Venous thromboembolism: Difference between revisions

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! align="center" style="background:#4479BA; color: #FFFFFF;" + |Score<ref name="pmid21436241">{{cite journal| author=Spyropoulos AC, Anderson FA, Fitzgerald G, Decousus H, Pini M, Chong BH et al.| title=Predictive and associative models to identify hospitalized medical patients at risk for VTE. | journal=Chest | year= 2011 | volume= 140 | issue= 3 | pages= 706-14 | pmid=21436241 | doi=10.1378/chest.10-1944 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21436241  }} </ref>
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==Preventive Approach In Acutely Ill Hospitalized Patients Based On Risk assessment==
==Preventive Approach In Acutely Ill Hospitalized Patients Based On Risk assessment==
<span style="font-size:85%"> '''Abbreviations:''' '''LDUH:''' low dose [[unfractionated heparin]]; '''LMWH:''' low molecular weight heparin; '''VTE:''' Venous thromboembolism </span>
<span style="font-size:85%"> '''Abbreviations:''' '''LDUH:''' low dose [[unfractionated heparin]]; '''LMWH:''' low molecular weight heparin; '''VTE:''' Venous thromboembolism </span>

Revision as of 17:42, 12 October 2017

Venous thromboembolism Microchapters

Patient Information

Deep vein thrombosis
Pulmonary embolism

Overview

Classification

Epidemiology

Risk Factors

Diagnosis

Treatment

Deep Vein Thrombosis
Pulmonary Embolism

Prevention

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]:Associate Editor(s)-in-Chief: Syed Hassan A. Kazmi BSc, MD [2]

Overiew

Classification

Venous thromboembolism (VTE) may be classified into:[1]

  • Deep vein thrombosis (DVT)
  • Pulmonary embolism (PE)

The following table further classifies DVT and PE:[2][3][4][5][4][6][7][8]

Classification of Venous thromboembolism
Clinical diagnosis Sub-classification Comments
Deep vein thrombosis Upper extremity
  • Uncommon and accounts for 1-5 % of all DVT
  • Most likely due to:
    • Central venous catheter
    • Cardiac pacemaker
    • Implantable cardioverter defibrillator
    • Effort thrombosis (Paget–Schroetter disease)
    • Cancer
Lower extremity
  • Proximal:
    • Popliteal veins
    • Femoral veins
    • Iliac veins
  • Isolated distal:
    • Calf veins (Peroneal, soleal, posterior tibial, gastrocnemial, soleal, gastrocnemial, peroneal, posterior tibial)
Pulmonary embolism (PE) Massive PE (High risk)
  • Sustained hypotension (systolic blood pressure <90 mm Hg), not due to arrhythmia, hypovolemia, sepsis, or left ventricular dysfunction, and either lasting for at least 15 minutes or necessitating the administration of inotropes

OR

  • Pulselessness

OR

  • Persistent profound bradycardia (heart rate < 40 bpm) plus findings of shock
Sub-massive PE (Intermediate risk PE)
  • Right ventricular dysfunction OR myocardial necrosis

AND

  • Absence of systemic hypotension (systolic blood pressure >90 mm Hg)
Low risk PE

Epidemiology

Risk Factors

Shown below is a list of predisposing factors for VTE.[9][10] The risk factors are classified as moderate or weak depending on how strongly they predispose for a VTE.

Moderate risk factors Weak risk factors
Chemotherapy

Chronic heart failure
Respiratory failure
Hormone replacement therapy
Cancer
Oral contraceptive pills
Stroke
Pregnancy
Postpartum
❑ Prior history of VTE
Thrombophilia

❑ Advanced age

Laparoscopic surgery
❑ Prepartum
Obesity
Varicose veins

Risk factors of VTE may be categorized in to modifiable, non-modifiable, temporary and other risk factors.

Modifiable Risk Factors Non-Modifiable Risk Factors Temporary Risk Factors Other Risk Factors

❑ Modifiable risk factors are reversible based upon lifestyle/behavior modification.
Obesity is defined as a body-mass index (BMI) above 30 kg/m2.[11] [12] [13]
Smoking:[11] Smoking significantly increases the risk of DVT, particularly among women who are taking oral contraceptive pills as well as among obese people.
❑ Use of oral contraceptives[14]
Hyperhomocysteinemia:[15] Hyperhomocysteinemia can be reduced with vitamin B supplementation.

❑ Advanced age
Heart failure
Thrombophilia or hypercoagulable state
Polycythemia vera

Factor V Leiden
Prothrombin G20210A mutation
Protein C deficiency
Protein S deficiency
Activated protein C resistance
Antithrombin III deficiency
Factor VIII mutation
Antiphospholipid syndrome
Heparin induced thrombocytopenia
Nephrotic syndrome
Paroxysmal nocturnal hemoglobinuria

Pregnancy and the peri-partum period
❑ Active cancer
Central venous catheter

❑ Other possible factors associated with VTE include:[16]

❑ Nutrition low in fish
Psychological stress
❑ Cardiovascular risk factors such as diabetes and hypercholesterolemia

Diagnosis

Treatment

Prevention In Acutely Ill Hospitalized Patients

Risk assessment in acutely ill patients

The following scoring systems can be used to assess the risk of VTE, based on risk factors:

Padua prediction score for VTE

Shown below is a table depicting Padua predictive score for VTE among hospitalized medical patients. The interpretation of the score is as follows:

  • Score≥ 4: High risk for VTE
  • Score< 4: Low risk for VTE[17]
Variable Score
Active cancer 3
Previous VTE 3
Decreased mobility 3
Thrombophilia 3
Previous trauma or surgery within that last month 2
Age≥ 70 1
Heart and/or respiratory failure 1
Ischemic stroke or acute myocardial infarction 1
Acute rheumatologic disorder and/or acute infection 1
Obesity 1
Hormonal therapy 1

IMPROVE predictive score for VTE

Calculation of the IMPROVE predictive score

Variable Score[18]
Prior episode of VTE 3
Thrombophilia 3
Malignancy 1
Age more than 60 years 1

Interpretation of the IMPROVE predictive score

Score Predicted VTE risk through 3 months[18]
0 0.5%
1 1.0%
2 1.7%
3 3.1%
4 5.4%
5-8 11%

Preventive Approach In Acutely Ill Hospitalized Patients Based On Risk assessment

Abbreviations: LDUH: low dose unfractionated heparin; LMWH: low molecular weight heparin; VTE: Venous thromboembolism

 
 
 
 
 
What is the risk of thrombosis in the acutely ill patient?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
High
 
Low
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is the patient bleeding or at high risk of bleeding?
 
No VTE prophylaxis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
Mechanical VTE prophylaxis
For the period of immobilization or hospital stay only
Graduated compression stocking
Intermittent pneumatic compression
 
Pharmacological VTE prophylaxis
For the period of immobilization or hospital stay only
LMWH
LDUH, BID
LDUH, TID
Fondaparinux
 
 
 
 
 
 
 
 
 
 
 
Did the bleeding or bleeding risk subside
AND
the patient is still at increased risk of thrombosis?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
❑ Substitute mechanical prophylaxis by pharmacological prophylaxis
 
❑ Continue mechanical prophylaxis

Prevention In Critically Ill Hospitalized Patients

Risk assessment in critically ill patients

IMPROVE bleeding risk score

Shown below is a table depicting the IMPROVE risk score for bleeding among hospitalized medical patients. The scores can be interpreted as such:[19]

  • Score ≥7: Elevated risk of bleeding
  • Score <7: Not elevated risk of bleeding
Variable Score
Active gastric or duodenal ulcer 4.5
Prior bleeding within the last 3 months 4
Thrombocytopenia (<50x109/L) 4
Age ≥ 85 years 3.5
Liver failure (INR>1.5) 2.5
Severe kidney failure (GFR< 30 mL/min/m2) 2.5
Admission to ICU or CCU 2.5
Central venous catheter 2
Rheumatic disease 2
Active malignancy 2
Age: 40-84 years 1.5
Male 1
Moderate kidney failure (GFR: 30-59 mL/min/m2) 1

Preventive Approach In Critically Ill Hospitalized Patients

Abbreviations: LDUH: low dose unfractionated heparin; LMWH: low molecular weight heparin; VTE: Venous thromboembolism

 
 
 
Is the critically ill patient bleeding or at risk for major bleeding?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
Mechanical VTE prophylaxis
 
Pharmacological VTE prophylaxis
LMWH
LDUH
 
 
 
 
 
 
 
 
 
 
 
Did the bleeding or bleeding risk subside?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
❑ Substitute mechanical prophylaxis by pharmacological prophylaxis
 
❑ Continue mechanical prophylaxis
  1. Moheimani F, Jackson DE (2011). "Venous thromboembolism: classification, risk factors, diagnosis, and management". ISRN Hematol. 2011: 124610. doi:10.5402/2011/124610. PMC 3196154. PMID 22084692.
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  5. Galanaud JP, Sevestre-Pietri MA, Bosson JL, Laroche JP, Righini M, Brisot D, Boge G, van Kien AK, Gattolliat O, Bettarel-Binon C, Gris JC, Genty C, Quere I (2009). "Comparative study on risk factors and early outcome of symptomatic distal versus proximal deep vein thrombosis: results from the OPTIMEV study". Thromb. Haemost. 102 (3): 493–500. doi:10.1160/TH09-01-0053. PMID 19718469. Retrieved 2011-12-14. Unknown parameter |month= ignored (help)
  6. Joffe HV, Kucher N, Tapson VF, Goldhaber SZ (2004). "Upper-extremity deep vein thrombosis: a prospective registry of 592 patients". Circulation. 110 (12): 1605–11. doi:10.1161/01.CIR.0000142289.94369.D7. PMID 15353493. Retrieved 2012-10-07. Unknown parameter |month= ignored (help)
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  8. Muñoz FJ, Mismetti P, Poggio R, Valle R, Barrón M, Guil M; et al. (2008). "Clinical outcome of patients with upper-extremity deep vein thrombosis: results from the RIETE Registry". Chest. 133 (1): 143–8. doi:10.1378/chest.07-1432. PMID 17925416.
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