As a #medicine resident you'll come across ๐๐ป scenario often.
Your #surgery colleagues want you to opine on the type and duration of ANTICOAGULATION and also want to know why it occured in the first place๐คทโโ๏ธ
Let's dig deeper ๐๐ป
1/24
#MedTwitter #DVT
Your #surgery colleagues want you to opine on the type and duration of ANTICOAGULATION and also want to know why it occured in the first place๐คทโโ๏ธ
Let's dig deeper ๐๐ป
1/24
#MedTwitter #DVT
Yeah, this is obviously a Deep Vein Thrombosis (DVT) !
It's fairly common, develops in about 1/1000 people ๐ฎ
Remember, DVT+PE = VTE
PE= pulm embolism
VTE= venous thromboembolism
โญ1/3 DVT develop PEโญ
The PE is what can lead to mortality!
Preventing PE is IMPORTANT ๐๐ป
2/24
It's fairly common, develops in about 1/1000 people ๐ฎ
Remember, DVT+PE = VTE
PE= pulm embolism
VTE= venous thromboembolism
โญ1/3 DVT develop PEโญ
The PE is what can lead to mortality!
Preventing PE is IMPORTANT ๐๐ป
2/24
DVT is not less of a monster !
Many w/ DVT will develop post thrombotic syndrome ๐ฎ That's a lot of morbidity, leg pain, swelling, ulceration and all ๐ญ
But
๐ธWhy does VTE occur ?
๐ธWho's at risk of developing it ?
๐ธCan we prevent it ?
๐ธHow does one treat it ?
3/24
Many w/ DVT will develop post thrombotic syndrome ๐ฎ That's a lot of morbidity, leg pain, swelling, ulceration and all ๐ญ
But
๐ธWhy does VTE occur ?
๐ธWho's at risk of developing it ?
๐ธCan we prevent it ?
๐ธHow does one treat it ?
3/24
Before we proceed any further, does anyone recognise ๐๐ป gentleman??
4/24
4/24
Yes, he's Dr Rudolf Carl Virchow, a ๐ฉ๐ช physician/pathologist.
He coined the terms "thrombosis" & "embolism" amongst others!
The first to propose that clots in the lower limbs "embolize" to the lungs, back in 1856.
THE Virchow after whom Virchow nodes are named!
5/24
He coined the terms "thrombosis" & "embolism" amongst others!
The first to propose that clots in the lower limbs "embolize" to the lungs, back in 1856.
THE Virchow after whom Virchow nodes are named!
5/24
Ok, so a clot forms when there's:
1๏ธโฃBad blood (hypercoag)
2๏ธโฃBad vessel (vessel wall injury)
3๏ธโฃLazy blood (stasis)
So, these are the risk factors for VTE:
1. Surgery
2. Immobilization
3. Cancer
4. Pregnancy/post partum
5. Obesity
6. โคด๏ธAge
7. Bad blood (thrombophilia)
6/24
1๏ธโฃBad blood (hypercoag)
2๏ธโฃBad vessel (vessel wall injury)
3๏ธโฃLazy blood (stasis)
So, these are the risk factors for VTE:
1. Surgery
2. Immobilization
3. Cancer
4. Pregnancy/post partum
5. Obesity
6. โคด๏ธAge
7. Bad blood (thrombophilia)
6/24
Most of these causes affect >1 of the Virchow triad factors !
As an example, cancer causes stasis + bad blood (cancer procoagulant) + bad vessel ๐ญ
Ok, enough with the history and bad blood etc ๐คฃ
7/24
#MedTwitter
As an example, cancer causes stasis + bad blood (cancer procoagulant) + bad vessel ๐ญ
Ok, enough with the history and bad blood etc ๐คฃ
7/24
#MedTwitter
What does a busy resident need to know ๐คทโโ๏ธ
๐ธHow to diagnose?
๐ธHow to treat?
There is something known as the Wells score !! It predicts the PRE-TEST PROBABILITY of DVT but I rarely use it.
So what do I use ?
๐ธD-dimer
๐ธCompression ultrasound (CUS)
8/24
#MedTwitter
๐ธHow to diagnose?
๐ธHow to treat?
There is something known as the Wells score !! It predicts the PRE-TEST PROBABILITY of DVT but I rarely use it.
So what do I use ?
๐ธD-dimer
๐ธCompression ultrasound (CUS)
8/24
#MedTwitter
The D-dimer is a fibrin degradation product. It is โคด๏ธ when the body tries to lyse a clot !!
DVT isn't the only cause of an โคด๏ธD-dimer. It's also โคด๏ธ in:
๐ธPregnancy
๐ธMalignancy
๐ธLiver disease
So we can't use D-dimer to diagnose DVT in these conditions !!
#MedTwitter
9/24
DVT isn't the only cause of an โคด๏ธD-dimer. It's also โคด๏ธ in:
๐ธPregnancy
๐ธMalignancy
๐ธLiver disease
So we can't use D-dimer to diagnose DVT in these conditions !!
#MedTwitter
9/24
The D-dimer is NOT SPECIFIC for DVT but it is QUITE SENSITIVE !
What I mean to say is that it can RULE OUT a DVT โ
Normal D-dimer=โคต๏ธprobability of DVT
โฌ๏ธ
If the D-dimer is โ get a compression ultrasound (CUS)
10/24
#MedTwitter
What I mean to say is that it can RULE OUT a DVT โ
Normal D-dimer=โคต๏ธprobability of DVT
โฌ๏ธ
If the D-dimer is โ get a compression ultrasound (CUS)
10/24
#MedTwitter
There are other imaging modalities to diagnose DVT, like CT/MR venography !
But CUS is easy, cheap and accurate.
If a vein doesn't compress when the probe presses on it = thrombus โ
#MedTwitter
11/24
But CUS is easy, cheap and accurate.
If a vein doesn't compress when the probe presses on it = thrombus โ
#MedTwitter
11/24
CUS is good for picking up proximal DVT, not so much for distal DVT.
PROXIMAL = above the knee
PROXIMAL = ilio-femoral-popliteal veins
What you need to recognise clinically are the limb threatening signs ๐ฎ
Why?
Because, in addition to anticoag you will need to lyse the clot!
PROXIMAL = above the knee
PROXIMAL = ilio-femoral-popliteal veins
What you need to recognise clinically are the limb threatening signs ๐ฎ
Why?
Because, in addition to anticoag you will need to lyse the clot!
What are these LIMB THREATENING SIGNS?
๐ธAbsent pulse
๐ธCyanosis
๐ธGangrene
This is what we call PHELGMASIA CERULEA DOLENS (PCD) ๐
PCD is the ONLY indication of thrombolysis/ thrombectomy.
And catheter directed is always better than systemic thrombolysis ๐๐ป
13/24
๐ธAbsent pulse
๐ธCyanosis
๐ธGangrene
This is what we call PHELGMASIA CERULEA DOLENS (PCD) ๐
PCD is the ONLY indication of thrombolysis/ thrombectomy.
And catheter directed is always better than systemic thrombolysis ๐๐ป
13/24
Let's summarise what we've learnt till now !
๐ธDVT is bad/morbid
๐ธRisk โคด๏ธ w/ โคด๏ธage
๐ธHospitalisation/SX is a risk factor
๐ธVirchow triad messed up
๐ธD-dimer negative = DVT unlikely
๐ธCUS is good to pick it up
๐ธPCD needs thrombolysis !!
#MedTwitter
14/24 phew ๐คฃ
๐ธDVT is bad/morbid
๐ธRisk โคด๏ธ w/ โคด๏ธage
๐ธHospitalisation/SX is a risk factor
๐ธVirchow triad messed up
๐ธD-dimer negative = DVT unlikely
๐ธCUS is good to pick it up
๐ธPCD needs thrombolysis !!
#MedTwitter
14/24 phew ๐คฃ
How do we treat run of the mill DVT ??
ANTICOAGULATION obviously ๐คทโโ๏ธ
But,
๐ธWhich one ?
๐ธFor how long ?
For DVT, I can now safely say ๐๐ป
โญNOAC > VKA/Heparinโญ
NOAC include:
๐ธApiXaban
๐ธRivaroXaban
๐ธEdoXaban
๐ธDabigatran
Xa = Factor Xa inhibitors
#MedTwitter
15/24
ANTICOAGULATION obviously ๐คทโโ๏ธ
But,
๐ธWhich one ?
๐ธFor how long ?
For DVT, I can now safely say ๐๐ป
โญNOAC > VKA/Heparinโญ
NOAC include:
๐ธApiXaban
๐ธRivaroXaban
๐ธEdoXaban
๐ธDabigatran
Xa = Factor Xa inhibitors
#MedTwitter
15/24
Dosing NOACs:
-ApiXAban:10mg BD x 7dโก๏ธ5mg BD
-RivaroXaban:15mg BD x 21dโก๏ธ20 OD
-EdoXaban: 60mg OD
-Dabigatran: 150mg BD
Can these be used in patients w/ cancer asso. thrombosis ?
YES โ โ (avoid in GI malignancies)
No money for NOAC, no problem. Use VKA, monitor INR !!
16/24
-ApiXAban:10mg BD x 7dโก๏ธ5mg BD
-RivaroXaban:15mg BD x 21dโก๏ธ20 OD
-EdoXaban: 60mg OD
-Dabigatran: 150mg BD
Can these be used in patients w/ cancer asso. thrombosis ?
YES โ โ (avoid in GI malignancies)
No money for NOAC, no problem. Use VKA, monitor INR !!
16/24
Next important question ๐๐ป
That depends on whether the DVT was provoked or unprovoked ??
Provoked = Risk factor identified
Let's recap the risk factors:
Pregnancy
Surgery
OCP
Long distance travel
Immobilization
Cancer
Obesity
Provoked = 3 months of anticoagulation
Unprovoked = Tricky business ๐คทโโ๏ธ
See ๐๐ป
Provoked = Risk factor identified
Let's recap the risk factors:
Pregnancy
Surgery
OCP
Long distance travel
Immobilization
Cancer
Obesity
Provoked = 3 months of anticoagulation
Unprovoked = Tricky business ๐คทโโ๏ธ
See ๐๐ป
To answer this we must remember that we need to balance the risk vs benefit of anticoagulation!
Risk=bleeding risk
Benefit=preventing recurrent clots
So who has โคด๏ธrisk of recurrent clots?
-previous h/o VTE
-โ๏ธ
-Obese
-thrombophiliaโ
May consider longer duration rx here!
19/24
Risk=bleeding risk
Benefit=preventing recurrent clots
So who has โคด๏ธrisk of recurrent clots?
-previous h/o VTE
-โ๏ธ
-Obese
-thrombophiliaโ
May consider longer duration rx here!
19/24
LONGER DURATION ๐คทโโ๏ธ
What does that even mean ??
ANYTHING >3 MONTHS. Sometimes lifelong, sometimes till there is resolution of the underlying "provoking" factor !!
20/24
#MedTwitter
What does that even mean ??
ANYTHING >3 MONTHS. Sometimes lifelong, sometimes till there is resolution of the underlying "provoking" factor !!
20/24
#MedTwitter
Next question ๐๐ป
I've heard so much about these IVC filters, what's all that about ??
I almost never recommend it!
The only indication is:
Acute, proximal leg vein DVT and an ABSOLUTE CONTRAINDICATION to ANTICOAGULATION !
If necessary, place it for the shortest possible time!
I've heard so much about these IVC filters, what's all that about ??
I almost never recommend it!
The only indication is:
Acute, proximal leg vein DVT and an ABSOLUTE CONTRAINDICATION to ANTICOAGULATION !
If necessary, place it for the shortest possible time!
Summary slide for those lazy to read the whole thread ๐คทโโ๏ธ
-DVT is common
-โคด๏ธRisk during hospital stay/SX/๐คฐ
-Normal D-dimer can rule it out
-CUS is a good test, sensitiveโ
-DOAC > VKA/heparin
-LWMH = DOAC for cancer asso VTE
-NOAC not safe in pregnancy !
22/24
#MedTwitter
-DVT is common
-โคด๏ธRisk during hospital stay/SX/๐คฐ
-Normal D-dimer can rule it out
-CUS is a good test, sensitiveโ
-DOAC > VKA/heparin
-LWMH = DOAC for cancer asso VTE
-NOAC not safe in pregnancy !
22/24
#MedTwitter
The most important point ๐๐ป
โญโญNOT EVERY DVT NEEDS A FULL THROMBOPHILIA WORKUP โญโญ
No factor V Leiden, Protein C/S/AT/APLA et al ๐
There are a lot of other "provoking" factors like obesity, immobility, smoking, surgery, drugs like OCP. Plz take a detailed history
23/24
โญโญNOT EVERY DVT NEEDS A FULL THROMBOPHILIA WORKUP โญโญ
No factor V Leiden, Protein C/S/AT/APLA et al ๐
There are a lot of other "provoking" factors like obesity, immobility, smoking, surgery, drugs like OCP. Plz take a detailed history
23/24
If you have read the whole thread, THANK YOU ๐ช๐ผ๐๐ป
If you have read just the summary slides, I still THANK YOU ๐คฃ
Share, retweet if you found this useful !
24/24 ๐๐ป
#MedTwitter
If you have read just the summary slides, I still THANK YOU ๐คฃ
Share, retweet if you found this useful !
24/24 ๐๐ป
#MedTwitter
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