Venous Thromboembolism

in the

general practice setting

.

Department of Family Medicine and Community Nursing.
Medical University of Bialystok, Poland. 2011

Jolanta Sawicka - Powierza

Polish guidelines for the prevention and
treatment of venous thromboembolism:
2009. Zawilska K, Jaeschke R, Tomkowski
W, Mayzner-Zawadzka E, Nizankowski R,
Olejek A, Pasierski T, Torbicki A, Undas A,
Jawień A, Gajewski P, Sznajd J, Brozek J. Pol
Arch Med Wewn. 2009;119 Suppl 1:1-69.
Review. Polish.

VTE (venous

thromboembolism)

mortality rates of 5-23%

DVT (deep vein

thrombosis)

PE (pulmonary embolism)

RISK FACTORS ASSOCIATED WITH VTE:

I. General



Older age



Immobility,

p

aresis



Ma

li

gnancy



O

b

esity



P

revious VTE



Family history of VTE



Oral contraceptive pill, hormone replacement,
tamoxifen



Venous insufficiency/varicose

v

eins   

II.

High risk clinical situations



Surgery (especially hip and knee surgery or major
surgery for malignancy)



Pregnancy/puer

p

erium



Acute medical illness



Congestive cardiac and respiratory failure



Trauma



Central venous c

a

theter

III.

Diseases associated with a

prothrombotic state



Myeloproliferative disorders



Antiphospholipid syndrome



Paroxysmal nocturnal haemoglobinuria



Nephrotic syndrome



Hyperviscosity syndrome



Inflammatory bowel disease

IV.

Inherited thrombophilia



Factor V Leiden mutation



Antithrombin, protein C and protein S deficiency



Prothrombin gene mutation (Factor II G20210A
mutation

)

Assessment clinical probability

of DVT

due to the Wells

score

DVT suspected

high

low

moderate

Wells criteria

– Clinical probability of DVT



active cancer (treatment ongoing, within previous 6 months,
or palliative)



paralysis, paresis, or recent plaster immobilization of the
lower extremities



recently bedridden >3 days or major surgery within 4 weeks



localized tenderness along the distribution of the deep
venous system



entire leg swollen



calf swelling 3 cm larger than on the asymptomatic side
(measured 10 cm below tibial tuberosity)



pitting edema (greater in the symptomatic leg)



collateral superficial veins (non-varicose)



alternative diagnosis as likely or greater than that of DVT

+1

+

1

+

1

+

1

low =<0

moderate 1-2

high >=3

+

1

+

1

-2

+

1

+

1

P.S. Wells i wsp., Lancet, 1997; 350:

1795-1798

clinical probability

Diagnostic tests to confirm

DVT

Low risk

Moderate risk

High risk

DD

+

--

clinical follow-up

CUS

+

--

treat DVT

repeat CUS

treat DVT

CUS

repeat CUS

--

+

DD - D-dimer; CUS - commpression ultrasound

MANAGEMENT OF DVT

Morphology, blood group, APTT, INR,

creatinine

Start the treatment with LMWH, UFH, or

fondaparinux

To asses if are there any contraindications

for antithrombotic therapy

To order D-dimer and CUS detecting

DVT

Confirmed DVT

Excludet DVT

Without treatment

high

low or moderate

Is it possible to

perform D-
dimer and
CUS?

yes

no

Treatment

Confirmed DVT - treatment

Is it the threatening of

leg lossing ?

Is it extensive acute
proximal DVT?

Are there any

contraindications for
antithrombotic therapy?

Is it the cancer

coexisting ?

To start or continue the

treatment with LMWH, UFH, or
fondaparinux

Are there any contraindications for

VKAs?

Start of vitamin K antagonists (VKAs) together with LMWH, UFH, or

fondaparinux on the first treatment day, and stop heparin preparations
when the international normalized ratio (INR) is >2.0 for at least 24 h.

Are there any

contraindicatio
ns for
thrombolytic
therapy?

Think of placement of an vena caval

filter

LMWH for the first 3 to 6

months

, next

VKA or LMWH

indefinitely or until the
cancer is resolved

no

yes

no

n

o

no

yes

yes

yes

n

o

Think of venous
thrombectomy.

Think of catheter-

directed
thrombolysis
(CDT) or systemic
thrombolytic
therapy

yes

All patients should undergo rapid risk stratification PE-
related early mortality rate

PE (

pulmonary embolism) -

confirmed or

evaluated

Clinical: shock or hypotension

non high

Markers of right ventricle dysfunction/injury

or markers of myocardial injury ( cardiac
troponin)

high >15%

Intermediate 3-

15%

low <3%

absent

present

yes

no

guidelines ESC 2008

Hypotension is defined as:



Systolic blood preasure < 90 mmHg

or



Decrease of blood preasure ≥ 40mmHg lasting
more than 15 min.

guidelines ESC 2000

PE - High-risk
MANAGEMENT

Start the treatment of hypoxemia, shock or

hypotension

Morphology, blood group, APTT, INR,

creatinine

To asses if are there any contraindications for antithrombotic

therapy

Echocardiograp

hy

Is it possible to perform a computed tomography

CT (spiral CT or CT angiography)?

Start the treatment with UFH, LMWH or

fondaparinux

Is it right ventricle overload?

Search for other

causes

Is it CT available?

Are there any contraindications for thrombolytic

therapy?

Treatment with

thrombolytic
therapy

Pulmonary Embolectomy or mechanic

fragmentation

of the clot or usunięcie zakrzepu przez

cewnik

no

yes

yes

CT

+

-

Search

for
other

causes

no

no

yes

yes

no

no

Thrombolytic

therapy

Pulmonary Embolectomy or mechaniczna
fragmentacja lub usunięcie zakrzepu przez

cewnik

Are there any

contraindications for
antithrombotic therapy

Is it the cancer coexisting?

Start the treatment with UFH, LMWH or

fondaparinux

Are there any contraindications for VKA

Start of vitamin K antagonists (VKAs) together with LMWH, UFH, or

fondaparinux on the first treatment day, and stop of these heparin
preparations when the international normalized ratio (INR) is >2.0
for at least 24 h.

Think of placement of an vena caval filter

LMWH for the first 3 to 6 months,

next long-therm therapy with VKA or
LMWH or until the cancer is resolved

no

no

no

yes

yes

Assess clinical probability

of PE

by the Wells score for PE

PE - non high risk

high

low

moderate

Wells criteria

– Clinical probability of PE



Clinical signs and symptoms of DVT (min. of leg swelling and
pain with palpation of the deep vein)



Alternative diagnosis less likely than PE



Heart rate >100/min



Immobilisation (>3d) or surgery in the previous 4 weeks



Previous PE or DVT



Hemoptysis



Maligancy (receiving treatment,treated in the last 6 months
or palliative)

+3,0

+3,0

+1,5
+1,5

low 0-1

moderate 2-6

high

>=7

+1,5

+1,

0

+1,

0

P.S. Wells et al, Thromb. Haemost., 2000; 83: 416-420

3 levels

PE - non high risk

Assess clinical probability

of DVT

Morphology, blood group,

APTT, INR, creatinine

Are there any

contraindications for
antithrombotic therapy

high

CT

Start the treatment with

LMWH UFH, or
fondaparinux

D-dimer + morphology, blood

group, APTT, INR,
creatinine

Moderate and

low

Are there any

contraindications for
antithrombotic therapy

no

yes

yes

Start the treatment with

LMWH UFH, or
fondaparinux

no

yes

D-dimer

+

-

-

No treatment, investigate further

+

Treatment

CT +

Are there any contraindications for
antithrombotic therapy

Is it the cancer coexisting ?

Start the treatment with

LMWH,

UFH, or fondaparinux

Are there any contraindications for VKA

Start of vitamin K antagonists (VKAs) together with

LMWH, UFH, or fondaparinux on the first treatment day,
and discontinuate of these heparin preparations when the
international normalized ratio (INR) is >2.0 for at least 24
h.

Think of placement of an

vena

caval filter

LMWH for the first 3 to 6 months,

next long-therm therapy with VKA
or LMWH or until the cancer is
resolved

no

no

no

yes

yes

yes

Thank you