Deep vein thrombosis medical therapy
Editors-in-Chief: C. Michael Gibson, M.S., M.D. Associate Editor-In-Chief: Ujjwal Rastogi, MBBS [1]
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Overview
The primary purpose of treatment is to prevent the following:
- Further clot extension,
- Acute Pulmonary embolism,
- Recurrence of thrombosis,
- Prevention of late complications such as:
- the post-thrombotic syndrome
- chronic thromboembolic pulmonary hypertension.
Medical Therapy
Since PE is a fatal complication occurring in half of the untreated patients within few days to weeks, anticoagulant therapy is indicated for patients with symptomatic proximal lower extremity DVT.
Anticoagulation
Anticoagulation is the usual treatment for DVT. In general, patients are initiated on a brief course (less than a week) of Low molecular weight heparin[1], before they are started on a chronic (3 to 6 month) course of warfarin (or related vitamin K inhibitors).
An abnormal D-dimer level at the end of treatment, signals the need for continued treatment, in patients with first unprovoked proximal deep-vein thrombosis.[2]
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,[3] 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".[4] 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.[5] The number needed to treat is quite potent at 4 to 5 patients need to prevent one case of post-phlebitic syndrome.[6]
References
- ↑ 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.