This was powerpoint was requested by an attending physician to be shared with the Psychiatric providers regarding DVT prophylaxis in patients who may have been on the unit. They include recommendations as outlined by the ACCP 2012 Guidelines for prevention of venous thromboembolism
This was powerpoint was requested by an attending physician to be shared with the Psychiatric providers regarding DVT prophylaxis in patients who may have been on the unit. They include recommendations as outlined by the ACCP 2012 Guidelines for prevention of venous thromboembolism
In the NOACs era , how to deal with liver cirrhosis needing anticoagulation?magdy elmasry
Is My Cirrhotic Patient Auto-anticoagulated?
Does "Auto-anticoagulation" Protect Against thrombosis in Patients with Liver Disease?
The normal balance of hemostasis and rebalanced hemostasis in liver disease.Should we anti-coagulate patients with cirrhosis?How safe is anticoagulation therapy to use in those with chronic liver disease?
Co-Chairs, Alok A. Khorana, MD, FACP, FASCO, and Robert D. McBane, II, MD, along with Dana Angelini, MD, prepared useful Practice Aids pertaining to VTE for this CME/MOC/NCPD/CPE activity titled “Reducing the Global Burden of Cancer-Associated VTE: Applying Guideline-Concordant, Evidence-Based Care and Shared Decision-Making Strategies to Improve Patient Outcomes.” For the full presentation, downloadable Practice Aids, and complete CME/MOC/NCPD/CPE information, and to apply for credit, please visit us at https://bit.ly/3pxFR5t. CME/MOC/NCPD/CPE credit will be available until August 9, 2022.
Anticoagulation in CKD patients with AFد.محمود نجيب
chronic kidney disease is associated with increased risk of both thrombosis and bleeding, so in CKD patients with AF it is a challenging problem whether to be anticoagulated or not
Deep Venous Thrombosis and Pulmonary Embolism : Diagnostic Approach and Curre...Bassel Ericsoussi, MD
Acute pulmonary embolism: Overview, Diagnosis, Treatment
DVT/PE in pregnancy
Prevalence of PE in COPD exacerbations
Diagnostic vascular ultrasonography
In the NOACs era , how to deal with liver cirrhosis needing anticoagulation?magdy elmasry
Is My Cirrhotic Patient Auto-anticoagulated?
Does "Auto-anticoagulation" Protect Against thrombosis in Patients with Liver Disease?
The normal balance of hemostasis and rebalanced hemostasis in liver disease.Should we anti-coagulate patients with cirrhosis?How safe is anticoagulation therapy to use in those with chronic liver disease?
Co-Chairs, Alok A. Khorana, MD, FACP, FASCO, and Robert D. McBane, II, MD, along with Dana Angelini, MD, prepared useful Practice Aids pertaining to VTE for this CME/MOC/NCPD/CPE activity titled “Reducing the Global Burden of Cancer-Associated VTE: Applying Guideline-Concordant, Evidence-Based Care and Shared Decision-Making Strategies to Improve Patient Outcomes.” For the full presentation, downloadable Practice Aids, and complete CME/MOC/NCPD/CPE information, and to apply for credit, please visit us at https://bit.ly/3pxFR5t. CME/MOC/NCPD/CPE credit will be available until August 9, 2022.
Anticoagulation in CKD patients with AFد.محمود نجيب
chronic kidney disease is associated with increased risk of both thrombosis and bleeding, so in CKD patients with AF it is a challenging problem whether to be anticoagulated or not
Deep Venous Thrombosis and Pulmonary Embolism : Diagnostic Approach and Curre...Bassel Ericsoussi, MD
Acute pulmonary embolism: Overview, Diagnosis, Treatment
DVT/PE in pregnancy
Prevalence of PE in COPD exacerbations
Diagnostic vascular ultrasonography
Deep Vein Thrombosis is an important and frequently missed out diagnosis that can often lead to sudden death in post operative patients. Did this powerpoint for an O&G seminar. Mainly focusses on DVT in OBG and its management and prevention. Kindly leave a comment and let me know what you think.
Preventing Amputation with an Arterial Compression PumpACI Medical, LLC
This slideshow is designed to give non-professionals a "plain English" explanation of how ArtAssist®...The Arterial Assist Device® became successful at saving legs from arterial disease-related amputation.
You'll get a glimpse some of the landmark clinical studies that shaped and tested this powerful home-use arterial compression pump to be the industry standard.
to down load this presentation from this link
https://mohmmed-ink.blogspot.com/2020/11/deep-vein-thrombosis-dvt.html
deep vein thrombosis, diagnosis and managment.
Lymphoscintigraphy As an Imaging Modality in Lymphatic SystemApollo Hospitals
Lymphedema is a chronic debilitating disease that results from chronic lymphatic insufficiency. Lymphoscintigraphy forms an authentic yet simple diagnostic and screening procedure in patients with preclinical and clinical lymphedema of different etiologies. Our study population consisted of 540 patients with diagnosed lymphedema of different etiologies and grading. Here we highlight our experience of lymphoscintigraphy in different clinical situations and staging of lymphedema. Lymphoscintigraphy is a simple, noninvasive procedure, which documents clinical diagnosis and guides the management of Lymphedema
Direct oral anticoagulants (DOACs) have quickly become attractive alternatives to the long‐standing standard of care in anticoagulation, vitamin K antagonist. DOACs are indicated for prevention and treatment of several cardiovascular conditions. Since the first approval in 2010, DOACs have emerged as leading therapeutic alternatives that provide both clinicians and patients with more effective, safe, and convenient treatment options in thromboembolic settings. With the expanding role of DOACs, clinicians are faced with increasingly complex decisions relating to appropriate agent, duration of treatment, and use in special populations. This review will provide an overview of DOACs and act as a practical reference for clinicians to optimize DOAC use among common challenging scenarios. Topics addressed include (1) appropriate indications; (2) use in patients with specific comorbidities; (3) monitoring parameters; (4) transitioning between anticoagulant regimens; (5) major drug interactions; and (6) cost considerations.
Direct oral anticoagulants (DOACs)—dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis), edoxaban (Savaysa), and betrixaban (Bevyxxa) are anticoagulation pharmacotherapy used for the prevention of thrombosis in several cardiovascular contexts.1 DOACs are categorized into 2 main classes: oral direct factor Xa inhibitors (ie, rivaroxaban, apixaban, edoxaban, and betrixaban) and direct thrombin inhibitors (ie, dabigatran). In 2010, the US Food and Drug Administration (FDA) approved its first DOAC, dabigatran, followed by rivaroxaban, apixaban, edoxaban, and betrixaban in the following years. DOACs are relatively new agents demonstrating superiority or noninferiority to prior standards of care, anticoagulation with vitamin K antagonists (VKA; ie, warfarin), or low‐molecular‐weight heparins (LMWHs), in reducing risk of thromboembolic complications with similar or reduced bleeding risk.2, 3, 4, 5 Advantages of DOACs compared with VKAs include fewer monitoring requirements, less frequent follow‐up, more immediate drug onset and offset effects (important for periprocedural and acute bleeding management), and fewer drug and food interactions.6 As a result, DOAC prescriptions exceeded those for warfarin by 2013, with apixaban being the most frequently prescribed DOAC for patients with nonvalvular atrial fibrillation (NVAF).7
Over the past decade, DOACs have been the subject of extensive investigation in many clinical scenarios. Though guidelines and review articles have provided detailed and in‐depth analyses of the immense literature base, these can be too cumbersome and challenging to integrate into everyday clinical use
In general, FDA‐approved indications for each of the DOACs are comparable (see Table 1). Dabigatran, rivaroxaban, apixaban, and edoxaban are approved for the lowering the risk of stroke and embolism in NVAF as well as deep vein thrombosis and pulmonary embolism treatment/prophylaxis.8, 9, 10, 11 Unique indications
Deep vein thrombosis (DVT) and Pulmonary embolism (PE)Aminul Haque
Deep vein thrombosis (DVT) and pulmonary embolism (PE), collectively referred to as venous thromboembolism (VTE), constitute a major global burden of disease.
Francesca Gottschalk - How can education support child empowerment.pptxEduSkills OECD
Francesca Gottschalk from the OECD’s Centre for Educational Research and Innovation presents at the Ask an Expert Webinar: How can education support child empowerment?
The French Revolution, which began in 1789, was a period of radical social and political upheaval in France. It marked the decline of absolute monarchies, the rise of secular and democratic republics, and the eventual rise of Napoleon Bonaparte. This revolutionary period is crucial in understanding the transition from feudalism to modernity in Europe.
For more information, visit-www.vavaclasses.com
Welcome to TechSoup New Member Orientation and Q&A (May 2024).pdfTechSoup
In this webinar you will learn how your organization can access TechSoup's wide variety of product discount and donation programs. From hardware to software, we'll give you a tour of the tools available to help your nonprofit with productivity, collaboration, financial management, donor tracking, security, and more.
A Strategic Approach: GenAI in EducationPeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
Introduction to AI for Nonprofits with Tapp NetworkTechSoup
Dive into the world of AI! Experts Jon Hill and Tareq Monaur will guide you through AI's role in enhancing nonprofit websites and basic marketing strategies, making it easy to understand and apply.
2024.06.01 Introducing a competency framework for languag learning materials ...Sandy Millin
http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
The Roman Empire A Historical Colossus.pdfkaushalkr1407
The Roman Empire, a vast and enduring power, stands as one of history's most remarkable civilizations, leaving an indelible imprint on the world. It emerged from the Roman Republic, transitioning into an imperial powerhouse under the leadership of Augustus Caesar in 27 BCE. This transformation marked the beginning of an era defined by unprecedented territorial expansion, architectural marvels, and profound cultural influence.
The empire's roots lie in the city of Rome, founded, according to legend, by Romulus in 753 BCE. Over centuries, Rome evolved from a small settlement to a formidable republic, characterized by a complex political system with elected officials and checks on power. However, internal strife, class conflicts, and military ambitions paved the way for the end of the Republic. Julius Caesar’s dictatorship and subsequent assassination in 44 BCE created a power vacuum, leading to a civil war. Octavian, later Augustus, emerged victorious, heralding the Roman Empire’s birth.
Under Augustus, the empire experienced the Pax Romana, a 200-year period of relative peace and stability. Augustus reformed the military, established efficient administrative systems, and initiated grand construction projects. The empire's borders expanded, encompassing territories from Britain to Egypt and from Spain to the Euphrates. Roman legions, renowned for their discipline and engineering prowess, secured and maintained these vast territories, building roads, fortifications, and cities that facilitated control and integration.
The Roman Empire’s society was hierarchical, with a rigid class system. At the top were the patricians, wealthy elites who held significant political power. Below them were the plebeians, free citizens with limited political influence, and the vast numbers of slaves who formed the backbone of the economy. The family unit was central, governed by the paterfamilias, the male head who held absolute authority.
Culturally, the Romans were eclectic, absorbing and adapting elements from the civilizations they encountered, particularly the Greeks. Roman art, literature, and philosophy reflected this synthesis, creating a rich cultural tapestry. Latin, the Roman language, became the lingua franca of the Western world, influencing numerous modern languages.
Roman architecture and engineering achievements were monumental. They perfected the arch, vault, and dome, constructing enduring structures like the Colosseum, Pantheon, and aqueducts. These engineering marvels not only showcased Roman ingenuity but also served practical purposes, from public entertainment to water supply.
Biological screening of herbal drugs: Introduction and Need for
Phyto-Pharmacological Screening, New Strategies for evaluating
Natural Products, In vitro evaluation techniques for Antioxidants, Antimicrobial and Anticancer drugs. In vivo evaluation techniques
for Anti-inflammatory, Antiulcer, Anticancer, Wound healing, Antidiabetic, Hepatoprotective, Cardio protective, Diuretics and
Antifertility, Toxicity studies as per OECD guidelines
Model Attribute Check Company Auto PropertyCeline George
In Odoo, the multi-company feature allows you to manage multiple companies within a single Odoo database instance. Each company can have its own configurations while still sharing common resources such as products, customers, and suppliers.
2. CASE
A 44-year-old man is evaluated in follow-up for an episode of unprovoked
left proximal leg deep venous thrombosis 3 months ago. Following initial
anticoagulation with low-molecular-weight heparin, he began treatment
with warfarin. INR testing done every 3 to 4 weeks has shown a stable
therapeutic INR. He has mild left leg discomfort after a long day of
standing, but it does not limit his activity level. He tolerates warfarin well.
Family history is unremarkable, and he takes no other medications.
Which of the following is the most appropriate management?
A. Continue anticoagulation indefinitely
B. Discontinue warfarin in another 3 months
C. Discontinue warfarin now
D. Discontinue warfarin and perform thrombophilia testing
3. OBJECTIVES
Review of anticoagulants
Recognize subgroups of VTE
Review guidelines for duration of therapy
Understand differences in therapy based on type of
VTE
4. Subgroups of VTE
Cancer-associated vs No cancer
Provoked vs Unprovoked
Proximal vs Distal DVT
Upper extremity vs Lower extremity DVT
7. Parental Anticoagulants Dosing
UFH
80 U/kg IV bolus followed by 18 U/kg/hr
5000U IV bolus followed by 1000 U/hr
Enoxaparin
1 mg/kg SQ Q12H
1.5 mg/kg SQ QD
CrCl < 30: 1 mg/kg SQ Q24H
Fondaparinux
< 50kg: 5mg SQ QD
50-100kg: 7.5mg SQ QD
> 100kg: 10mg SQ QD
Unfractioned Heparin
80 U/kg IV bolus followed by 18 U/kg/hr
5000U IV bolus followed by 1000 U/hr
Enoxaparin
1 mg/kg SC 12H
CrCl < 30: 1 mg/kg SC 24H
Fondaparinux
< 50kg: 5mg SC OD
50-100kg: 7.5mg SC OD
> 100kg: 10mg SC OD
8. Tinzaparin
175 U/kg SC OD
CrCl < 30: use with caution
Nadroparin
171 U/kg SC OD
CrCl 30-50: reduce dose by 25-33%
CrCl < 30: use with caution
9. Oral Anticoagulants Therapy
Vitamin K Antagonist - warfarin
Started on day 1 or 2 of parenteral anticoagulation
Maintain overlap for at least 5 days.
INR goal = 2-3
Many diet, drug, and disease interactions
OR
NOAC
Rivaroxaban, Apixaban, Edoxaban, Dabigatran
Preferred VTE treatment
10. Rivaroxoban
Dosing
DVT/PE treatment: 15mg BD x 21 days followed by 20mg OD
Take with food
Extremes in weight do not influence
Does not require parenteral anticoagulation prior to initiation
Reduction in risk of recurrence: 20mg OD
Renal and hepatic impairment
Cr Cl < 30: avoid use
Moderate-severe hepatic impairment: avoid use
11. Discontinuation for surgery or other procedures
Stop rivaroxaban at least 24 hours before procedure
Restart rivaroxaban after surgery/procedure as soon as adequate
hemostasis is established
Switching to rivaroxaban
From warfarin to rivaroxaban: Discontinue warfarin and start rivaroxaban as
soon as INR is below 3.0
From anticoagulant other than warfarin to rivaroxaban: Start rivaroxaban 0 to
2 hours prior to next scheduled evening administration of the drug and omit
administration of the other anticoagulant
From unfractionated heparin continuous infusion to rivaroxaban: Stop
infusion and start rivaroxaban at the same time
12. APIXABAN
Dosing
DVT treatment: 10mg BD x 7 days followed by 5mg BD
Does not require parenteral anticoagulation prior to initiation
Reduction in risk of recurrence: 2.5mg BD
Renal impairment
CrCl < 30: use with caution
Nonvalvular atrial fibrillation
Decrease dose to 2.5 mg PO BD in patients with any 2 of the
following characteristics:
Age ≥80 years
Weight ≤60 kg
Serum creatinine ≥1.5 mg/dL
13. Hepatic impairment
Mild : No dosage adjustment required
Moderate/Severe: Not recommended
Surgery/procedures
Discontinue at least 48 hr before elective surgery or invasive
procedures with a moderate or high risk of unacceptable or clinically
significant bleeding
14. EDOXABAN
DVT or PE Treatment
Indicated for treatment in patients who have been initially treated with
a parenteral anticoagulant for 5-10 days
>60 kg: 60 mg PO OD
≤60 kg: 30 mg PO OD
Renal impairment (DVT/PE)
>50 mL/min: No dosage adjustment required
15-50 mL/min: 30 mg PO OD
Renal impairment (NVAF)
CrCl >95 mL/min: Do not use; increased ischemic stroke compared with
warfarin
CrCl >50 to 95 mL/min: No dosage adjustment required
CrCl 15-50 mL/min: 30 mg PO OD
15. Hepatic impairment
Mild (Child-Pugh A): No dose adjustment required
Moderate-to-severe (Child-Pugh B/C): Not recommended;
Transition to edoxaban
From warfarin or other vitamin K antagonists (VKAs): Discontinue
warfarin and start edoxaban when INR ≤2.5
From oral anticoagulants other than warfarin or other VKAs:
Discontinue current oral anticoagulant and initiate edoxaban at the
time of the next scheduled dose of the previous oral anticoagulant
From low molecular weight heparin (LMWH): Discontinue LMWH and
initiate edoxaban at the time of the next scheduled administration of
LMWH
From unfractionated heparin: Discontinue heparin infusion and initiate
edoxaban 4 hr later
16. DABIGATRAN
DVT or PE Treatment
Indicated for patients who have been treated with a parenteral anticoagulant for 5-10
days
CrCl >30 mL/min: 150 mg PO BD
CrCl ≤30 mL/min or on dialysis: not indicated
Stroke Prophylaxis With Atrial Fibrillation
Prevention of stroke and systemic embolism associated with nonvalvular atrial
fibrillation
CrCl >30 mL/min: 150 mg PO BID
CrCl 15-30 mL/min: 75 mg PO BID
CrCl <15 mL/min or dialysis: not recommended
17. Discontinuation for surgery and other interventions
Discontinue dabigatran 1 to 2 days (CrCl ≥50 mL/min) or 3 to 5 days
(CrCl <50 mL/min) before invasive or surgical procedures because of
the increased risk of bleeding
Consider longer times for patients undergoing major surgery, spinal
puncture, or placement of a spinal or epidural catheter or port, in
whom complete hemostasis may be required
18. NOAC Parenteral
needed
Weight adj Unique Reversal
Rivaroxaban No No Take with food No
Apixaban No ~ No Pregnancy B No
Edoxaban Yes Yes CrCl > 95:
avoid
No
Dabigatran Yes No GI upset Praxbind,
dialyzable
19. NOAC Evidence
4 new RCTs and extensive clinical experience
Risk reduction similar between NOACs and VKA
Risk reduction greater with LMWH than VKA in patients with cancer
Risk reduction seems to be similar between all NOACs (No direct comparison)
Risk of bleeding less with NOACs than VKA
GI bleeding may be higher, though
Risk may be less with apixaban
Risk of fatal bleeding similar between VKA and NOACs
Conclusion, less bleeding and greater convenience with NOACs
22. Duration of anticoagulants
Four durations of treatment:
(1) 4 or 6 weeks; short term
(2) 3 months; long term
(3) longer than 3 months but still a time-limited course of therapy
(usually 6 or 12 months); or
(4) extended (also termed “indefinite”; no scheduled stopping date)
therapy
23. RISK FACTOR RATE OF RECURRENCE
SURGERY 3 % AT 5 YEARS
NON SURGICAL 15 % AT 5 YEARS
UNPROVOKED 30 % AT 5 YEARS
CANCER 15 % ANNUAL RISK
24. Risk Factors for Bleeding on
Anticoagulant Therapy
Age >65
Previous bleeding
Cancer
Metastatic cancer
Renal failure
Liver failure
Thrombocytopenia
Previous stroke
Diabetes
Anemia
Antiplatelet therapy
Poor anticoagulant control
NSAID use
Low risk 0 risk factors
Moderate risk 1 risk factor
High risk ≥2 risk factors
25. In patients with a proximal & distal DVT of the leg or PE
provoked by surgery or non surgical transient risk factor,
Treatment with anticoagulation for 3 months is preferred over
(i) treatment of a shorter period ,
(ii) treatment of a longer, time-limited period (eg 6, 12, or 24 months) , or
(iii) extended therapy (no scheduled stop date) .
.
26. In patients with a first VTE that is an unprovoked proximal DVT of
the leg or PE should have atleast 3 month anticoagulant therapy
(i) low or moderate bleeding risk ,extended anticoagulant therapy > long term
(ii) high bleeding risk , long term > extented therapy
In patients with a second unprovoked VTE and who have a
(i) low and moderate bleeding risk , extended anticoagulant therapy > long term
(ii) high bleeding risk , long term > extented therapy
27. In patients with DVT of the leg or PE and active cancer
(“cancer-associated thrombosis”) and who do not have a high
bleeding risk, recommendation are extended anticoagulant therapy
(no scheduled stop date) over 3 months of therapy .
28. Aspirin for Extended Treatment of VTE
In patients with an unprovoked proximal DVT or PE who are stopping
anticoagulant therapy and do not have a contraindication to aspirin, aspirin over
no aspirin to prevent recurrent VTE is suggested
These recommendations are based on two randomized trials.
Extended anticoagulant therapy reduce recurrent VTE by more than
80% and Aspirin by 33 % .
29. Whether and How to Prescribe Anticoagulants to Patients
With Isolated Distal DVT
Two management options for isolated DVT
1) treat patients with anticoagulant therapy or
2) follow-up US examination (eg, after 1 and 2 weeks, or sooner if
there is concern )
30. Risk factors for extension of distal DVT that would favor
anticoagulation over surveillance:
(1) D-dimer is positive
(2) thrombosis is extensive (eg, >5 cm in length, involves multiple
veins, >7 mm in maximum diameter);
(3) thrombosis is close to the proximal veins;
(4) there is no reversible provoking factor for DVT;
(5) active cancer;.
(6) history of VTE; and
(7) inpatient status.
(8) Severe symptoms
(9) DVT that are detected using a selective approach to whole-leg
US
31. Surveillance over anticoagulation
1) thrombosis that is confined to the muscular veins of the calf ( soleus,
gastrocnemius) to have a lower risk of extension than thrombosis that
involves the axial ( ie, true deep; peroneal, tibial ) veins.
2) high bleeding risk
3) whereas distal DVT detected by routine whole-leg US
32. In patients with acute, isolated, distal DVT of the leg who are
managed with serial imaging,
(i) no anticoagulation if the thrombus does not extend
(ii) suggest anticoagulation if the thrombus extends but remains
confined to the distal veins or extends into the proximal veins
33. CDT for Acute DVT of the Leg
In patients with acute proximal DVT of the leg,
anticoagulant therapy alone over CDT is preferred.
It was based on various randomized trials and cavenent study
(Catheter-Directed Venous Thrombolysis in Acute Iliofemoral
Vein Thrombosis Study) which shows CDT is associated with
an increase in transfusion (twofold), intracranial bleeding
(threefold),PE (1.5-fold), and vena caval filter insertion
(twofold);
34. CDT is preferred over anticoagulation in
patients having
1) Iliofemoral DVT,
2) Symptoms for <14 days,
3) Good functional status,
4) Life expectancy of >1 year, and
5) low risk of bleeding
35. Role of IVC Filter for Acute DVT or PE
In patients with acute DVT or PE who are treated with
anticoagulants, recommendations are against the use of an IVC
filter.
These recommendations are based on PREPIC 1 and PREPIC 2
trial (Prevention du Risque d’Embolie Pulmonaire par Interruption
Cave) which showed placement of a permanent IVC filter
increased DVT, decreased PE, and did not influence VTE (DVT
and PE combined) or mortality
36. Compression Stocking to Prevent PTS
In patients with acute DVT of the leg , compression stockings
routinely to prevent PTS are not recommended
These were based on findings of two small, single-center,
randomized trials in which patients and study personnel were not
blinded to stocking use (non placebo stocking) .
37. Subsegmental PE
Subsegmental PE refers to PE that is confined to the subsegmental pulmonary
arteries.
There is uncertainty whether these patients should be anticoagulated for two
reasons :
First because of false positive findings
Second, because a true subsegmental PE arises from a small DVT, the risk of
progressive or recurrent VTE without anticoagulation is expected to be lower.
.
38. Diagnosis of subsegmental PE
(1) the CT pulmonary angiogram is of high quality with
good opacification of the distal pulmonary arteries;
(2) there are multiple intraluminal defects;
(3) defects involve more proximal subsegmental arteries
(ie, are larger);
(4) defects are seen on more than one image;
(5) defects are surrounded by contrast rather than
appearing to be adherent to the pulmonary artery walls;
(6) defects are seen on more than one projection;
(7) patients are symptomatic, as opposed to PE being
an incidental finding;
(8) there is a high clinical pretest probability forPE;
(9) D-dimer level is elevated, particularly if the
increase is marked and otherwise unexplained.
39. Other risk factors for VTE in pt of subsegmental PE are the
patients who are
1.hospitalized or
2. Reduced mobility
3. Active cancer (particularly if metastatic or being treated
with chemotherapy);
4. No reversible risk factor for VTE such as recent surgery.
Favors anticoagulation
40. In patients with subsegmental PE (no involvement of more
proximal pulmonary arteries) and no proximal DVT in the legs
who have a
(i)low risk for recurrent VTE clinical surveillance over
anticoagulation is suggested
(ii) high risk for recurrent VTE , anticoagulation over clinical
surveillance
41. Treatment of Acute PE Out of the Hospital
Patients who satisfy all of the following criteria are suitable for treatment
of acute PE out of the hospital:
(1) clinically stable with good cardiopulmonary reserve;
(2) no contraindications such as recent bleeding, severe renal or liver
disease, or severe thrombocytopenia (ie, <70,000/mm3);
(3) expected to be compliant with treatment; and
(4) the patient feels well enough to be treated at home.
42. Systemic Thrombolytic Therapy for PE
Pulmonary Embolism Thrombolysis trial, which randomized
1,006 patients with PE and right ventricular dysfunction
showed that thrombolytic therapy prevented cardiovascular
collapse but increased major (including intracranial) bleeding;
with no convincing net benefit from thrombolytic therapy.
However favored “rescue thrombolytic therapy” on patients
who developed cardiovascular collapse after initially being
treated with anticoagulant therapy alone
43. PE With Hypotension
AT 10 suggsts that thrombolytic thearapy over
anticoagulation in pt with acute PE with hypotension (ie,
systolic BP <90 mm Hg for 15 min) and without high
bleeding risk.
44. PE Without Hypotension
In most patients with acute PE not associated with
hypotension, recommendations are against systemically
administered thrombolytic therapy
In selected patients with acute PE who deteriorate after
starting anticoagulant therapy but have yet to develop
hypotension and who have a low bleeding risk,
thrombolytic therapy is suggested.
45. Indications of thrombolytic therapy
1.Progressive increase in heart rate,
2.Decrease in systolic BP (which remains >90 mm Hg),
3. Increase in jugular venous pressure,
4. Worsening gas exchange,
5.Signs of shock (eg, cold sweaty skin, reduced urine output, confusion),
6. Progressive right heart dysfunction on echocardiography, or an
7. Increase in cardiac biomarkers.
46. Catheter-Based Thrombus Removal for the
Initial Treatment of PE
In patients with acute PE who are treated with a
thrombolytic agent, systemic thrombolytic
therapy using a peripheral vein over CDT is
recommended
In patients with acute PE associated with hypotension
and who have (i) a high bleeding risk,
(ii) failed systemic thrombolysis, or (iii) shock that is
likely to cause death before systemic thrombolysis
can take effect (eg, within hours), CDT > NO THERAPY
47. Thrombolytic Therapy in Patients With Upper
Extremity DVT
Thrombolysis is most likely to be of benefit in patients who meet the
following criteria:
1. severe symptoms
2.thrombus involving most of the subclavian vein and the axillary vein;
3.symptoms for <14 days;
4.Good functional status;
5.life expectancy of >1 year; and
6.Low risk for bleeding.
48. In patients with UEDVT who undergo
thrombolysis, same intensity and duration of
anticoagulant therapy as in patients with UEDVT
who do not undergo thrombolysis
49. Management of Recurrent VTE on
Anticoagulant Therapy
Unusual occurrence so reevaluate:
Diagnosis
Compliance
Underlying malignancy
If occurs while on therapeutic VKA or NOAC therapy, suggest
switching to LMWH therapy at least temporarily and for at least 1
month
If occurs while on long-term LMWH, suggest increasing dose
by 1/4 -1/3
50. SUMMARY
Non-Cancer: NOAC > VKA > LMWH
Cancer: LMWH
Recurrent: Switch to LMWH or increase LMWH dose
Provoked risk factor : long term > extented / short term
Unprovoked / cancer : extented > long term
Thrombolytic: only in massive or deteriorating PE
Compression stockings: do not routinely use
Subsegmental [PE: base therapy on risk
Aspirin > no aspirin in unprovoked dvt
Isolated distal dvt : severe symptoms or risk fctors anticoagulation >
surviellance.
PE with hypotension and progressive worsening on anticoagulant therapy
thrombolytic therapy > anticoagulation