Deep vein thrombosis treatment approach: Difference between revisions

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'''Editor(s)-In-Chief:''' {{ATI}}, [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com]; '''Associate Editor(s)-In-Chief:''' {{CZ}} ; [[User:Kashish Goel|Kashish Goel, M.D.]]; '''Assistant Editor(s)-In-Chief:''' [[User:Justine Cadet|Justine Cadet]]
{| class="infobox" style="float:right;"
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| <figure-inline><figure-inline>[[File:Siren.gif|link=Deep vein thrombosis resident survival guide|41x41px]]</figure-inline></figure-inline>|| <br> || <br>
| [[Deep vein thrombosis resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
|}
'''Editor(s)-In-Chief:''' {{ATI}}, [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com]; '''Associate Editor(s)-In-Chief:''' {{CZ}} ; [[User:Kashish Goel|Kashish Goel, M.D.]]; '''Assistant Editor(s)-In-Chief:''' [[User:Justine Cadet|Justine Cadet]]; {{Rim}}
{{Deep vein thrombosis}}
{{Deep vein thrombosis}}
'''This page provides algorithms about the treatment choices. For more details about the medical therapy, click [[Deep vein thrombosis medical therapy|here]]. For more details about invasive therapy, click [[Deep vein thrombosis medical therapy|here]].'''
==Overview==
[[Clinical practice guideline]]s by the [[American College of Chest Physicians]] guide management.<ref name="pmid26867832">{{cite journal| author=Kearon C, Akl EA, Ornelas J, Blaivas A, Jimenez D, Bounameaux H et al.| title=Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. | journal=Chest | year= 2016 | volume= 149 | issue= 2 | pages= 315-52 | pmid=26867832 | doi=10.1016/j.chest.2015.11.026 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26867832  }} </ref>
The treatment approach to deep vein thrombosis (DVT) depends on the location of DVT and the presence or absence of contraindications to anticoagulation.  In the absence of any contraindication to anticoagulation therapy, the treatment of DVT with parental anticoagulant should be initiated in case of intermediate or high suspicion of DVT even before the diagnostic confirmatory tests are complete.  The choice of parental anticoagulation include: low molecular weight heparin (LMWH), fondaparinux, IV unfractionated heparin (UFH), and SC-UFH; however, the administration of LMWH (once daily rather than twice daily) and fondaparinux is recommended over IV-UFH and SCUFH.  Parental anticoagulation therapy should be administered for at least 5 days and until the INR is equal or more than 2 for more than 24 hours.<ref name="pmid22315268"><nowiki>{{</nowiki>http://www.wikidoc.org//index.php/Template:Cite_journal{cite journal| author=Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ et al.| title=Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year=2012 | volume=141 | issue=2 Suppl | pages=e419S-94S | pmid=22315268 | doi=10.1378/chest.11-2301 | pmc=PMC3278049 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315268<nowiki>  }} </nowiki></ref>


==Treatment Algorithm==
==Treatment Approach==
The following algorithm describes the treatment approach to [[DVT]]<ref name="pmid22315257">{{cite journal |author=Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ |title=Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines|journal=Chest |volume=141 |issue=2 Suppl |pages=7S–47S |year=2012 |month=February |pmid=22315257 |doi=10.1378/chest.1412S3 |url=}}</ref>:
Shown below is an algorithm depicting the initial choice of treatment among patients with DVT.<ref name="pmid22315268"><nowiki>{{</nowiki>http://www.wikidoc.org//index.php/Template:Cite_journal{cite journal| author=Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ et al.| title=Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year=2012 | volume=141 | issue=2 Suppl | pages=e419S-94S | pmid=22315268 | doi=10.1378/chest.11-2301 | pmc=PMC3278049 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315268<nowiki>  }} </nowiki></ref>


{{Family tree/start}}
{{familytree | | | | | | | A01 | | | | | | | A01= Is the DVT proximal or distal?}}
{{familytree | | | |,|-|-|-|^|-|-|-|.| | | | }}
{{familytree | | | B01 | | | | | | B02 | | | B01= Proximal DVT| B02= Isolated distal DVT}}
{{familytree | | | |!| | | | | | | |!| | | | }}
{{familytree | | | C01 | | | | | | C02 | | | C01= Are there any contraindications to anticoagulation?| C02= Does the patient have severe symptoms <br> OR <br> risk factors for the extension of the thrombus?}}
{{familytree | |,|-|^|-|.| | | |,|-|^|-|.| | }}
{{familytree | D01 | | D02 | | D03 | | D04 | D01= No| D02= Yes| D03= Yes| D04= No}}
{{familytree | |!| | | |!| | | |!| | | |!| | }}
{{familytree | E01 | | E02 | | E03 | | E04 | E01= Begin initial anticoagulation treatment <br>Begin oral anticoagulant as an overlap therapy for the long term treatment| E02= IVC filter <br>Begin conventional course of anticoagulation if the risk of bleeding subsides| E03= Begin initial anticoagulation treatment (if there are no contraindications)<br>Begin oral anticoagulant as an overlap therapy for the long term treatment| E04= Perform serial imaging for 2 weeks}}
{{familytree | | | | | | | | | | | | | |!| | }}
{{familytree | | | | | | | | | | | | | E05 | E05= Does the repeated US demonstrate any extension of the thrombus (with or without extension to the proximal veins)}}
{{familytree | | | | | | | | | | | |,|-|^|-|.| | }}
{{familytree | | | | | | | | | | | F01 | | F02 | F01= Yes| F02= No}}
{{familytree | | | | | | | | | | | |!| | | |!| | }}
{{familytree | | | | | | | | | | | J01 | | J02 | J01= Begin initial anticoagulation treatment (if there are no contraindications)<br>Begin oral anticoagulant as an overlap therapy for the long term treatment| J02= No anticoagulation therapy}}
{{Family tree/end}}


[[Image:DVT_treatment_approach.jpg]]
===Initial Anticoagulation Choices===
❑ SC [[low molecular weight heparin]] (1st line)
:❑ Enoxaparin 1.0 mg/kg every 12 hours OR 1.5 mg/kg once daily
:❑ Tinzaparin 175 U/kg once daily
❑ SC [[fondaparinux]] (1st line)
:❑ 5 mg once daily (if body weight <50 kg)
:❑ 7.5 mg once daily (if body weight <50-100 kg)
:❑ 10 mg once daily (if body weight >100 kg)
❑ IV [[unfractionated heparin]]
:❑ 80 U/kg as bolus, followed by 18 U/kg/h, OR
:❑ 70 U/kg as bolus, followed by 15 U/kg/h for stroke or cardiac patients<ref name="pmid22315259">{{cite journal| author=Holbrook A, Schulman S, Witt DM, Vandvik PO, Fish J, Kovacs MJ et al.| title=Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e152S-84S | pmid=22315259 | doi=10.1378/chest.11-2295 | pmc=PMC3278055 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315259  }} </ref>
:❑ Adjust the dosages according to the [[aPTT]]
❑ SC [[unfractionated heparin]]
:❑ 333 U/kg as bolus, followed by 250 U/kg<ref name="pmid22315259">{{cite journal| author=Holbrook A, Schulman S, Witt DM, Vandvik PO, Fish J, Kovacs MJ et al.| title=Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e152S-84S | pmid=22315259 | doi=10.1378/chest.11-2295 | pmc=PMC3278055 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315259  }} </ref>


<sup>*</sup>Click [[Deep vein thrombosis diagnosis algorithm|here]] for Diagnosis approach.
==Long Term Treatment==
Shown below is the long term treatment for DVT.  Note that not all patients with isolated distal DVT are started on anticoagulation, only those who are started require long term therapy with anticoagulation.  Patients who are planned to receive long term therapy with [[anticoagulation]] should be assessed regularly for the risks vs benefits of [[anticoagulation therapy]].<ref name="pmid22315257">{{cite journal| author=Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ, American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel| title=Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= 7S-47S | pmid=22315257 | doi=10.1378/chest.1412S3 | pmc=PMC3278060 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315257  }} </ref>


<sup>#</sup>Administer parenteral anticoagulants as per [[Guidelines for DVT#ACCP Guidelines- Recommendations for initial choice of treatment in patients with acute DVT of the leg (DO_NOT_EDIT)|ACCP guidelines]] using the recommended [[Deep vein thrombosis medical therapy#Parenteral Anticoagulants|doses]].
{{Family tree/start}}
{{familytree | | | | | | | | A01 | | | | | | | | A01= '''Is the DVT provoked or unprovoked?'''}}
{{familytree | | | |,|-|-|-|-|^|-|-|-|-|.| | | }}
{{familytree | | | B01 | | | | | | | | B02 | | B01= '''Provoked'''| B02= '''Unprovoked'''}}
{{familytree | | | |!| | | | | | | | | |!| | | }}
{{familytree | | | B03 | | | | | | | | B04 | | B03= '''What is the predisposing factor?'''|B04= '''Is this the first or second episode?'''}}
{{familytree | |,|-|^|-|.| | | |,|-|-|-|^|-|-|-|.| | | }}
{{familytree | C01 | | C02 | | C03 | | | | | | C04 | | C01= '''Surgical''' <br>OR <br>'''Transient non surgical predisposing factor''' | C02= '''Cancer'''| C03='''First episode'''| C04= '''Second episode'''}}
{{familytree | |!| | | |!| | | |!| | | | | | | |!| | | }}
{{familytree | D01 | | D02 | | D03 | | | | | | D04 | | D01= '''Therapy for 3 months'''<br><div style="float: left; text-align: left; padding:1em;">❑ [[VKA]] (first line)<br> OR <br> ❑ [[LMWH]] <br> OR <br> ❑ [[Dabigatran]] <br> OR <br> ❑ [[Rivaroxaban]] </div>|D02= '''Extended therapy or until cancer is cured'''<br><div style="float: left; text-align: left; padding:1em;">❑ [[LMWH]] (first line)<br> OR <br> ❑ [[VKA]] <br> OR <br> ❑ [[Dabigatran]] <br> OR <br> ❑ [[Rivaroxaban]] </div>| D03= '''Is the DVT proximal or distal?'''|D04= '''What is the risk of bleeding?'''}}
{{familytree | | | | | | | |,|-|^|-|.| | | |,|-|^|-|.| }}
{{familytree | | | | | | | E01 | | E02 | | E03 | | E04 | E01= '''Proximal DVT'''|E02= '''Isolated distal DVT'''| E03= '''Low or moderate risk of bleeding'''| E04= '''High risk of bleeding'''}}
{{familytree | | | | | | | |!| | | |!| | | |!| | | |!| | }}
{{familytree | | | | | | | F01 | | F02 | | F03 | | F04 | F01= '''What is the risk of bleeding?'''| F02= '''Therapy for 3 months (irrespective of the risk of bleeding)'''<br><div style="float: left; text-align: left; padding:1em;">❑ [[VKA]] (first line)<br> OR <br> ❑ [[LMWH]] <br> OR <br> ❑ [[Dabigatran]] <br> OR <br> ❑ [[Rivaroxaban]] </div>| F03= '''Extended therapy'''<br><div style="float: left; text-align: left; padding:1em;">❑ [[VKA]] (first line)<br> OR <br> ❑ [[LMWH]] <br> OR <br> ❑ [[Dabigatran]] <br> OR <br> ❑ [[Rivaroxaban]] </div>| F04= '''Therapy for 3 months'''<br><div style="float: left; text-align: left; padding:1em;">❑ [[VKA]] (first line)<br> OR <br> ❑ [[LMWH]] <br> OR <br> ❑ [[Dabigatran]] <br> OR <br> ❑ [[Rivaroxaban]] </div>}}
{{familytree | | | | | |,|-|^|-|.| | | | | | | | | | | | }}
{{familytree | | | | | G01 | | G02 | | | | | | | G01= '''Low or moderate'''| G02= '''High'''}}
{{familytree | | | | | |!| | | |!| | | | | | | | }}
{{familytree | | | | | H01 | | H02 | | | | | | | H01= '''Extended therapy'''<br><div style="float: left; text-align: left; padding:1em;">❑ [[VKA]] (first line)<br> OR <br> ❑ [[LMWH]] <br> OR <br> ❑ [[Dabigatran]] <br> OR <br> ❑ [[Rivaroxaban]] </div>| H02= '''Therapy for 3 months'''<br><div style="float: left; text-align: left; padding:1em;">❑ [[VKA]] (first line)<br> OR <br> ❑ [[LMWH]] <br> OR <br> ❑ [[Dabigatran]] <br> OR <br> ❑ [[Rivaroxaban]] </div>}}
{{Family tree/end}}


<sup></sup>Comorbid conditions may include history of hemorrhagic CVA, recent bleeding episodes, recent surgery or trauma, severe uncontrolled hypertension, renal failure, potential for non-compliance, suspicion of [[PE]] or pregnancy.
===Assessment of Risk of Bleeding===
The risk factors of bleeding with [[anticoagulation therapy]] are:<ref name="pmid22315268">{{cite journal| author=Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ et al.| title=Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e419S-94S | pmid=22315268 | doi=10.1378/chest.11-2301 | pmc=PMC3278049 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315268  }} </ref>
* [[Age]] > 75 years
* [[Alcohol abuse]]
* [[Anemia]]
* [[Antiplatelet|Antiplatelet therapy]]
* [[Cancer]]
* Comorbidity and reduced functional capacity
* [[Diabetes]]
* Frequent [[falls]]
* [[Liver failure]]
* [[Metastatic cancer]]
* Poor [[anticoagulant]] control
* Previous [[bleeding]]
* Prior [[stroke]]
* Recent [[surgery]]
* [[Renal failure]]
* [[Thrombocytopenia]]
 
Shown below is a table summarizing the risk of bleed based on the number of risk factors. Note that, although the presence of one risk factor signify moderate risk of bleeding, if the single risk factor is severe (such as severe [[thrombocytopenia]] or recent major [[surgery]]) then the patient is at high risk of bleeding despite the presence of a single risk factor.
 
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align="center" | '''Risk of bleeding'''|| style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align="center" | '''Number of risk factors'''<ref name="pmid22315268">{{cite journal| author=Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ et al.| title=Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e419S-94S | pmid=22315268 | doi=10.1378/chest.11-2301 | pmc=PMC3278049 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315268  }} </ref>
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align="left" | '''Low Risk'''|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align="left" | 0
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align="left" | '''Moderate Risk'''|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align="left" | 1
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align="left" | '''High Risk'''|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align="left" | ≥2
|}


==ACCP 2012 Guidelines: Recommendations for initial approach in patients with acute DVT of the leg (DO NOT EDIT)<ref name="pmid22315257">{{cite journal |author=Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ |title=Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines|journal=Chest |volume=141 |issue=2 Suppl |pages=7S–47S |year=2012 |month=February |pmid=22315257 |doi=10.1378/chest.1412S3 |url=}}</ref>==
==ACCP 2012 Guidelines: Recommendations for Initial Approach in Patients with Acute DVT of the Leg (DO NOT EDIT)<ref name="pmid22315257">{{cite journal |author=Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ |title=Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines|journal=Chest |volume=141 |issue=2 Suppl |pages=7S–47S |year=2012 |month=February |pmid=22315257 |doi=10.1378/chest.1412S3 |url=}}</ref>==


{|class="wikitable"
{| class="wikitable"
|-
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACCP guidelines classification scheme#Grading Scheme Classification|Grade 1]]
| colspan="1" style="text-align:center; background:LightGreen" |[[ACCP guidelines classification scheme#Grading Scheme Classification|Grade 1]]
|-
|-
| bgcolor="LightGreen"| <nowiki>"</nowiki>'''1.''' In patients with acute DVT of the leg treated with vitamin K antagonist (VKA) therapy,  we recommend initial treatment with parenteral anticoagulation (low-molecular-weight heparin [LMWH], fondaparinux, IV unfractionated heparin [UFH], or subcutaneous [SC] UFH) over no such initial treatment. ([[ACCP guidelines classification scheme#Level of Evidence|Level of evidence B]])<nowiki>"</nowiki>
| bgcolor="LightGreen" | <nowiki>"</nowiki>'''1.''' In patients with acute DVT of the leg treated with vitamin K antagonist (VKA) therapy,  we recommend initial treatment with parenteral anticoagulation (low-molecular-weight heparin [LMWH], fondaparinux, IV unfractionated heparin [UFH], or subcutaneous [SC] UFH) over no such initial treatment. (''[[ACCP guidelines classification scheme#Level of Evidence|Level of evidence B]]'')<nowiki>"</nowiki>
|}
|}
{|class="wikitable"
{| class="wikitable"
|-
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACCP guidelines classification scheme#Grading Scheme Classification|Grade 2]]
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACCP guidelines classification scheme#Grading Scheme Classification|Grade 2]]
|-
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' In patients with a high clinical suspicion of acute VTE, we suggest treatment with parenteral anticoagulants compared with no treatment while awaiting the results of diagnostic tests. ([[ACCP guidelines classification scheme#Level of Evidence|Level of evidence C]])<nowiki>"</nowiki>
| bgcolor="LemonChiffon" |<nowiki>"</nowiki>'''1.''' In patients with a high clinical suspicion of acute VTE, we suggest treatment with parenteral anticoagulants compared with no treatment while awaiting the results of diagnostic tests. (''[[ACCP guidelines classification scheme#Level of Evidence|Level of evidence C]]'')<nowiki>"</nowiki>
|-
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' In patients with an intermediate clinical suspicion of acute VTE, we suggest treatment with parenteral anticoagulants compared with no treatment if the results of diagnostic tests are expected to be delayed for more than 4 h ([[ACCP guidelines classification scheme#Level of Evidence|Level of evidence C]]).<nowiki>"</nowiki>
| bgcolor="LemonChiffon" |<nowiki>"</nowiki>'''2.''' In patients with an intermediate clinical suspicion of acute VTE, we suggest treatment with parenteral anticoagulants compared with no treatment if the results of diagnostic tests are expected to be delayed for more than 4 h (''[[ACCP guidelines classification scheme#Level of Evidence|Level of evidence C]]'').<nowiki>"</nowiki>
|-
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' In patients with a low clinical suspicion of acute VTE, we suggest not treating with parenteral anticoagulants while awaiting the results of diagnostic tests, provided test results are expected within 24 h ([[ACCP guidelines classification scheme#Level of Evidence|Level of evidence C]]).<nowiki>"</nowiki>
| bgcolor="LemonChiffon" |<nowiki>"</nowiki>'''3.''' In patients with a low clinical suspicion of acute VTE, we suggest not treating with parenteral anticoagulants while awaiting the results of diagnostic tests, provided test results are expected within 24 h (''[[ACCP guidelines classification scheme#Level of Evidence|Level of evidence C]]'').<nowiki>"</nowiki>
|}
|}



Latest revision as of 19:20, 6 March 2018

<figure-inline><figure-inline></figure-inline></figure-inline>

Resident
Survival
Guide

Editor(s)-In-Chief: The APEX Trial Investigators, C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2] ; Kashish Goel, M.D.; Assistant Editor(s)-In-Chief: Justine Cadet; Rim Halaby, M.D. [3]

Deep Vein Thrombosis Microchapters

Home

Patient Information

Overview

Classification

Pathophysiology

Causes

Differentiating Deep vein thrombosis from other Diseases

Epidemiology and Demographics

Risk Factors

Triggers

Screening

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Approach

Assessment of Clinical Probability and Risk Scores

Assessment of Probability of Subsequent VTE and Risk Scores

History and Symptoms

Physical Examination

Laboratory Findings

Ultrasound

Venography

CT

MRI

Other Imaging Findings

Treatment

Treatment Approach

Medical Therapy

IVC Filter

Invasive Therapy

Surgery

Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Special Scenario

Upper extremity DVT

Recurrence

Pregnancy

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Risk calculators and risk factors for Deep vein thrombosis treatment approach

This page provides algorithms about the treatment choices. For more details about the medical therapy, click here. For more details about invasive therapy, click here.

Overview

Clinical practice guidelines by the American College of Chest Physicians guide management.[1]

The treatment approach to deep vein thrombosis (DVT) depends on the location of DVT and the presence or absence of contraindications to anticoagulation. In the absence of any contraindication to anticoagulation therapy, the treatment of DVT with parental anticoagulant should be initiated in case of intermediate or high suspicion of DVT even before the diagnostic confirmatory tests are complete. The choice of parental anticoagulation include: low molecular weight heparin (LMWH), fondaparinux, IV unfractionated heparin (UFH), and SC-UFH; however, the administration of LMWH (once daily rather than twice daily) and fondaparinux is recommended over IV-UFH and SCUFH. Parental anticoagulation therapy should be administered for at least 5 days and until the INR is equal or more than 2 for more than 24 hours.[2]

Treatment Approach

Shown below is an algorithm depicting the initial choice of treatment among patients with DVT.[2]

 
 
 
 
 
 
Is the DVT proximal or distal?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proximal DVT
 
 
 
 
 
Isolated distal DVT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Are there any contraindications to anticoagulation?
 
 
 
 
 
Does the patient have severe symptoms
OR
risk factors for the extension of the thrombus?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
Yes
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Begin initial anticoagulation treatment
Begin oral anticoagulant as an overlap therapy for the long term treatment
 
IVC filter
Begin conventional course of anticoagulation if the risk of bleeding subsides
 
Begin initial anticoagulation treatment (if there are no contraindications)
Begin oral anticoagulant as an overlap therapy for the long term treatment
 
Perform serial imaging for 2 weeks
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the repeated US demonstrate any extension of the thrombus (with or without extension to the proximal veins)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Begin initial anticoagulation treatment (if there are no contraindications)
Begin oral anticoagulant as an overlap therapy for the long term treatment
 
No anticoagulation therapy

Initial Anticoagulation Choices

❑ SC low molecular weight heparin (1st line)

❑ Enoxaparin 1.0 mg/kg every 12 hours OR 1.5 mg/kg once daily
❑ Tinzaparin 175 U/kg once daily

❑ SC fondaparinux (1st line)

❑ 5 mg once daily (if body weight <50 kg)
❑ 7.5 mg once daily (if body weight <50-100 kg)
❑ 10 mg once daily (if body weight >100 kg)

❑ IV unfractionated heparin

❑ 80 U/kg as bolus, followed by 18 U/kg/h, OR
❑ 70 U/kg as bolus, followed by 15 U/kg/h for stroke or cardiac patients[3]
❑ Adjust the dosages according to the aPTT

❑ SC unfractionated heparin

❑ 333 U/kg as bolus, followed by 250 U/kg[3]

Long Term Treatment

Shown below is the long term treatment for DVT. Note that not all patients with isolated distal DVT are started on anticoagulation, only those who are started require long term therapy with anticoagulation. Patients who are planned to receive long term therapy with anticoagulation should be assessed regularly for the risks vs benefits of anticoagulation therapy.[4]

 
 
 
 
 
 
 
Is the DVT provoked or unprovoked?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Provoked
 
 
 
 
 
 
 
Unprovoked
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
What is the predisposing factor?
 
 
 
 
 
 
 
Is this the first or second episode?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Surgical
OR
Transient non surgical predisposing factor
 
Cancer
 
First episode
 
 
 
 
 
Second episode
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Therapy for 3 months
VKA (first line)
OR
LMWH
OR
Dabigatran
OR
Rivaroxaban
 
Extended therapy or until cancer is cured
LMWH (first line)
OR
VKA
OR
Dabigatran
OR
Rivaroxaban
 
Is the DVT proximal or distal?
 
 
 
 
 
What is the risk of bleeding?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proximal DVT
 
Isolated distal DVT
 
Low or moderate risk of bleeding
 
High risk of bleeding
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
What is the risk of bleeding?
 
Therapy for 3 months (irrespective of the risk of bleeding)
VKA (first line)
OR
LMWH
OR
Dabigatran
OR
Rivaroxaban
 
Extended therapy
VKA (first line)
OR
LMWH
OR
Dabigatran
OR
Rivaroxaban
 
Therapy for 3 months
VKA (first line)
OR
LMWH
OR
Dabigatran
OR
Rivaroxaban
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Low or moderate
 
High
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Extended therapy
VKA (first line)
OR
LMWH
OR
Dabigatran
OR
Rivaroxaban
 
Therapy for 3 months
VKA (first line)
OR
LMWH
OR
Dabigatran
OR
Rivaroxaban
 
 
 
 
 
 

Assessment of Risk of Bleeding

The risk factors of bleeding with anticoagulation therapy are:[2]

Shown below is a table summarizing the risk of bleed based on the number of risk factors. Note that, although the presence of one risk factor signify moderate risk of bleeding, if the single risk factor is severe (such as severe thrombocytopenia or recent major surgery) then the patient is at high risk of bleeding despite the presence of a single risk factor.

Risk of bleeding Number of risk factors[2]
Low Risk 0
Moderate Risk 1
High Risk ≥2

ACCP 2012 Guidelines: Recommendations for Initial Approach in Patients with Acute DVT of the Leg (DO NOT EDIT)[4]

Grade 1
"1. In patients with acute DVT of the leg treated with vitamin K antagonist (VKA) therapy, we recommend initial treatment with parenteral anticoagulation (low-molecular-weight heparin [LMWH], fondaparinux, IV unfractionated heparin [UFH], or subcutaneous [SC] UFH) over no such initial treatment. (Level of evidence B)"
Grade 2
"1. In patients with a high clinical suspicion of acute VTE, we suggest treatment with parenteral anticoagulants compared with no treatment while awaiting the results of diagnostic tests. (Level of evidence C)"
"2. In patients with an intermediate clinical suspicion of acute VTE, we suggest treatment with parenteral anticoagulants compared with no treatment if the results of diagnostic tests are expected to be delayed for more than 4 h (Level of evidence C)."
"3. In patients with a low clinical suspicion of acute VTE, we suggest not treating with parenteral anticoagulants while awaiting the results of diagnostic tests, provided test results are expected within 24 h (Level of evidence C)."

References

  1. Kearon C, Akl EA, Ornelas J, Blaivas A, Jimenez D, Bounameaux H; et al. (2016). "Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report". Chest. 149 (2): 315–52. doi:10.1016/j.chest.2015.11.026. PMID 26867832.
  2. 2.0 2.1 2.2 2.3 {{http://www.wikidoc.org//index.php/Template:Cite_journal{cite journal| author=Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ et al.| title=Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year=2012 | volume=141 | issue=2 Suppl | pages=e419S-94S | pmid=22315268 | doi=10.1378/chest.11-2301 | pmc=PMC3278049 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315268 }}
  3. 3.0 3.1 Holbrook A, Schulman S, Witt DM, Vandvik PO, Fish J, Kovacs MJ; et al. (2012). "Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e152S–84S. doi:10.1378/chest.11-2295. PMC 3278055. PMID 22315259.
  4. 4.0 4.1 Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ, American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel (2012). "Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): 7S–47S. doi:10.1378/chest.1412S3. PMC 3278060. PMID 22315257.

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