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Management of Acute VTE

Management of Acute VTE. Acute DVT. Acute PE. Treatment of objectively confirmed DVT. Short term treatment LMWH, UFH (IV or SC), fondaparinux Initiate VKA therapy (target INR 2-3). Advantages of LMWH over UFH More reliable relationship between dose and response No monitoring

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Management of Acute VTE

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  1. Management of Acute VTE

  2. Acute DVT Acute PE

  3. Treatment of objectively confirmed DVT • Short term treatment LMWH, UFH (IV or SC), fondaparinux • Initiate VKA therapy (target INR 2-3) • Advantages of LMWH over UFH • More reliable relationship between dose and response • No monitoring • No dose adjustments • Low incidence of HIT • No excess bleeding • Can be administered at home • Reduced admission time Kearon C et al. Chest 2008:133: 454S-545S Turpie AGG et al. BMJ 2002;325: 946-50

  4. Duration of anticoagulant therapy • 1. DVT secondary to reversible risk factors • VKA for 3 months • 2. Unprovoked DVT • VKA for at least 3 months • After 3 months, evaluate for risk/benefit of continued VKA • Long term treatment if • first, unprovoked proximal DVT • no bleeding risk • anticoagulant monitoring achievable Kearon C et al. Chest 2008:133: 454S-545S

  5. Duration of anticoagulant therapy • 3. Second unprovoked DVT • Long term treatment with VKA • 4. First unprovoked distal DVT • VKA for 3 months sufficient • 5. DVT and cancer • LMWH for 3 – 6 months • Anticoagulant indefinitely or cancer resolved Kearon C et al. Chest 2008:133: 454S-545S

  6. Stocking and Compression Bandages to prevent PTS • 1. Symptomatic proximal DVT • Elastic compression stockings • Start as soon as feasible after anticoagulation started • Minimum of 2 years (longer if symptoms of PTS) Kearon C et al. Chest 2008:133: 454S-545S

  7. Management of probable massive PE Assess clinical state Cardiac arrest Deteriorating Condition seems stable (1) 80 units/kg heparin iv (2) Urgent echo or CTPA* (1) Contact consultant (2) 50mg alteplase iv (3) Urgent echo or CTPA* (1) Resuscitation (CPR) (2) 50mg alteplase iv (3) Reassess at 30 min In event of deterioration *Computed tomographic pulmonary angiography BTS GuidelinesThorax 2003;58: 470-484

  8. Management of suspected non-massive PE with isotope scanning off-site only Assess clinical probability Intermediate Low Any D-dimer High D-dimer N/A Vidas/MHRA available SimpliRED available D-dimer assay +ve -ve Start LMWH CT pulmonary angiogram PE present No PE Another diagnosis Add warfarin BTS GuidelinesThorax 2003;58: 470-484

  9. Management of suspected non-massive PE with isotope scanning on site Assess clinical probability High D-dimer N/A Low Any D-dimer Intermediate Vidas/MHRA available SimpliRED available D-dimer assay Negative Positive Start LMWH Abnormal CXR or cardiorespiratory disease? Neither Isotope lung scan Yes PE present Indefinite No PE CT pulmonary angiogram No PE PE present Another diagnosis Add warfarin BTS GuidelinesThorax 2003;58: 470-484

  10. New anticoagulants for VTE treatment • No alternatives to VKA currently licensed for VTE treatment (January 2010) • Direct thrombin inhibitor shown to be as effective as warfarin in VTE treatment1 • Direct inhibitors of Factor Xa under investigation for treatment of VTE2 1. Schulman S et al. NEJM 2009;361: 2342-52. The RE-COVER study 2. www.clinicaltrials.gov

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