Deep Vein Thrombosis (DVT) The Patient Journey Marilyn Rees Venous Thrombosis Nurse Specialist

Deep Vein Thrombosis (DVT)

The Patient JourneyMarilyn Rees

Venous Thrombosis Nurse Specialist

Overview

Diagnosis of DVTGoals of treatmentChallenges of DVT TreatmentCase studiesQuiz

Clinical Diagnosis of DVT

• DVT symptoms can be nonspecific, making it difficult to diagnose.

• Presence of DVT risk factors increase the likelihood of having the disease

• Objective testing must be used to confirm or rule out suspicion

Approaches to Diagnosis of DVT

• Patient History • Clinical Symptoms and Signs • Clinical Probability Score • Laboratory Testing • Imaging Testing

Clinical Signs and Symptoms of DVT (Nonsurgical Patients)

• Leg pain (90%) • Tenderness (85%) • Ankle oedema (76%) • Calf swelling (42%) • Dilated veins (33%) • Homan’s sign (33%) (sharp pain in the calf on dorsiflexion of the foot)

Reference Haeger K. Problems of acute deep venous thrombosis. I. The interpretation of signs and symptoms. Angiology. 1969;20:219-223.

Clinical Signs and Symptoms of DVT (cont’d)

• DVT cannot be reliably diagnosed on the basis of history and physical exam, even in high-risk patients.

• Patients with lower extremity DVT often do not exhibit erythema, warmth, swelling, or tenderness

(Symptoms in surgical patients are often masked by common post- operative pain and limb swelling)

• When present, these findings merit further evaluation despite lack of specificity

Diagnostic Algorithms

• Clinical diagnosis of DVT is non-specific because none of the signs in isolation are particular to the disease

• In symptomatic patients, clinical pre-test models can be used to determine probability of DVT or PE

Wells Scoring System for Diagnosing DVTClinical Characteristic Score*

Active cancer (treatment ongoing, within, 6 months or palliative) 1

Paralysis, paresis, or recent plaster immobilization of the lower extremity 1

Bedridden for >3 days or major surgery with general/regional anaesthesia within previous 12 weeks

1

Localized tenderness along the distribution of the deep venous system 1

Entire leg swollen 1

Calf swelling 3 cm larger than asymptomatic side (measured 10 cm below tibial tuberosity)

1

Pitting oedema confined to symptomatic leg 1

Collateral superficial veins (non-varicose) 1

Previous documented DVT 1

Alternative diagnosis at least as likely as DVT e.g(Popliteal (Baker) cyst, superficial thrombophlebitis, muscle pulls/tears, chronic venous insufficiency, and others)

-2

Clinical probability simplified score

DVT likely 2 points or more

DVT unlikely 1 point or less

Alternative Diagnosis

VTE Investigations Laboratory

• D Dimer (degradation product of a cross- linked fibrin blood clot) D-dimer has a high false-positive rateSensitive but nonspecific also increased in other conditions: cancer, inflammation, postoperatively, injury, pregnancy.

Non-invasive testing

Doppler Compression Ultrasound

Non-invasive, no contraindications. High accuracy insymptomatic patients (91%)

PROXIMAL VEINS

DISTAL VEINS

Venous system in lower limbs

D-DIMER

Suspected Leg Deep Vein Thrombosis

Well’s score UNLIKELY probability Well’s score LIKELY probability

-ve +ve

+ve

-ve

Full leg Ultrasound

+ve

Deep Vein Thrombosis

-ve

NO DVT

Patient discharged

back to referrer

NO DVT

Patient discharged

back to referrer

Full leg Ultrasound

What happens next?

Four Goals of VTE Treatment

1.Prevent fatal PE 2.Reduce morbidity associated

with acute leg or lung thrombus

3.Prevent recurrent VTE 4.Prevent long-term sequelae

DVT Confirmed

1.Full medical assessment to consider underlying pathology including breast examination in women over 30yrs of age and rectal examination if indicated by symptoms.

2. If pv examination is necessary this will be highlighted in the discharge letter as the DVT clinic is not a suitable environment for this to occur.

3. Full blood screen including : FBC, Ferritin, U+E/ eGFR, LFT, Baseline Coag and INR, Bone profile, Urine dipstick (and Pregnancy test in women of child

bearing age) CXR in unprovoked DVT PSA if required (following PR examination/if prostatic symptoms) Tumour markers if abdominal symptoms/signs.

Malignancy

10% Unprovoked DVT / PE present with cancer within 1 year

A Presenting sign in: Pancreatic cancer Prostate cancer

Late sign in: Breast cancer Lung cancer Uterine cancer Brain cancer

Investigations for cancer

Offer all patients diagnosed with unprovoked DVT or PE who are not already known to have cancer the following investigations for cancer:

a physical examination (guided by the patient's full history) anda chest X-ray andblood tests (full blood count, serum calcium and liver function tests) andurinalysis.

Consider Further investigations for cancer with an abdomino-pelvic CT scan (and a mammogram for women) in all patients aged over 40 years with a first unprovoked DVT or PE who do not have signs or symptoms of cancer based on initial investigation (see 'Investigations for cancer' above).

Two Phases of VTE Management

Initial Treatment • ≥5 d treatment with SC LMWH or

IV UFH, • Discontinue when INR >2.0 for 48

hr • Initiation of VKA together with LMWH or UFH on first treatment

dayOr

Initiation with New Oral Anti-coagulant (Rivaroxaban) Long-term treatment

• Necessary for patients at continuous risk for recurrence

• Duration of treatment is dependent on underlying disease

and risk factors • Appropriate treatment can reduce

the risk of recurrence to approximately 5% at 3 months

TIME

Distal DVT (below knee)

□

Refer to ART (if suitable) □

If no family history DVT / PE Discharge at end of

treatment □

If family history DVT / PE □

Distal DVT (below

knee) □Proximal DVT (above

knee) □Proximal DVT (above

knee) □

Refer to ART (if suitable) □

1st idiopathic DVT □ Recurrent DVT □1st Precipitated DVT □ Surgery past 12 weeks Lower limb fracture Lower limb in plaster Pregnant Post partum up to 12 weeks (Travel / COCP / HRT)

Thrombosis Clinic

Follow up at 3 months □

Anticoagulate

3 months □

Anticoagulate

3 months □

Traditional approaches of Anticoagulation

Heparin Minimum of 5 days Until INR > 2 on at least 2 occasions

Warfarin PE minimum 3 months Idiopathic proximal DVT minimum 3 months Idiopathic distal DVT 3 months Provoked distal DVT 3 months Recurrent DVT / PE long term

New approaches to anticoagulationVitamin K antagonists (VKAs) and ODIs

Inactive factor

Active factor

Transformation

Catalysis

Initiation

Propagation

Clot formation Fibrinogen

X IX

Xa IXa

II

IIa

VIIaTFVII

VKA

VKA

VKA

RIVAROXABAN

APIXABAN

EDOXABAN

Fibrin

DABIGATRAN

Day 1 and 2 Day 3 Day 4

  INR Dose INR Dose

Warfarin 5mg each day

< 1.5 10 mg1.5-2.0 5 mg2.1-2.5 3 mg2.6-3.0 1 mg>3.0 0 mg

< 1.6 10 mg1.6-1.7 7 mg1.8-1.9 6 mg2.0-2.3 5 mg2.4-2.7 4 mg2.8-3.0 3 mg3.1-3.5 2 mg3.6-4.0 1 mg>4.0 0 mg

Indication Target INR (+/-

0.5)

Duration Follow up

1st idiopathic proximal DVT

2.5 ≥ 3 months Thrombosis Clinic

1st precipitated proximal DVT

2.5 3 months *No follow up

1st idiopathic distal DVT

2.5 3 months *No follow up

1st precipitated distal DVT

2.5 3 months *No follow up

Recurrent DVT not on warfarin / sub-therapeutic INR

2.5 ≥ 3 months Thrombosis Clinic

Recurrent DVT on warfarin and therapeutic INR

3.5 Long-term Thrombosis Clinic

OUT-PATIENT TREATMENT OF DVTLow molecular weight heparin• Enoxaparin should be continued until the INR has been >2 for 2 consecutive days

and for a minimum of 5 days.Warfarin• If the initial PT is <17s (INR <1.3) the patient will receive 5mg of warfarin on the

evenings (17:00 to 19:00) of days 1 and 2. • The INR is checked on the mornings of day 3 and 4 and the warfarin dose is

adjusted according to the schedule:

If the patient is on an anti-platelet medication a doctor should review whether this is to continue, whilst the patient is on warfarin.

First 3 weeks Subsequent 9 weeks

Rivaroxaban 15mg bd 

Rivaroxaban 20mg od

Rivaroxaban as an alternative to warfarin

• Patients who have suffered a 1st precipitated DVT and only require 3 months anticoagulation will be offered the option of warfarin or rivaroxaban

• Patients with a history of excessive alcohol consumption, in whom warfarin and INR monitoring will be difficult will be offered the option of LMWH or rivaroxaban

• Patients with poor venous access e.g. history of IVDU will be offered the option of LMWH or rivaroxaban

Treatment options for Venous Thromboembolism in patients with solid tumours

Shared agreement between Bro Taf and Cardiff and Vale

Extended treatment with Dalteparin for up to 6 months

Prescribe Dalteparin at approximately 200 iu/ kg total body weight subcutaneously once daily for the first 30days

Months 2-6 Dalteparin should be administered at a dose of approxiamtely 150 iu/kg s/c once daily

Recommended treatment is 6 months.

Continuing beyond this period will be evaluated according to individuals risk/benefits and progression of cancer

Treat for 3 months

and reassess

Isolated distal DVT

Stop at 3 months

Reversible provoking factor

Stop at 3 months

Unprovoked proximal DVT or

PEReview options

CancerIndefinite

therapy or until cancer inactive

Not High Bleeding Risk and prefers to stay on even if

D Dimer is negative

Second VTE

Indefinite therapy

OthersStop and

measure D Dimer at 1

month

High Bleeding RiskOR

Prefers to stop even if D Dimer

positive

Negative D DimerStay off therapy

(Stop at 3 months)

Positive D DimerRestart therapy

(Indefinite therapy)

TAKE 100 ASYMPTOMATIC CALF DVT

16%-20% of them become proximal Half of these will embolise i.e.8%-10% Half of these will be symptomatic PE ( i.e. 4%-5% or PE’s) Untreated PE (1.0% of the total) symptomatic and non-fatal –26% (1.0% of the total) will be fatal PE.

TAKE 100 SYMPTOMATIC CALF DVT

100 symptomatic DVT 21%-36% of them become proximal Half of these will embolisei.e.8%-18% Half of these will be symptomatic PE (ie4%-9% or PE’s) Untreated PE –26% (1.5% of the total) symptomatic and non-fatal –26% (1.5% of the total) will be fatal PE.

Cohen AT, JTH 2006

Case History 148yr old malePresenting with 4/52 history of ‘sciatic’ type lower back pain radiating down left leg.No past medical history but awaiting private gastro-enterologist review for ‘epigastric’ type pain and MRI for back painWells score – 2 ( Calf >3cms, pitting oedema unilaterally)• Doppler Ultrasound – Gastrocnemius vein clot (not extending into

popliteal vein)• Re-scanned in 1/52 – Gastrocnemius clot extended into popliteal

ven• Initial treatment with LMWH whilst awaiting result of MRI• Urgent CT Chest, abdo and pelvis• Malignant sacral bone lesion with widespread retroperitoneal and

thoracic small volume tissue deposits• Plan – Admission – Biopsy• Management of DVT – insertion of IVC filter• Anti-coagulation – determined following biopsy result.

Case history 263yr old femalePresenting with one day history of calf painHistory of 7hr car journey plus 31/2hr flightLower leg feeling ‘itchy’PMH – AsthmaWells Score 1D Dimer +veDoppler Ultrasound – Left Tibial DVTTreatment choice – RivaroxabanNo follow up

Case history 3

83yr old female5/52 history of painful/ swollen left legInitially treated by GP as cellulitis with antibioticsNo response after 2/52Doppler ultrasound – Left ileo-femoral DVTNo provoking factors other than age and limited mobility (chronic)No red flagsPlanWarfarin/LMWHReview at 3/12

Clot Quiz

DVT?

Or something else………

One Final Point

http://www.youtube.com/watch?v=TVKIyy9dcKc

Why you should ask about clotsBlood clots can happen to anyone.If you are in hospital – or have left hospital in the last three months – you are at greater risk of developing a clot.Blood clots are preventable!Ask your doctor, nurse or healthcare professional to help you reduce your risk of developing a clot.Watch the video to find out more

Thank YouThe venous return from your leg has now slowed by 50%.

Please ensure you have re-established sufficient flow before the next speaker to

reduce your risk of a (potentially fatal) VTE.