Deep Vein Thrombosis and Pulmonary Embolism

• History

  • Presenting symptoms (sudden onset)

    • PE: Dyspnea, cough, hemoptysis, chest pain

    • DVT: Unilateral leg swelling/edema, calf pain

  • Transient VTE risk factors:

    • OR > 10 if within previous 3 months: Hip/leg fracture, spinal cord injury, cesarean section or surgery requiring general anesthesia,

    • OR 2-9: Pregnancy, estrogen therapy, central venous line, arthroscopic knee surgery

    • OR < 2: Immobilization (bedrest) due to illness/injury for 3+ days, prolonged travel in motor vehicle, varicose veins

  • Persistent risk factors (OR 2-9): Morbid obesity, heart failure, inherited thrombophilia, active cancer within previous 6 months +/- chemotherapy

• Physical exam

  • Vitals (PE): Heart rate > 100 BPM, tachypnea, hypoxemia

  • DVT: Unilateral calf redness, warmth, swelling/edema, tenderness

• Initial diagnostics

  • CBC, BMP

  • EKG: Precordial T-wave inversion, RBBB, S1-Q3-T3 suggesting PE

• Well's score

  • Less than 2: Calculate PERC and if ≥ 1, obtain d-dimer to rule out PE

  • Greater than or equal to 2:

    • Obtain lower extremity DVT ultrasound

    • No history of pulmonary HTN, heart failure: CT-angiography if lower extremity DVT is negative

Confirmed PE and/or DVT

• Persistent shock including hypotension: Consider thrombolysis

• Platelets > 70,000 with low hemorrhage risk and no limb ischemia, liver disease, ESRD, concerns for follow up:

  • Treat as outpatient

  • Anticoagulation regimens

    • No morbid obesity and no current pregnancy/malignancy with weight > 60 kg and Cr < 1.5: Apixaban 10 mg BID x 7 days followed by 5 mg BID

    • Elevated bleeding risk: Start concomitant LMWH/warfarin x 5 days. Continue warfarin and titrate to INR 2-3.

    • Hemodynamically unstable with high bleeding risk, renal insufficiency, and/or morbid obesity: Start unfractionated heparin

• Duration of anticoagulation

  • First event

    • Provoked with immediately reversible risk factor: 3 months

    • Provoked with persistent risk factor (e.g. immobility, pregnancy): 3 months and consider extending to up to 12 months

    • Unprovoked and not a candidate for indefinite anticoagulation: 3 months

    • Indefinite anticoagulation for unprovoked proximal DVT, unprovoked symptomatic PE, active malignancy, or antiphospholipid antibody syndrome

  • Repeat event: Initiate indefinite anticoagulation

• IVC filter: Consider for patients who are not candidates for anticoagulation or fail anticoagulation

• Counseling: Patient informed that s/he may develop post-thrombotic syndrome, venous ulcers

Notes

Wells’ Criteria

• DVT and PE risk factors: Previous DVT, active cancer during previous 6 months, immobility for > 3 days

• DVT risk factors: Major surgery during previous 3 months

• PE risk factors: Previous PE, major surgery during previous month

S1Q3T3

• S wave in lead I, Q wave in lead 3, inverted T wave in lead 3

• S wave = downward deflection after QRS complex (similar to a Q wave, but after the QRS)

• Rarely seen in PE EKGs

Anticoagulation

• Should not exceed 3 months if a reversible provoking factor/etiology is identified (see Wells’ criteria above)

• Lovenox should be continued in patients with active malignancy

• Apixaban

  • Selected over rivaroxaban in this vignette because rivaroxaban must be taken with food

  • Apixaban reduce dosing applies to patients who meet two of the following criteria: Age > 80 years, weight < 60 kg, serum creatinine > 1.5