physician must assess The patient is ambulatory and in stable condition, with normal vital signs There is a low a prior risk of bleeding in the patient Severe renal insufficiency is not present There is a practical system in place for the following: Administration of LMW heparin and/or warfarin with appropriate monitoring, and Surveillance and treatment of recurrent VTE and bleeding complications
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Therapies Warfarin Low-molecular weight heparin Fondaparinux Non-vitamin K antagonist oral anticoagulants (NOACs)
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Warfarin Vitamin K antagonist Preferred due to longer clinical experience, available antidotes, and cost Drawbacks 1.5-2x recurrence of DVT if treatment was 4-6 wks vs 3-6 months
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Low-molecular weight heparin Indirect Xa inhibitor through ATIII Dosing 1 mg/kg SC BID (ABW) If Cl Cr 20-29mL/min, 1mg/kg SC daily Considerations Potential benefits compared to warfarin Post-thrombotic syndrome Recanalization of thrombosed veins Venous ulceration
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Fondaparinux Indirect Xa inhibitor through ATIII Monitoring not required Considerations Like enoxaparin, transition from unfractionated heparin can be immediate
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Factor Xa and direct thrombin inhibitors Avoid in CKD Patient preference Considerations Ileofemoral DVT Pregnancy Active cancer Rivaroxaban 15mg BID x 3 weeks; then 20mg daily Apixaban 10mg BID x 1 week; then 5mg BID Dabigatran 150mg BID*
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Contraindications Active bleeding Severe bleeding diathesis PLT <50,000 Recent, planned, or emergent surgery/procedure, major trauma History of intracranial hemorrhage
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Duration Unprovoked DVT or symptomatic PE Indefinitely Second episode of provoked DVT Provoked DVT with persistent risk factors Provoked DVT with persistent risk factors APS, malignancy
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American College of Chest Physicians (ACCP) Guidelines 2012 Isolated distal DVT Severe symptoms Treat 3 months regardless of etiology (surgery, hospitalization, estrogen therapy, vs unprovoked Mild symptoms Physician can do serial ultrasound Treat if clot extension present
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ACCP Proximal DVT Traditional treatment 3 months Surgery Estrogen therapy Long-distance travel Inpatient status Indefinite Unprovoked (idiopathic)
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ACCP Incidental finding Leg, pelvic, or IVC Standard therapy Cancer associated DVT 3 months Upper extremity DVT 3 months Catheter
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ACCP Superficial thrombophlebitis LMWH or fondaparinux 45 days IVC filter Active or high risk bleeding
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ACCP Compression stockings 2 years
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Other considerations Recurrent unprovoked VTE Recurrent provoked VTE Provoked VTE with persistent risk factors Indefinite Depends on risk factors
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DASH prediction score Age ≤ 50+1 Male sex+1 Hormone use at the time of VTE-2 D-dimer+2 DASH score: ≤ 1 annual VTE recurrence risk 3.1% ≥ 2 annual VTE recurrence risk 6.4%
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Special populations Pregnancy risk factors >35 yo C-sectionPre-eclampsia Prior DVT history LMWH at least 6 weeks post-partum
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IVC filter High bleeding risk Active bleeding, major surgery, hemorrhagic stroke
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Other considerations Malignancy decision to anticoagulate for extended periods, should be balanced against the risk of bleeding, cost of therapy, quality of life, life expectancy, and patient preference.
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Thrombectomy
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References Hopkinsmedicine.orgUptodate.comClevlandclinicmeded.com
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