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Current Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With the Evidence. John Heick, PT, DPT, OCS, NCS Jim Farris, PT, PhD Arizona School of Health Sciences A.T. Still University, Mesa, Arizona

Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

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Page 1: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

Current Practice and Screening for Deep

Vein Thrombosis and Pulmonary Embolism:

Keeping Up With the Evidence.

John Heick, PT, DPT, OCS, NCS

Jim Farris, PT, PhD

Arizona School of Health Sciences

A.T. Still University, Mesa, Arizona

Page 2: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

Disclosure

• We have nothing to disclose as no relevant financial

relationship exists.

Page 3: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

Learning Objectives

– After this session, you will be able to:

• 1. Identify the pathology leading to formation of a DVT and PE.

• 2. Discuss the morbidity and mortality related to DVT.

• 3. Compare and contrast signs and symptoms related to differential diagnosis of a DVT to a PE.

• 4. Analyze the models of assessment for identifying a DVT.

• 5. Introduce clinical algorithms for PE to guide clinicians for intervention decisions.

• 6. Critically evaluate the use of Homan’s sign.

• 7. Discuss current practice related to interventions of a patient with a DVT and PE.

• 8. Advocate for the use of clinical decision rules and clinical practice guidelines in evaluating and providing interventions for patients with a DVT or PE.

Page 4: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

Poll

Page 5: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

Questions to Ponder

Page 6: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

Session Outline

• Identify pathology of DVT & PE

• Analyze model of assessment for identifying a DVT

• Critically evaluate the use of Homans sign

• Introduce clinical algorithms for PE to guide clinicians

• Case studies

• Implementing guidelines

• Discussion

Page 7: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

Introduction to Pathology of VTE

• VTE refers to all forms of thrombosis in the venous

circulation and manifests in 2 ways: deep vein thrombosis

(DVT) and pulmonary embolism (PE).

• DVTs affect ~ 2 million Americans per year, is the 3rd most

common cardiovascular disease after CAD and stroke, and

PE are responsible for 10% of hospital deaths. Anand et al 1998;

Autar, 1996

Page 8: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

VTE

– Can occur in any vein, most

common in the legs

– If superficial, then usually

varicosities, benign & self-

limiting

– Long saphenous vein

thrombosis extends into

deep veins (DVT)

– DVT localized in the calf

veins are often small & less

commonly associated with a

PE

– Associated with significant

morbidity

Page 9: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

Initiation of a Thrombosis

• Venous stasis

– Immobility

– Venous obstruction

– Increased venous pressure

– Venous dilation

– Increased blood viscosity

Page 10: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

DVT

Anderson FA.

• Proximal DVTs involve the popliteal, femoral, or iliac

venous system.

• Approximately 20% of untreated silent calf vein thrombi

and 20% to 30% of untreated symptomatic calf vein

thrombi extend into the popliteal vein.

• When the DVT extends and is untreated, it is associated

with a 40% to 50% risk of clinically detectable PE. Anderson FA

• VTEDVTPE

– Important causes of morbidity and mortality in hospitalized

patients.

– VTE also occurs spontaneously in healthy, ambulatory

outpatients.

Page 11: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

PDVT

• Proximal deep vein thrombosis (PDVT) is the more

dangerous form of lower-extremity DVT because it is more

likely to cause life-threatening PE and may result in a

greater risk of postthrombotic syndrome. Riddle & Wells 2004

• Calf DVT, although less serious than PDVT, must be

considered because the thrombus extends proximally in

approximately 30% of cases. Riddle & Wells 2004

Page 12: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

PE

Stein 2010

• ~ 10% of all patients with

acute PE die during the

first 1 to 3 months after

diagnosis.

• Overall, 1% of all patients

admitted to hospitals die of

acute PE, and 10% of all

hospital deaths are related

to a PE.

Page 13: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

DVT incidence trends

• From 1989-2006, hospital DVT increased 3.1 times

from 35 to 107/100,000 population. Stein 2010

• From 1992-2006, the incidence of PE in hospitalized

patients increased 2.5 times from 33 to 83/100,000

population. Stein 2010

– The incidence of a secondary diagnosis of PE increased at a

lower rate.

• Stein concluded that “Efforts to prevent DVT in high-

risk hospitalized patients appear to be inadequate.

Therapy of DVT, however, appears to be effective.”

Page 14: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

DVT trends: Stein 2010• The proportion of hospitalized patients with DVT

has decreased as a result of early discharge home.

• The incidence of PE increases exponentially with

age, but no age group is immune.

• Asians and Native Americans have a lower

incidence of PE than whites or African Americans.

• Epidemiologic data and new information on risk

factors provide insight into making an informed

clinical assessment and evaluation for

antithrombotic prophylaxis.

Page 15: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

Risk factors for DVT

Previous venous thrombosis or embolism Age, over 55-60 years Active cancer or cancer treatment Severe infection Oral contraceptives, hormonal replacement therapy Pregnancy or given birth within the previous six weeks Immobility (bed rest, flight travel, fractures) Surgery, anesthesia Critical care admission, central venous catheters Inherited thrombophilia Obesity One or more significant medical comorbidities (for example: heart

disease; metabolic, endocrine or respiratory pathologies; acute infectious diseases; inflammatory conditions, peripheral arterial insufficiency)

Page 16: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

Clinical manifestations of a PE

• S&S of VTE are caused by obstruction to venous outflow,

inflammation of the vessel wall or perivascular tissues, or

embolization of thrombus into the pulmonary circulation.

• Most clinically significant and fatal PE probably arise from

thrombi in the proximal veins of the legs.

• Asymptomatic PE is detected by perfusion lung scanning in

approximately 50% of patients with documented proximal

vein thrombosis.

Page 17: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

Clinical manifestations of a PE

• Although PE also may complicate calf vein

thrombosis, these emboli tend to be smaller

in size, and PE occurs less commonly than in

patients with proximal vein thrombosis.

• Asymptomatic VTE is found in 70% of

patients who present with confirmed PE.

These thrombi usually are large and involve

the proximal veins.

Page 18: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

Clinical manifestations continued

• In approximately 70% of patients referred for clinically suspected venous thrombosis, the diagnosis will be excluded by objective tests.

• Of the 30% who have VTE, approximately 85% will have proximal DVTs and the remainder will have thrombosis confined to the calf.

Page 19: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

Signs & Symptoms

• The classic signs and symptoms of DVT are

localized pain, tenderness, swelling, and

discoloration.

• Other symptoms may include lower extremity

edema, fever, extremity warmth, and pain.

– Symptoms can serve only as a trigger for further

diagnostic inquiry; they cannot, by themselves, rule a

DVT in or out.

• Like symptoms, physical examination findings are

not sensitive or specific; in more than 50% of the

instances in which there was a verified DVT, there

was a normal physical examination.

Page 20: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

Signs & Symptoms

Riddle & Wells 2004 article

• Most clinicians attempt to identify outpatients

suspected of having PDVT by considering the

patients’ signs and symptoms and associated risk

factors. For example, patients with symptomatic

PDVT tend to complain of lower extremity pain,

calf tenderness, and lower extremity swelling.

• However, approximately 75% of all patients who

are suspected of having PDVT are found not to

have PDVT when formal diagnostic testing is

completed.

Page 21: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

Other conditions to consider

• Malignant disease

• Morbid obesity

• Previous history of VTE

• Stroke

• Irritable bowel syndrome

• Congestive heart failure

• Pregnancy

• Advanced age

• Hereditary conditions

–Include deficiencies in protein C and protein S and familial thrombophilia.

Page 22: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

Differential Dx of DVT

• Common conditions that mimic a VTE:

• Muscle hematoma

• Muscle or tendon tear

• Muscle cramp

• Superficial thrombophlebitis

• Postphlebitic syndrome

• Cellulitis

• Sciatica

• External venous compression

Page 23: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

Conditions that may mimic symptoms

associated w/ pDVT

Prandoni P, Mannucci PM. 1999.

Musculoskeletal : trauma, hematoma, myositis, tendinitis,

Baker’s cyst, synovitis, osteoarthritis, osteomyelitis, tumors,

fractures

Neurological : sciatica, lower-limb paralysis

Venous: phlebitis, postthrombotic syndrome,

compressed veins

Arterial : acute arterial occlusions, a-v fistula

Generalized: edema, cardiogenic, nephrogenic, dysproteinemic

Cutaneous: dermatitis, cellulitis, lipoedema, panniculitis

Localized: edema, pregnancy, oral contraceptive intake, limb

immobilization

Page 24: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

Current practice evolving

ten Cate Hoek 2009

• Current practice is to refer all patients presenting with

complaints suspected of a DVT, to specialized diagnostic

services for objective testing.

Studies have revealed that 80–90% of these referred

patients do not have a DVT.

• Rapid point-of-care D-dimer assays combined with a

specific CDR makes it possible to realize a diagnostic work-

up in a primary care setting.

Page 25: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

Sensitivity & Specificity

Riddle & Wells 2004

• Given that PDVT is a serious disorder with

potentially life-threatening consequences, tests

used by physical therapists to identify patients with

PDVT should have a very high sensitivity

(proportion of patients with the disorder who have

a positive test) so that negative tests would indicate

that the clinician can confidently rule out the

disorder.

Page 26: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

Sensitivity & Specificity

Riddle & Wells 2004

• False negative tests would be potentially catastrophic in this

case because the patient would actually have a PDVT even

though the test result was negative.

• The therapist would potentially falsely conclude that

referral to a physician is unnecessary.

Page 27: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

Homans sign

Page 28: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

In Our Current & “Classic” Texts

Page 29: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

Homans’ Sign Evaluated

(Urbano, 2001 - review)

• Homans’ sign present in 33% pts with thrombosis, also present

in 21% without

• Estimates of accuracy of Homans’

– positive in 8% to 56% of proven DVT cases, positive in 50% of

symptomatic pts without proven DVT

– More common in pts clinically suspected of DVT with negative

venogram than in clinically suspected with positive venogram

• “This has led nearly all authors to declare that Homans’ sign in

unreliable, insensitive, and nonspecific in the diagnosis of

DVT.”

(Urbano, FL. Homans’ sign in the diagnosis of deep vein thrombosis.

Hospital Physician. March 2001, pp. 22-24)

Page 30: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

Wells CDR

• “The diagnosis of DVT relies heavily on the use of objective

tests because signs and symptoms are not thought to be

specific.”

• “It has been our impression that clinical features can be

used to classify symptomatic patients with suspected DVT

as having a high or low probability for DVT before

diagnostic testing.”

Page 31: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

Clinical Pretest Probability - Wells DVT Score

Active cancer (on treatment for last 6 months or palliative) 1

Paralysis, paresis or plaster immobilization of lower extremity 1

Immobilization previous 4 days or major surgery within 4 weeks 1

Entire leg swollen 1

Calf swollen by more than 3 cm 1

Pitting edema 1

Collateral superficial veins (non-varicose) 1

Probable alternative diagnosis -2

--------------------------------------------------------------------------------------------

High DVT Risk = 3+

Moderate DVT Risk = 1-2

Low DVT Risk = < 1

(If both legs are symptomatic, score the more severe leg)

Page 32: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

CURRENT Wells CDR (2-level)

Active Cancer (ongoing treatment, w/in 6 months or

palliative)

1

Paralysis paresis or recent plaster immobilization of

LE’s

1

Recently bedrest 3 days or > or major surgery w/in

12 weeks requiring general or regional anaesthesia

1

Localized tenderness along deep venous distribution 1

Entire leg swollen 1

Calf edema @ least 3 cm larger than asymptomatic

side

1

Pitting edema confined to symptomatic side 1

Collateral superficial veins (non-varicose) 1

Previously documented DVT 1

Alternative diagnosis at least as likely as DVT - 2

Clinical probability simplified score

DVT ‘likely’ 2 points or more

DVT ‘unlikely’ Less than 2 points

Page 33: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

Padua CDR for Hospitalized Patients

Active Cancer* 3

Previous VTE (excludes superficial vein

thrombosis)

3

Reduced mobility** 3

Already known thrombophilic condition 3

Recent (<1 month) trauma/surgery 2

> 70 years old 1

Heart and/or respiratory failure 1

Acute MI or CVA 1

Obesity (BMI > 30 kg/m) 1

Ongoing hormonal treatment 1

High risk > 4

*Patients with local or distant metastases and/or in

whom chemotherapy or radiotherapy had been

performed in the previous 6 months.

**Bedrest with bathroom privileges for @ least 3 days

Page 34: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

Wells Rule for PE

Clinical signs & symptoms of DVT 3.0

Alternative diagnosis less likely than PE 3.0

Heart rate > 100 1.5

Immobilization > 3 days or surgery in past 4 weeks 1.5

Previous PE or DVT 1.5

Hemoptysis 1.0

Cancer (tx in last 6 months) 1.0

Clinical probability of PE

Low < 2

Intermediate 2 to 6

High 6

Alternate scoring

Unlikely < 4

Likely > 4

Page 35: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

Revised Geneva Rule for PE

Age > 65 1

Previous PE or DVT 3

Surgery or fx of LE’s in past month 2

Cancer (active or cured < 1 year 2

Unilateral LE pain 3

Heart rate

75 to 94 bpm

> 95 bpm

3

5

Hemoptysis 2

Pain on deep venous palpation of LE & unilateral

edema

4

Clinical probability of PE

Low < 4

Intermediate 4 to 10

High > 10

Page 36: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

Clinical algorithm for PE

Page 37: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

Suspect PE

Clinically unstable?

Consider Massive PE

CT angiogram

PERC positive?

Begin Anticoagulation

Estimate clinical Pretest

Probability Using CDR

NO

YES

> 6< 4

5-6

NO

YES

Page 38: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

Reassess likelihood of

PE

PE

unlikely

CT angiogram

PERC positive?

NO

YES

NO YES D-dimer

D-

dimer?

PE

confirmed

PE

unlikely

NO

Page 39: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

Case studies

Page 40: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

Implementing guidelines

Page 42: Current Practice and Screening for Deep Vein …cardiopt.org/csm2015/CSM-2015_DVT.pdfCurrent Practice and Screening for Deep Vein Thrombosis and Pulmonary Embolism: Keeping Up With

References

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References

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