DVT & PEDeep vein thrombosis &Pulmonary embolism

Deep vein thrombosisA form of thrombophlebitisIncidence- ~1 per 1000 persons per yearCommonly affects leg veins (L>R)- popliteal, femoral, pelvicVirchows triad-Decreased blood flow- stasisDamage to vessel wallHypercoagulability Complication-Pulmonary embolismPost-phlebitic syndrome

DVT- risk factorsRecent surgeryHospitalizationAdvanced ageObesity ImmobilizationThrombophilia- AT-III/protein C or S deficiencyPregnancy Estrogen containing OCPTobacco useProlonged economy class air travelCancerInfection

DVT-clinical presentationUnderlying risk factorsSymptomsPain, swelling, redness of legSuperficial vein dilatationSignsEdema, tender veinsHomans sign- calf pain on dorsiflexion of footAcute DVT may cause impaired circulation cold extremity, absent pulse, even gangrene

DVT- diagnosisD-dimer level- a FDPDuplex ultrasonography, with compressionCT venography (iliocaval DVT)

DVT- managementMostly out-patient, using LMWHHospitalization recommended-B/L DVTExtensive proximal DVTCRICHFCancerRecent immobilityLow body weight

Anticoagulation Low molecular weight heparin (LMWH)Fondaparinux Unfractionated heparin- requires hospitalization & monitoring (aPTT)Dose- 80 U/kg bolus18 U/kg/hr infusionmonitor aPTT

Long-term Warfarin- at least 3 monthsDose- 5 mg OD x 3 daysmonitor PTLife-long for life-threatening/recurrent DVTMonitor PT/INR- 2-3 times normal

Other Rx optionsThrombolysis for extensive proximal clot, increases risk of bleeding

Intermittent pneumatic compression- (IPC) if heparin CI or post-op.

IVC filter- reduces PE, used in patients with ICH, potentially prothrombotic

DVT- prevention LMWH/UFH in hospitalised patients with risk factors for DVTLMWH post-op.IPC after knee/hip surgeryElastic compression stockings during long-haul flightsHeparin/LMWH/Warfarin in at risk pregnancyEarly mobilization

Post-phlebitic syndromeOccurs in ~15% patients with DVTConsequences-EdemaPainCrampsVenous claudicationSkin pigmentationDermatitisUlceration

Pulmonary embolismCommonly embolism from DVT

Risk more with proximal DVT

Risk factors- as for DVT

Clot obstructs pulmonary arterial circulation & strains right ventricle

PE- diagnosisRisk factors DVTSymptoms- Mostly silent~15% of sudden deaths attributable to PEMay cause sudden SOB, pleuritic chest pain, hemoptysisSignsTachypnea, cyanosis, pleural rub, low-grade feverRV strain- loud P2, LPSH, raised JVP

PE- diagnosisInvestigations-CBC, PT/aPTT, LFT, RFT- for R/FCxR- mainly to rule out other pathologyECG- tachycardia, RV strain, R/O MIECHO- RV dysfunction, R/O MID-dimer US- for DVTCT pulmonary angiography- for PE DxV-Q scan- contrast allergy/CI

PE- treatmentAnticoagulationLMWH/Fondaparinux/HeparinWarfarin x minimum 3 months, lifelong if recurrent

ThrombolysisPE with hemodynamic instabilityPE with RV dysfunction on ECHO Surgical thrombectomy

H.I.THeparin induced thrombocytopeniaAn immune reaction to Heparin/LMWHParadoxical increase in arterial/venous thrombosis, with thrombocytopeniaCan occur upto 100 days after exposureRx- Stop Heparin/LMWHAnticoagulation with direct thrombin inhibitors (monitor aPTT)- lepirudin, argatroban, bivaluridin- until platelet count stabilizesLong-term Warfarin