Venous Thromboembolism (DVT and PE) Overview

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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 Page 10 10
8 th ACCP Conference: Managing VKA Dosing In patients with mild to moderately elevated INRs without major bleeding, we recommend that when vitamin K is to be given, it be administered orally rather than subcutaneously (Grade 1A). A 56 year old woman with an acute left popliteal DVT develops a GI bleed. IVC Filters in the Prevention of Pulmonary Embolism in Patients with Proximal DVT No Odds Ratio P End Point at Day 12 Filter Filter (99% CI)* Value (N=200) (N=200) Pulmonary embolism 2 (1.1) 9 (4.8) 0.22 0.03 (0.05-0.90) Major bleeding 9 (4.5) 6 (3.0) 1.49 0.44 (0.53-4.20) Death 5 (2.5) 5 (2.5) 0.99 0.99 (0.29-3.42) Decousus et al. NEJM 1998;338:409 IVC Filters in the Prevention of Pulmonary Embolism in Patients with Proximal DVT No Odds Ratio P Events at 2 years Filter Filter (99% CI)* Value (N=200) (N=200) Symptomatic PE 6 (3.4) 12 (6.3) 0.50 0.16 (0.19-1.33) Recurrent DVT 37 (20.8) 21 (11.6) 1.87 0.02 (1.10-3.20) Major bleeding 17 (8.8) 22 (11.8) 0.77 0.41 (0.41-1.45) Death 43 (21.6) 40 (20.1) 1.10 0.65 (0.72-1.70) Decousus et al. NEJM 1998;338:409 New anticoagulants and their targets in the coagulation cascade Intrinsic or Extrinsic Activation DX-9065 Rivaroxaban Apixaban LY 517717 Otamixaban Factor IX Factor X Factor II (Prothrombin) Factor Xa Factor VII Factor IIa (Thrombin) Dabigatran Fibrinogen Fibrin Page 11 11
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