Venous Thromboembolism (DVT and PE) Overview

8 th ACCP Recommendations
VTE Treatment
For patients with unprovoked DVT, we
recommend treatment with a VKA for at
least 3 months (Grade 1A).
For patients with a first unprovoked VTE
that is a proximal DVT, and in whom
risk factors for bleeding are absent and
for whom good anticoagulant
monitoring is achievable, we
recommend long-term treatment (Grade
1A).
There is increasing evidence that a normal D-D
dimer level and the absence of residual
thrombus after discontinuation of oral
anticoagulation are associated with a lower risk
of recurrent VTE events.
Zhu, et. al. Venous Thromboembolism: Risk Factors for Recurrence;
Arteriosler Thromb Vasc Biol.2009;29:298-310.
75 yo WF with h/o HTN, MI and CRI is
seen in clinic for her routine INR. She
is on warfarin for recurrent DVT. Her
INR today is 6.0. She denies any
bleeding or bruising or use of OTC
meds.
What are her risk factors for bleeding
on warfarin?
How do you want to manage her?
8 th ACCP Conference: Managing
VKA Dosing
For patients with INRs of > 5.0 but < 9.0 and no significant
bleeding, we recommend omitting the next one or two doses,
monitoring more frequently, and resuming therapy at an
appropriately adjusted dose when the INR is at a therapeutic
level (Grade 1C).
Alternatively, we suggest omitting a dose and administering
vitamin K (1 to 2.5 mg) orally, particularly if the patient is at
increased risk of bleeding (Grade 2A).
High INR Management
Question: does vitamin K decrease bleeding in high INR?
Design: RCT, double blinded (INR 4.5-10.0)
Patients: 724 Canadian, American and Italian patients
Intervention: vitamin K 1.25 mg po
Comparison: placebo
Outcome:major bleeding, any bleeding, thromboembolism and
death
Timeframe: 7, 30 and 90 outcomes
High INR Management
Crowthers MA. Ann Intern Med. . 2009 Mar 3;150(5):293-300. 300. PMID: 19258557
Crowthers MA. Ann Intern Med. . 2009 Mar 3;150(5):293-300. 300. PMID: 19258557
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