Update Management of

Venous Thromboembolism

M. Riswan
Division of Hematology Medical Oncology of Internal Medicine
dr. Zainoel Abidin Hospital / Faculty of Medicine Syiah Kuala University
Banda Aceh, Indonesia
Overview

• Introduction
• Definition
• Risk Factor
• Diagnostic
• Prophylaxis
• Treatment
• Conclussion
Epidemiology
Epidemiology
Epidemiology
Overview

• Introduction
• Definition
• Risk Factor
• Diagnostic
• Prophylaxis
• Treatment
• Conclussion
 Definition
VTE

DVT PE

•Deep vein thrombosis is • Pulmonary embolism is a

the formation of a blood condition when a clot
clot in one of the deep breaks free and enters
veins of the body, usually the arteries of the lungs
in the leg
Overview

• Introduction
• Definition
• Risk Factor
• Diagnostic
• Prophylaxis
• Treatment
• Conclussion
Virchow Triad
Overview

• Introduction
• Definition
• Risk Factor
• Diagnostic
• Prophylaxis
• Treatment
• Conclussion
Diagnostic Studies

• Clinical examination alone is able to confirm

only 20-30% of cases of DVT
• Blood Tests
• D-dimer
• INR (useful for guiding the management of
patients with known DVT who are on warfarin)
• Imaging
 DVT – Clinical Presentation

• Classically
• Calf or thigh pain
• Tenderness
• Leg swelling
• redness
• Homan’s sign
• Overall sens/spec = 3-91%
• Unreliable for diagnostic decisions
• Wells developed and tested a clinical prediction
model for DVT
Wells PS, Anderson DR, Bormanis J, et al. Value of assessment of pretest probability of deep-vein thrombosis
in clinical management. Lancet 1997;350 (9094):1795-8.
 PE – Clinical Presentation

• Dyspnea, pleuritic pain and cough most

common symptoms
• Tachypnea, rales and tachycardia most
common signs
• ABG limited value for diagnosis
• ECG and CXR often abnormal, but usually
lacking specificity to aid diagnosis

PIOPED Study. JAMA. 1990;263(20):2753-59. Stein PD, Goldhaber SZ, Henry JW. Chest 1995;107:139-43
 DVT

Wells Clinical Score

PE
 D-Dimer

• Fibrin degradation product elevated in

active thrombosis
• Negative test can help exclude VTE
• Preferred test
• Quantitative Rapid ELISA – sensitivity 96/95% for
DVT/PE
• Other methods include latex agglutination and
RBC agglutination (SimpliRED)

Stein PD, Hull RD, Patel KC, et al. D-dimer for the exclusion of acute venous thrombosis and pulmonary
embolism: a systematic review. Ann Int Med. 2004;140(8):589-602
Imaging Studies

oInvasive
Venography
Radiolabeled fibrinogen
o noninvasive
Ultrasound,
Plethysmography,
MRI
 Diagnosis algorithm of DVT

Scarvelis, D, Wells, P. Diagnosis and treatment of deep-vein thrombosis. CMAJ 2006; 175:1087
 Diagnosis algorithm of PE

Soheir S. Adam, et al. D-dimer antigen: current concepts and future prospects. Blood Journal. 2009
Overview

• Introduction
• Definition
• Risk Factor
• Diagnostic
• Prophylaxis
• Treatment
• Conclussion
VTE - Prophylaxis

• Venous tromboembolism (VTE), which includes

deep vein trombosis (DVT) and pulmonary
embolism(PE), is common complication among
hospitalized patients associated with considerable
long –term morbidity, functional disability and
mortality (Huang W, Anderson FA. J TROMB
Thrombolysis, 2013).
• Therefore, more attention should be paid to
appropriate trombosis prophylaxis in hospitalized
medical patients
VTE – Prophylaxis in Medical
Patients

• Indications
• CHF or severe respiratory disease
• Bedrest with additional risk factor
• Cancer
• Prior VTE
• Acute neurologic disease
• Inflammatory bowel disease
• Most ICU patients

• Options
• Low dose unfractionated heparin or LMWH
• Sequential compression devices
• Graduated compression stockings
VTE - Prophylaxis

Thrombosis Prevention and Anticoagulation Policy, NHS, Jun 2016

Zachary Stacy. Novel Oral Anticoagulants for Venous Thromboembolism Prophylaxis After Total Hip or Knee
Replacement. P&T. 38(1). 2013
Overview

• Introduction
• Definition
• Risk Factor
• Diagnostic
• Prophylaxis
• Treatment
• Conclussion

Primary prevention or
prevention of a first event
Patient at risk and undergoing
orthopaedic surgery, other
type of surgery and non-
surgical patient (eg. Critical ill
medical patient, people with
cancer)
Management of VTE
(DVT & PE)
Acute VTE Treatment Secondary prevention on
prevention of recurrent
event and long term
treatment
Patient who experiance a
Patient at risk of recurrent
venous event rapidly and/or
venous events. This risk
severely that requires
increases cumulatively over
immediate treatment
time in patients who are not
treated
Principles Therapy of Thrombosis Based on
Pathogenesis
PATHOGENESIS THERAPY

RISK FACTOR PREVENTION

• PLATELET ADHESION
ANTIPLATELET
• PLATELET AGGREGATION

• BLOOD COAGULATION ANTICOAGULANT

• THROMBOSIS THROMBOLYTIC
 Gold standard for VTE treatment
5 to 7 days

IV UFH
SC LMWH & Fondaparinux

5 days overlap

Warfarin Duration for

Monitor INR Daily Target INR 2.0-3.0 Prox DVT

Kearon C et al.2008;135:454-5459
 Risk and Benefit
Recent Surgery Respiratory failure Active Gastroduodenal ulcer
Sepsis Renal failure Bleeding in 3 m before
Hearth Failure Immobilisation admission
Obesity Paralysis Platelet Count <50x109/L
Sedation Malignancy Age > 85 years
Previous VTE Hepatic Failure
Trauma SCI Severe renal failure

Anticoagulation
benefit Bleeding Risk
What to choose?

• Unfractional Heparin
• LMWH
• Vitamin K Antagonist (VKA)
• Direct Oral Anticoagulant (DOAC)
• The optimal regimen for the treatment of DVT
is anticoagulation with heparin or an LMWH
followed by DOAC or VKA with oral
anticoagulant for 3-6 months
DOAC Avalability

• Apixaban (2.5mg, 5mg)

• Dabigatran (75mg, 110mg, 150mg)
• Edoxaban (15mg, 30mg, 60mg)
• Rivaroxaban (2.5mg, 10mg, 15mg, 20mg)
Do not use DOAC :

• Active Bleeding or high risk bleeding

• Renal failure (CrCl <30 ml/min)
• Severe liver disease
• Uncontrolled severe hypertension
• Pregnancy (edoxaban)
• In patients with DVT or pulmonary embolism (PE), we
recommend long-term (3 months) anticoagulant therapy
over no such therapy
• In patients with DVT of the leg or PE and no cancer, as long-
term (first 3 months) anticoagulant therapy, we suggest
dabigatran, rivaroxaban, apixaban, or edoxaban over
vitamin K antagonist (VKA) therapy.
• In patients with DVT of the leg or PE and cancer (“cancer-
associated thrombosis”), as long-term (first 3 months)
anticoagulant therapy, we suggest LMWH over VKA therapy,
dabigatran, rivaroxaban, apixaban, or edoxaban

Antithrombotic Therapy for VTE Disease, CHEST Guideline and Expert Panel Report, 2015
Take Home Points

• VTE (DVT&PE) is a major problem and a leading

cause of death in worldwide.
• There is many risk factor to VTE, the main
concept is Virchow triad
• The ideal diagnostic strategy uses the clinical
presentation, blood test and imaging tests.
• Always consider VTE prophylaxis in inpatients or
in patient with high risk of DVT/PE
• Treatment including the primary prevention,
acute phase DVT and secondary prevention
THANK YOU