1. 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

2. 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: )
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.