Venous Thromboembolism Quiz

Venous Thromboembolism (VTE)

• VTE is a potentially fatal disorder and a significant health problem.
• VTE results from clot formation within the venous circulation and manifests as deep vein thrombosis (DVT) or pulmonary embolism (PE).
• Deep vein thrombosis (DVT) is rarely fatal.
• Pulmonary embolism (PE) can result in death within minutes of symptom onset.

Learning Outcomes

• Students will understand the pathophysiology of VTE.
• Students will identify common vital/lab tests used to assess VTE.
• Students will recognize common risk factors for developing VTE.
• Students will compare and contrast different types of anticoagulation.
• Students will develop a therapeutic plan, including monitoring for efficacy and toxicity, for different patient populations with VTE.
• Students will formulate a prevention strategy for different patient populations at high risk for deep vein thrombosis (DVT) consistent with clinical practice guidelines.

Vascular Disease

• VTE is a type of vascular disease.
• Related vascular diseases include coronary, cerebral, peripheral, renal, mesenteric, and aorta diseases.
• Diseases also includes IHD & ACS, Stroke & TIA.

Pathophysiology of Clots

• Arterial clots ("white clots") are platelet-rich and associated with high blood pressure.
• Venous clots ("red clots") are red blood cell-rich and associated with low blood pressure.
• Treatments for arterial clots involve antiplatelet agents, while anticoagulant agents treat venous clots.

Introduction

• VTE is a significant health problem.
• Clots form within the venous circulation and result in deep vein thrombosis (DVT) and pulmonary embolism (PE).

Risk Factors for VTE

• Hypercoagulable State: Malignancy, pregnancy, estrogen therapy, trauma or surgery (lower extremity, hip, abdomen, or pelvis), inflammatory bowel disease, nephrotic syndrome, sepsis, and thrombophilia.
• Vascular Wall Injury: Trauma or surgery, venipuncture, chemical irritation, heart valve disease or replacement, atherosclerosis, and indwelling catheters.
• Circulatory Stasis: Atrial fibrillation, left ventricular dysfunction, immobility or paralysis, venous insufficiency or varicose veins, venous obstruction from tumors, obesity, or pregnancy.

Presentation & Evaluation

• A combination of medical history, physical examination, and laboratory findings are required to establish a diagnosis and develop a treatment plan.

Clinical Presentation

• DVT: Unilateral swelling, warmth, discoloration, calf tenderness, pain, and Homans sign.
• PE: Shortness of breath, tachycardia, tachypnea, hemoptysis, anxiety, dyspnea, cough, and chest pain.

Assessment & Diagnosis

• DVT: Wells Model, D-dimer, Doppler ultrasound, and venography.
• PE: Wells Model, D-dimer, ECG, chest X-ray, arterial blood gas, CT scan, ventilation/perfusion scan (VQ scan), and pulmonary angiography.

D-Dimer

• D-dimer is a degradation product of fibrin clot.
• It is sensitive to acute thrombosis but not specific.
• Conditions such as trauma, pregnancy, cancer, surgery, infection, and inflammation can elevate D-dimer levels.

Clinical Model (Wells Score)

• DVT and PE can be evaluated using the Wells score model.

Goals of VTE Treatment

• Prevent thrombus extension and embolization.
• Reduce recurrence risk.
• Prevent long-term complications (post-thrombotic syndrome).
• Decrease consequences of PE (death, pulmonary hypertension, impaired function).

Approaches to VTE Treatment

• Bridging Therapy: Involves initial injectable anticoagulants (UFH, LMWH, fondaparinux) overlapped with warfarin until INR reaches 2-3.
• Switching Therapy: Injectable anticoagulants (UFH, LMWH and fondaparinux) for at least 5 days followed by dabigatran or edoxaban.
• Monotherapy: Initiate rivaroxaban or apixaban at higher dose followed by lower dose.

Acute VTE Management

• Thrombolytic therapy is used in specific situations.

Nonpharmacological Management

• Inferior vena cava filter (IVCF) placement.
• Thrombectomy (suctioning).
• Anti-embolic leg exercise.

Chest Guidelines Recommendation: Oral Anticoagulants

• In patients with proximal DVT or PE, long-term (3 months) anticoagulation is recommended.
• Patients without cancer should use dabigatran, rivaroxaban, apixaban, or edoxaban instead of vitamin K antagonists for VTE.
• Patients with cancer should use rivaroxaban, apixaban, or edoxaban over LMWH.
• In other cases consider aspirin, or warfarin instead of LMWH.

Chest Guidelines Recommendation: Systemic Thrombolytic Therapy for PE

• Systemic thrombolytic therapy is generally not recommended for PE without hypotension.
• Thrombolytic therapy may be used in cases of PE with hypotension or other high-risk characteristics.

Duration of Anticoagulant Therapy

• Duration of anticoagulation varies depending on the clinical setting (provoked vs. unprovoked, first VTE vs. recurrent VTE,bleeding risk).
• For proximal DVT or PE caused by surgery, anticoagulation is typically administered for 3 months. Extended duration or indefinite treatment are considered in specific circumstances.

Overview & Duration of Anticoagulant Therapy for VTE

• Treatment duration varies based on whether the patient has an acute or chronic condition.
• Different oral anticoagulants are used for different time periods.

VTE Prophylaxis

• VTE prophylaxis is used to prevent the development of VTE.
• Risk factors and specific strategies vary based on the clinical setting (e.g., surgical patients vs. medically ill patients).

Risk Factors for Development of VTE

• Increasing age, surgery, trauma, pregnancy, hypercoagulable states, estrogen use, central venous catheterization, cancer, immobility, certain medical conditions, and acute medical illnesses.

Mechanical Prophylaxis

• Early ambulation, graduated compression stockings (GCS), and intermittent pneumatic compression (IPC) are mechanical methods for VTE prevention.

Pharmacological Prophylaxis

• LMWH (subcutaneous enoxaparin or dalteparin), UFH (subcutaneous), fondaparinux, Adjusted-dose warfarin, DOACs (dalteparin, rivaroxaban, and apixaban).

General Approach to VTE Prophylaxis

• Patients should be assessed for risk factors and bleeding risk.
• Prophylaxis recommendations vary by risk level and presence of other conditions like cancer or bleeding risk.

VTE & bleeding Risk Assessment in Medically Ill Patients

• Specific criteria and scoring system to determine the risk of developing VTE.

Non-Surgical Patients

• Prophylaxis recommendations vary based on risk assessment (low, increased, high, high+ bleeding risk, critically ill).

Non-Orthopedic Surgery

• Various levels of risk and prophylaxis recommendations suggested depending on specific factors and surgical interventions.

Orthopedic Surgery

• Prophylaxis methods and durations tailored for orthopedic surgical procedures (e.g., THA, TKA, HFS).

Duration of Prophylaxis

• Prophylaxis duration should be guided by the specific characteristics of the surgical/medical presentation and should be reevaluated over time.

Thank You

• Concluding statement for the presentation material.

Test your knowledge on venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE). This quiz covers symptoms, diagnostic tests, and treatment importance related to these conditions. Challenge yourself and see how much you know about VTE management!