Tuesday, May 9, 2017

Step 2 CK: Treatment of DVT notes

Here are my notes for Step 2 CK exam!

DVT treatment: Anticoagulation.

Duration: Minimum 3 months.

DVT with high risk of bleeding: IVC filter.

DVT in pregnancy, malignancy: LMW heparin.

Massive DVT: Thrombolysis / clot removal with anticoagulation.

DVT due to HIT: Stop heparin containing products. Start non heparin anticoagulation.

When should you hospitalize: Patients with massive DVT (eg, iliofemoral DVT, phlegmasia cerulea dolens), concurrent pulmonary embolism, a high risk of bleeding on anticoagulant therapy, comorbid conditions, or other factors that warrant in-hospital care. 

Notes from UpToDate:

Anticoagulation is the mainstay of therapy for patients with acute lower extremity deep vein thrombosis (DVT).

In patients with asymptomatic proximal DVT, we suggest anticoagulation identical to that for patients with symptomatic DVT.

Options include subcutaneous low molecular weight (LMW) heparin, subcutaneous fondaparinux, the oral factor Xa inhibitors rivaroxaban or apixaban, or unfractionated heparin (UFH).

Although there is agreement on the minimum length of time a patient with a first episode of DVT should be treated (ie, three months), the optimal length of time is not known.

Outpatient anticoagulation rather than inpatient therapy can be considered when patients are hemodynamically stable, have a low risk of bleeding, do not have renal insufficiency, and have a practical system in place at home for the administration and surveillance of anticoagulant therapy. It is not appropriate in patients with massive DVT (eg, iliofemoral DVT, phlegmasia cerulea dolens), concurrent pulmonary embolism, a high risk of bleeding on anticoagulant therapy, comorbid conditions, or other factors that warrant in-hospital care. 

For patients in whom anticoagulation is contraindicated or in whom the risk of bleeding is estimated to outweigh the risk of recurrent thromboembolism, we suggest the insertion of an IVC filter rather than no therapy.

For patients with active malignancy and pregnant women, we suggest that LMW heparin be selected as the initial and long-term anticoagulant of choice rather than other agents.

For patients with massive iliofemoral DVT or phlegmasia cerulea dolens with symptoms for <14 days and good functional status, we suggest systemic or catheter-directed thrombolytic therapy, and/or clot removal (eg, catheter extraction, catheter fragmentation, surgical thrombectomy) rather than anticoagulation alone.

For patients with a DVT and a diagnosis of heparin-induced thrombocytopenia (HIT), all forms of heparin should be discontinued and immediate anticoagulation with a non-heparin anticoagulant started.

Extra: For select patients with isolated distal DVT (eg, those at high risk of bleeding, negative D-dimer level, asymptomatic or minor symptoms, without risk factors for extension, and/or minor thrombosis of the muscular veins), we suggest surveillance with serial ultrasound over a two-week period rather than anticoagulation. Those who exhibit signs of thrombus extension should be anticoagulated. 

That's all!
-IkaN

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