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.
