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Deep vein thrombosis Pulmonary embolism

Venous Thromboembolism. Treatment. Deep vein thrombosis Pulmonary embolism. …All the same?. Acute DVT. Management. What is the goal of therapy?. Acute DVT. Therapeutic Goals/Options. Caval Filter. Anticoagulation. Thrombolytic Rx. Thrombectomy. No Rx. Reduce PE. X. X. X. X.

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Deep vein thrombosis Pulmonary embolism

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  1. Venous Thromboembolism Treatment • Deep vein thrombosis • Pulmonary embolism …All the same?

  2. Acute DVT Management What is the goal of therapy?

  3. Acute DVT Therapeutic Goals/Options Caval Filter Anticoagulation Thrombolytic Rx Thrombectomy No Rx Reduce PE X X X X Prevent Extension X X + Reduce Recurrence X X + Restore Patency X X Preserve Valve Function X X + Reduce CVI X X

  4. Isolated Calf DVT 51 patients randomized Rx Heparin x 5 days Heparin x 5 days Warfarin x 3 mos 29% recurrent VTE No recurrent VTE 19% proximal DVT 4% pulmonary emboli Langerstedt CI, et al. Lancet 1985.

  5. Deep Vein Thrombosis Treatment • Initial treatment • Importance of therapeutic levels • Compression • Ambulation • Long-term treatment • 5 patient categories

  6. Acute DVT Importance of Early Rx Recurrent VTE* PTT <1.5x (24 hrs.) 24.5% (15:1) PTT >1.5x 1.6% <0.001 * • most occur > 4 weeks • association with poor initial response not appreciated by attending MDs Hull, RD et al NEJM 1990

  7. Heparin/LMWH Bioavailability Heparin for Acute DVT Plasma Level After SQ - Volunteers Single Subcutaneous Injection Plasma Recovery LMWH 90% Unfractionated heparin (UFH) 20% Bratt G, et al. Thromb Rea 1986;42(5):613-620. Bara L, et al. Thromb Res. 1985;39(5):631-636.

  8. LMWH vs. UFH for Acute DVT A Meta-Analysis of 10 Studies (n=759) • Prospective • Adjusted dose unfractionated heparin • Fixed dose SQ LMWH • Objective outcome measures Symptomatic recurrent DVT Change in thrombus size Major bleeding Mortality Bratt G, et al. Thromb Rea 1986;42(5):613-620. Bara L, et al. Thromb Res. 1985;39(5):631-636.

  9. LMWH vs. UFH for Acute DVT A Meta-Analysis of 10 Studies (n=759) Risk Reduction UFH LMWH P-value Venographic Change 6.5% 3.1% 53% <0.01 52% 63% - Improved 12% 6% <0.001 Worse Major Bleed 2.8% 0.8% 68% <0.005 Mortality 7.1% 3.9% 47% <0.04 Lensing AWA, et al Arch Intern Med 1995

  10. Deep Vein Thrombosis Initial Treatment: Compression & Ambulation • Proximal DVT- 53 patients • LMWH...then randomize: • Bed rest • Ambulation + 35 mm Hg stocking • Ambulation + 50 mm Hg compression bandage • Activity measured - pedometer • Venous duplex days 0 & 9 1. Blattler W., et al Int’l Angiol. 2003; 32: 861-9 2. Partsch H. et al J Vasc Surg 2000; 32: 861-9

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