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Deep Vein Thrombosis (DVT) The Patient Journey Marilyn Rees Venous Thrombosis Nurse Specialist Slide 2 Overview Diagnosis of DVT Goals of treatment Challenges of DVT Treatment Case studies Quiz Slide 3 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 Slide 4 Approaches to Diagnosis of DVT Patient History Clinical Symptoms and Signs Clinical Probability Score Laboratory Testing Imaging Testing Slide 5 Clinical Signs and Symptoms of DVT (Nonsurgical Patients) Leg pain (90%) Tenderness (85%) Ankle oedema (76%) Calf swelling (42%) Dilated veins (33%) Homans 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. Slide 6 Clinical Signs and Symptoms of DVT (contd) 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 Slide 7 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 Slide 8 Wells Scoring System for Diagnosing DVT Clinical CharacteristicScore* Active cancer (treatment ongoing, within, 6 months or palliative)1 Paralysis, paresis, or recent plaster immobilization of the lower extremity1 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 system1 Entire leg swollen1 Calf swelling 3 cm larger than asymptomatic side (measured 10 cm below tibial tuberosity) 1 Pitting oedema confined to symptomatic leg1 Collateral superficial veins (non-varicose)1 Previous documented DVT1 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 likely2 points or more DVT unlikely1 point or less Slide 9 Alternative Diagnosis Slide 10 VTE Investigations Laboratory D Dimer (degradation product of a cross- linked fibrin blood clot) D-dimer has a high false-positive rate Sensitive but nonspecific also increased in other conditions: cancer, inflammation, postoperatively, injury, pregnancy. Slide 11 Non-invasive testing Doppler Compression Ultrasound Non-invasive, no contraindications. High accuracy in symptomatic patients (91%) Slide 12 PROXIMAL VEINS DISTAL VEINS Venous system in lower limbs Slide 13 Slide 14 What happens next? Slide 15 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 Slide 16 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. Slide 17 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 Slide 18 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:unprovokedDVTPE a physical examination (guided by the patient's full history) and a chest X-ray and blood tests (full blood count, serum calcium and liver function tests) and urinalysis. 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).CT Slide 19 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 day Or 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 Slide 20 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) 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 Slide 21 Traditional approaches of Anticoagulation Heparin Minimum of 5 days Until INR > 2 on at least 2 occasions Warfarin PEminimum 3 months Idiopathic proximal DVTminimum 3 months Idiopathic distal DVT3 months Provoked distal DVT3 months Recurrent DVT / PElong term Slide 22 New approaches to anticoagulation Vitamin K antagonists (VKAs) and ODIs Inactive factor Active factor Transformation Catalysis Initiation Propagation Clot formation Fibrinogen XIX Xa IXa II IIa VIIaTF VII VKA RIVAROXABAN APIXABAN EDOXABAN Fibrin DABIGATRAN Slide 23 Slide 24 Day 1 and 2Day 3Day 4 INR Dose Warfarin 5mg each day < 1.5 10 mg 1.5-2.0 5 mg 2.1-2.5 3 mg 2.6-3.0 1 mg >3.0 0 mg < 1.6 10 mg 1.6-1.7 7 mg 1.8-1.9 6 mg 2.0-2.3 5 mg 2.4-2.7 4 mg 2.8-3.0 3 mg 3.1-3.5 2 mg 3.6-4.0 1 mg >4.0 0 mg Indication Target INR (+/- 0.5) DurationFollow up 1 st idiopathic proximal DVT 2.5 3 monthsThrombosis Clinic 1 st precipitated proximal DVT 2.53 months*No follow up 1 st idiopathic distal DVT2.53 months*No follow up 1 st precipitated distal DVT 2.5 3 months *No follow up Recurrent DVT not on warfarin / sub- therapeutic INR 2.5 3 monthsThrombosis Clinic Recurrent DVT on warfarin and therapeutic INR 3.5Long-termThrombosis Clinic OUT-PATIENT TREATMENT OF DVT Low 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 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. Slide 30 Case history 2 63yr old female Presenting with one day history of calf pain History of 7hr car journey plus 31/2hr flight Lower leg feeling itchy PMH Asthma Wells Score 1 D Dimer +ve Doppler Ultrasound Left Tibial DVT Treatment choice Rivaroxaban No follow up Slide 31 Case history 3 83yr old female 5/52 history of painful/ swollen left leg Initially treated by GP as cellulitis with antibiotics No response after 2/52 Doppler ultrasound Left ileo-femoral DVT No provoking factors other than age and limited mobility (chronic) No red flags Plan Warfarin/LMWH Review at 3/12 Slide 32 Clot Quiz DVT? Or something else Slide 33 Slide 34 Slide 35 Slide 36 Slide 37 Slide 38 Slide 39 Slide 40 One Final Point http://www.youtube.com/watch?v=TVKIyy9dcKc Why you should ask about clots Blood 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 Slide 41 Slide 42 Thank You The 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.