Venous Thromboembolism (VTE) has an annual incidence of approximately 1:1000 in Western populations.
The most common forms of VTE are deep vein thrombosis (DVT) legs & pulmonary embolism (PE). The relative incidence of DVT: PE is approximately 2:1.
This post will give you the most practical key points in the management of VTE cases.
Anticoagulation
1. The mainstay of treatment for all forms of VTE is anticoagulation.
a. One option is to use low molecular weight heparin (LMWH) followed by a coumarin anticoagulant, such as warfarin.
b. Alternatively, patients may be treated with a direct acting oral anticoagulant (DOAC).
2. DOACs such as Rivaroxaban & Apixaban can be used immediately after diagnosis, without the need for overlap with LMWH.
On the contrary, for using Dabigatran & Edoxaban, initial treatment with LMWH for a minimum of 5 days is needed.
3. In provoked VTE cases, the optimal initial period of anticoagulation is between 6 weeks and 6 months.
Patients with a temporary risk factor, which is removed, can be treated for short periods (e.g. 3 months).
4. In patients with unprovoked VTE, the optimum duration of anticoagulation is difficult to establish. Most of the patients, who have had unprovoked episodes of VTE, will benefit from long-term anticoagulation.
5. In patients with active cancer and VTE, maintenance anti-coagulation is preferably done with LMWH. Compared with warfarin, this approach is associated with a lower recurrence rate of VTE.
6. In cases with ongoing risk factors that cannot be alleviated (e.g., active cancer), long-term anticoagulation is recommended. However, the benefits of anticoagulation need to be weighed against the risk of bleeding.
Inferior Vena Cava Filter
7. Insertion of inferior vena cava (IVC) filter is needed to prevent life-threatening PE in:
a. VTE patients with a strong contraindication to anticoagulation.
b. In patients who continue to have new pulmonary emboli despite therapeutic anticoagulation.
Thrombolysis
8. Thrombolysis is indicated in patients presenting with acute massive PE accompanied by hemodynamic instability.
There is an associated high risk of intracranial bleeding, therefore patients must be screened carefully for this risk.
9. Thrombolysis can also be done in cases of limb-threatening DVT.
Embolectomy
10. Surgical or percutaneous pulmonary embolectomy can be considered in patients with an absolute contraindication to thrombolysis. This carries a high mortality, however.
Supportive Measures
11. Supportive measures for DVT of the leg include elevation of the affected limb and analgesia.
VTE recurrence risk-assessment
12. The strongest predictors of recurrence are the male gender and a positive D-dimer assay measured one month after stopping anticoagulant therapy.
13. Scoring systems to predict the recurrence of VTE include the DASH score, HERDOO2 score & the Vienna prediction model.
Prevention of VTE
14. Risk assessment for VTE shall be done for all inpatients and then provide appropriate prophylactic measures.
15. Aim for the early mobilization of patients.
16. Patients at medium or high risk of developing VTE are candidates for additional antithrombotic measures, which can be pharmacological or mechanical.