Deep vein thrombosis medical therapy: Difference between revisions
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==Overview== | ==Overview== | ||
VTE is an important cause of morbidity and mortality, particularly in hospitalized patients. Pulmonary embolism is one of the major cause of death in hospitalized patient. Unfortunately the diagnosis can only be made in less than thirty percent of the cases. Thus, it is important to suspect the presence of VTE, and to initiate appropriate diagnostic tests and therapy. In patients with moderate-to-high risk of venous thrombo-embolism, a primary prophylaxis with pharmacologic agents should be used. | |||
==Medical Therapy== | ===Medical Therapy=== | ||
===Hospitalization=== | ===Hospitalization=== |
Revision as of 19:44, 7 September 2011
Editors-in-Chief: C. Michael Gibson, M.S., M.D. Associate Editor-In-Chief: Ujjwal Rastogi, MBBS [1]
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Overview
VTE is an important cause of morbidity and mortality, particularly in hospitalized patients. Pulmonary embolism is one of the major cause of death in hospitalized patient. Unfortunately the diagnosis can only be made in less than thirty percent of the cases. Thus, it is important to suspect the presence of VTE, and to initiate appropriate diagnostic tests and therapy. In patients with moderate-to-high risk of venous thrombo-embolism, a primary prophylaxis with pharmacologic agents should be used.
Medical Therapy
Hospitalization
Treatment at home is an option according to a meta-analysis by the Cochrane Collaboration.[1]
- bilateral DVT,
- Renal insufficiency,
- Body weight <70 kg,
- Recent immobility,
- Chronic heart failure
- Cancer
Anticoagulation
Anticoagulation is the usual treatment for DVT. In general, patients are initiated on a brief course (i.e., less than a week) of heparin, while they start on a 3 to 6 month course of warfarin (or related vitamin K inhibitors). Low molecular weight heparin (LMWH) is preferred,[2]
An abnormal D-dimer level at the end of treatment might signal the need for continued treatment among patients with a first unprovoked proximal deep-vein thrombosis.[3]
Thrombolysis
Thrombolysis is generally reserved for extensive clot, e.g. an iliofemoral thrombosis. Although a meta-analysis of randomized controlled trials by the Cochrane Collaboration shows improved outcomes with thrombolysis,[4] there may be an increase in serious bleeding complications.
Compression stockings
Elastic compression stockings should be routinely applied "beginning within 1 month of diagnosis of proximal DVT and continuing for a minimum of 1 year after diagnosis".[5] The stockings in almost all trials were stronger than routine anti-embolism stockings and created either 20-30 mm Hg or 30-40 mm Hg. Most trials used knee-high stockings. A meta-analysis of randomized controlled trials by the Cochrane Collaboration showed reduced incidence of post-phlebitic syndrome.[6] The number needed to treat is quite potent at 4 to 5 patients need to prevent one case of post-phlebitic syndrome.[7]
References
- ↑ Othieno R, Abu Affan M, Okpo E (2007). "Home versus in-patient treatment for deep vein thrombosis". Cochrane Database Syst Rev (3): CD003076. doi:10.1002/14651858.CD003076.pub2. PMID 17636714.
- ↑ Hutten BA, Prins MH (2006). "Duration of treatment with vitamin K antagonists in symptomatic venous thromboembolism". Cochrane Database Syst Rev (1): CD001367. doi:10.1002/14651858.CD001367.pub2. PMID 16437432.
- ↑ Palareti G, Cosmi B, Legnani C, Tosetto A, Brusi C, Iorio A; et al. (2006). "D-dimer testing to determine the duration of anticoagulation therapy". N Engl J Med. 355 (17): 1780–9. doi:10.1056/NEJMoa054444. PMID 17065639. Review in: Evid Based Med. 2007 Apr;12(2):45 Review in: ACP J Club. 2007 Mar-Apr;146(2):29
- ↑ Watson L, Armon M. "Thrombolysis for acute deep vein thrombosis". Cochrane Database Syst Rev: CD002783. PMID 15495034.
- ↑ Prandoni P, Lensing AW, Prins MH, Frulla M, Marchiori A, Bernardi E; et al. (2004). "Below-knee elastic compression stockings to prevent the post-thrombotic syndrome: a randomized, controlled trial". Ann Intern Med. 141 (4): 249–56. PMID 15313740. Review in: ACP J Club. 2005 Jan-Feb;142(1):7
- ↑ Kolbach D, Sandbrink M, Hamulyak K, Neumann H, Prins M. "Non-pharmaceutical measures for prevention of post-thrombotic syndrome". Cochrane Database Syst Rev: CD004174. doi:10.1002/14651858.CD004174.pub2. PMID 14974060.
- ↑ Kakkos S, Daskalopoulou S, Daskalopoulos M, Nicolaides A, Geroulakos G (2006). "Review on the value of graduated elastic compression stockings after deep vein thrombosis". Thromb Haemost. 96 (4): 441–5. PMID 17003920.