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10/11/2017 1 James Neuenschwander, MD, FACEP Research DirectorGenesis HealthCare Emergency Department. Zanesville, Ohio Adjunct Associate Professor The Ohio State University Wexner Medical Center. Columbus, Ohio Atlantic City, NJ September 2017 Disclosures Janssen Consultant and speaker bureau Tattoo of the Year Objectives Identify the causes and risk factors of DVT/PE Present clinical work up and evaluation of DVT/PE Offer options for treatment and management of DVT/PE Definitions Venous Thromboembolism = Deep Venous Thrombosis (DVT) and Pulmonary Embolism (PE) Venous Thromboembolism (VTE) Unprovoked VTE implies that no identifiable provoking environmental event for VTE is evident Provoked VTE is one that is usually caused by a known event (eg, surgery, trauma, significant immobility)

Final Atlantic City DVT PE september 2017 · PERC (Pulmonary Embolism Rule Out Criteria) Age

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Text of Final Atlantic City DVT PE september 2017 · PERC (Pulmonary Embolism Rule Out Criteria) Age

  • 10/11/2017

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    James Neuenschwander, MD, FACEPResearch Director Genesis HealthCare Emergency Department. Zanesville, OhioAdjunct Associate Professor The Ohio State University WexnerMedical Center. Columbus, OhioAtlantic City, NJ September 2017

    Disclosures � Janssen Consultant and speaker bureau

    Tattoo of the Year

    Objectives � Identify the causes and risk factors of DVT/PE

    � Present clinical work up and evaluation of DVT/PE

    � Offer options for treatment and management of DVT/PE

    Definitions� Venous Thromboembolism = Deep Venous

    Thrombosis (DVT) and Pulmonary Embolism (PE)

    Venous Thromboembolism (VTE)

    � Unprovoked VTE implies that no identifiable provoking environmental event for VTE is evident

    � Provoked VTE is one that is usually caused by a known event (eg, surgery, trauma, significant immobility)

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    DVT� Proximal DVT is one that is located in the popliteal,

    femoral, or iliac veins

    DVT� Distal: does not have proximal component, is located

    below the knee, and is confined to the calf veins (perineal, anterior tibial, and muscular veins

    Risk Factors� Virchow’s Triad

    � Inherited Thrombophilia

    � Gender-Related Factors

    � Acquired Risk Factors

    Virchow’s Triad

    � Blood flow alteration

    � Vascular injury

    � Blood constituent alteration

    INHERITED THROMBOPHILIACommon inherited hypercoagulable states

    � Factor V Leiden mutation

    � Prothrombin gene mutation

    � Protein S deficiency

    � Protein C deficiency

    � Antithrombin deficiency

    Risk Factors: Gender� Pregnancy

    � Oral Contraceptives: Risk increases within the first 6 to 12 months

    � HRT: Approximately twofold increase in VTE risk, greatest in the first year of treatment

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    Major Acquired Risk Factors• More than 48

    hours of immobility in the preceding month

    • Hospital admission in the past three months

    Major Acquired Risk Factors

    (Pt. 2)• Surgery in the past

    three months

    • Malignancy in the past three months

    • Infection in the past three months

    Other Acquired Risk Factors� Trauma

    � IV Drug Use

    � Glucocorticoids

    � Tamoxifen

    � Chronic Renal Disease

    � Chronic Liver Disease

    � Cardiovascular Disease

    � Obesity

    � Hypertension

    � Smoking

    � Age

    � IBS

    Why?� Why do supermarkets make the sick walk all the way

    to the back of the store for their prescriptions while healthy people can buy cigarettes at the front?

    DVT Presentation� Features are nonspecific and sometimes

    asymptomatic.

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    DVT Presentation (Symptoms)� Most Common Symptoms

    � Leg swelling or edema

    � Leg pain

    � Leg warmth

    DVT Presentation (Physical Exam)� Dilated superficial veins

    � Unilateral edema or swelling with a difference in calf or thigh diameters

    � Unilateral warmth, tenderness, erythema

    � Pain and tenderness along the course of the involved major veins

    � Local (eg, inguinal mass) or general signs of malignancy

    DVT Presentation (Scoring)� Wells Score

    � -2 to 8 Point Scale

    � ≤ 0 = Low Probability

    � 1-2 = Moderate Probability

    � 3-8 = High Probability

    DVT Diagnosis (D-Dimer)� Elevated in nearly all patients with acute DVT

    (Sensitive)

    � Found in many other conditions (Not Specific)

    � Negative result (

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    Why?� Is the person that invests your money called a broker?

    DVT Treatment: Anticoagulation� Anticoagulation is the mainstay therapy

    � Benefits vs Risk of bleeding

    � Benefits - Prevention clot extension, PE, and improved mortality

    � Risk of bleeding.

    Traditional Therapy

    � Low molecular weight heparin (LMWH) 1 mg/kg bid vs 1.5 mg/kg once daily

    � Coumadin (Vitamin K antagonist) with bridging to INR of 2.0 to 3.0

    � 3, 6, to 12 months

    Cancer Patients and Pregnancy� LMWH

    End stage renal disease and

    mechanical valves� No DOAC with CrCl < 15 ml/min

    � Recommendation vs Indication

    � Valvular disease with native valves

    Direct Oral AntiCoagulants (DOACS) � Rivaroxaban, Apixaban, Edoxaban Factor Xa inhibitors

    � Rivaroxaban and Apixaban do not need LMWH bridging – but Edoxaban does

    � Fast onset

    � No need for routine monitoring

    � Expense of the drug vs in patient stay?

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    Doacs continued…� Drug-Drug interactions

    � CYP3A4 and P-gp inhibitors. Ketoconazole. Itraconazole. Ritonavir. Clarithromycin.

    � CYP3A4 and P-gp inducers. Rifampin. Carbamazepine. Phenytoin. St. John’s Wort.

    � CrCl < 30 ml/min

    Dabigatran (Thrombin Inhibitor)� LMWH or UFH for transition

    DrugsTrade Name

    Scientific Name

    Bridging Dose Study

    Coumadin Warfarin LMWH or UFH

    Variable Numerous

    Xarelto Rivaroxaban None 15 mg BID x 21 days,20 mg once daily

    Einstein

    Eliquis Apixaban None 10 mg BID x 7d, 5 mg bid

    Amplify

    Pradaxa Dabigatran LMWH or UFH

    150 mg BID Re-Cover

    DVT Treatment: Serial

    Ultrasonography� Possible with some distal DVT, can possibly avoid

    anticoagulation with serial surveillance

    Contraindications to

    anticoagulation� Active bleeding

    � Severe bleeding diathesis

    � Platelet count than 50,oo0 (can be lower based on the strength of the indication)

    � Recent planned or emergent high bleeding-risk surgery procedure

    � Major trauma

    � History of ICH

    Relative contraindications

    � Recurrent GI bleed

    � Intracranial or spinal tumors

    � Platelet count less than 100,000

    � Large AAA with concurrent HTN

    � Stable aortic dissection

    � Recent, planned, or emergent low bleeding-risk surgery/procedure

    � Frequent falls

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    DVT Treatment: Thrombolytic

    Therapy/ Thrombectomy� Not usually indicated for DVT –can be used for

    extensive ileofemoral. Ekos catheter

    � Phlegmasia cerulea dolens: may be important for patients with PCD who have severe venous gangrene

    When to stop before a procedure?Many cardiologists say if they will cath on Friday, hold Thursday night dose of DOAC

    Roughly 36 to 48 hours based on the procedure

    Why?� Didn’t Noah swat those 2 mosquitos?

    Reversal � Warfarin

    � Vitamin K: oral vs IV

    � PCCC (factors II, VII, IX, X) or Recombinant factor VIIa

    � FFP (15 ml/kg)

    Reversal cont…� Dabigatran

    � Idaruczumad (Praxbind)

    � IV administration 5 gm

    � Widely available?

    � Can restart 24 hours after reversal agent

    Reversal cont…� Rivaroxaban, Apixaban, Edoxaban, LMWH

    � No specific antidote but date set in February 2018 for Portola – Will only be indicated for Rivaroxaban and Apixaban. LMWH?

    � Can not use dialysis (protein binding)

    � Vitamin K will not work

    � Protamine will not work on DOACs but will for LMWH anf UFH

    � PCCC (factors II, VII, IX, X)

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    Adexanet Alfa� Decoy protein that binds factor Xa inhibitor with

    stronger affinity than natural factor Xa

    � Decision in Feb. 2018 by FDA

    Obese patients� Data still out.

    DVT Treatment: Inferior Vena Cava

    Filter� Not routinely used

    � Used in patients with absolute contraindication to anticoagulation

    � Effective?

    DVT Disposition� Discharge if:

    � Hemodynamically stable

    � Low risk of bleeding.

    � No renal insuffiency

    � Favorable situation (caregiver support, phone, understanding of conditions in which to return if things detoriate)

    � NOT FOR: massive DVT to the iliofemoral, phlegmasiacerulean doleans)

    Why?� Is the time with the slowest traffic called rush hour?

    Pulmonary Embolism� Definition: obstruction of the pulmonary artery or

    one of its branches by material (eg, thrombus, tumor, air, or fat) that originated elsewhere in the body

    � Acute, Subacute, Chronic

    � Massive: Hemodynamically unstable

    � Submassive: Right ventricular strain

    � Low risk: No right ventricular strain

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    PE� Saddle, lobar, segmental, subsegmental

    � Bilateral or unilateral

    � Symptomatic or asymptomatic

    PE Presentation� Wide variety of features (no symptoms to shock or

    sudden death)

    � Most common presenting symptom is dyspnea followed by chest pain and cough.

    PE Presentation (Symptoms)� Most Common Symptoms

    � Dyspnea at rest or with exertion (73 percent)

    � Pleuritic pain (66 percent)

    � Cough (37 percent)

    � Orthopnea (28 percent)

    � Calf or thigh pain and/or swelling (44 percent)

    � Wheezing (21 percent)

    � Hemoptysis (13 percent)

    PE Presentation (Physical Exam)� Common Physical

    Examination Findings

    � Tachypnea (54 percent)

    � Calf or thigh swelling, erythema, edema, tenderness, palpable cords (47 percent)

    � Tachycardia (24 percent)

    � Rales (18 percent)

    � Decreased breath sounds (17 percent)

    � An accentuated pulmonic component of the second heart sound (15 percent)

    � Jugular venousdistension (14 percent)

    � Fever, mimicking pneumonia (3 percent)

    PE Presentation (Scoring)� PERC (Pulmonary Embolism Rule Out Criteria)

    � Age

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    PE Diagnosis (CT)� CTPA scan is the imaging modality of choice for

    suspected PE

    � Most sensitive and specific modality

    PE Diagnosis (VQ Scan)� Modality of choice with patients that should not be

    exposed to radiation or dye

    � Less conclusive than CT, more inconclusive scans

    PE Diagnosis (Radiography)� Not typically used to diagnose

    � Hampton’s Hump

    � Westmark’s Sign

    PE Treatment: Initial Approach� Initial approach for patients with suspected PE should

    focus upon stabilization

    � Risk stratification is crucial (Hemodynamically stable/unstable)

    PE Treatment: Initial Approach if

    Unstable� Restore perfusion with IVF and vasopressors

    � Stabilize airway

    � UFH

    PE Treatment: Definitive Approach

    for Unstable Patients� Thrombolytic therapy is indicated in most

    hemodynamically unstable patients, provided there is no contraindication

    � Embolectomy indicated in those for whom thrombolytic therapy is either contraindicated or unsuccessful

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    PE Treatment: Definitive Approach

    for Stable Patients� If low bleed risks, anticoagulation is indicated

    � For those with contraindications or a high bleeding risk, placement of an inferior vena cava (IVC) filter should be performed

    DrugsTrade Name

    Scientific Name

    Bridging Dose Study

    Coumadin Warfarin LMWH or UFH

    Variable Numerous

    Xarelto Rivaroxaban None 15 mg BID x 21 days,20 mg once daily

    Einstein

    Eliquis Apixaban None 10 mg BID x 7d, 5 mg bid

    Amplify

    Pradaxa Dabigatran LMWH or UFH

    150 mg BID Re-Cover

    PE Disposition� Discharge if HESTIA or PESI criteria met?

    Weeda et al. on Reduced PE LOS

    with rivaroxaban� 624 patients chart review

    � Decreased LOS/Cost

    � No Readmission Changes

    � No Bleeds

    Nguyen et al: Observation Not For

    Sick People� PE still a serious disease

    � According to IMPACT, ~46% of observation stay patients were at higher-risk for early post-PE mortality

    Objectives � Identify the causes and risk factors of DVT/PE

    � Present clinical work up and evaluation of DVT/PE

    � Offer options for treatment and management of DVT/PE

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    Questions??? References� UpToDate:� Overview of the causes of venous thrombosis - Authors: Kenneth A

    Bauer, MD, Gregory YH Lip, MD, FRCPE, FESC, FACC� Clinical presentation and diagnosis of the nonpregnant adult with

    suspected deep vein thrombosis of the lower extremity - Authors: Clive Kearon, MB, MRCP(I), FRCP(C), PhD, Kenneth A Bauer, MD

    � Overview of the treatment of lower extremity deep vein thrombosis (DVT) – Authors: Gregory YH Lip, MD, FRCPE, FESC, FACC, Russell D Hull, MBBS, MSc

    � Clinical presentation, evaluation, and diagnosis of the nonpregnantadult with suspected acute pulmonary embolism – Authors: B Taylor Thompson, MD, Christopher Kabrhel, MD, MPH

    � Treatment, prognosis, and follow-up of acute pulmonary embolism in adults – Author: Victor F Tapson, MD