Venous thromboembolisms (VTE)

What is deep vein thrombosis (DVT)?

A thrombus (clot) which partially or completely obstructs blood flow in your leg or pelvis, causing unilateral localised pain or swelling.

What is a pulmonary embolism (PE)?

A thrombus (clot) which partially or completely obstructs blood flow in your lungs, causing chest pain or shortness of breath.

What are some risk factors for VTE?

• DVT history

• Cancer

• Age 60+

• Overweight

• Male

• Heart failure

• Thrombophilia

• Inflammatory disorders

• Varicose veins

• Smoking

What factors can increase the risk of VTE?

• Surgery

• Hospitalisation

• Trauma

• Chemotherapy

• Immobility

• Prolonged travel

• Hormone treatment

• Pregnancy

• Dehydration

How is VTE diagnosed?

D-dimer test

How is confirmed proximal DVT or PE treated?

Apixaban or rivaroxaban

If apixaban and rivaroxaban are unsuitable, what is second line? (2 options)

1. LMWH for at least 5 days followed by dabigatran or edoxaban

2. LMWH + warfarin for at least 5 days or until INR is at least 2.0 for 2 consecutive readings followed by warfarin alone

What factors (4) might change the duration of treatment for VTE? And how does this change treatment course?

• Provoked DVT with a recent risk factors(s) in last 3 months: treat for 3 months

• Unprovoked DVT with no recent risk factors: treat for over 3 months

• Active cancer: treat for 3-6 months

• Recurrent: long term treatment

What are the two methods of thromboprophylaxis?

1. Mechanical with graduated compression stocking

2. Pharmacological using anticoagulants

How do we use these two methods?

1. Mechanical: compression stocking to be worn day and night until they no longer have significant reduced mobility

2. Pharmacological: anticoagulants started within 14 hours of hospital admission.

What must you consider with pharmacological thromboprophylaxis?

Bleeding risk.

Patients should only receive pharmacological prophylaxis if risk of VTE outweighs risk of bleeding

What anticoagulant is used for pharmacological thromboprophylaxis?

LMWH or fondaparinux

How long do we continue VTE prophylaxis post surgery? Consider general surgery, major abdominal cancer surgery and spinal surgery.

Continue for at least 7 days post surgery or until sufficiently mobile.

Continue for 28 days after major cancer surgery in abdomen.

Continue for 30 days after spinal surgery.

How long do we continue VTE prophylaxis post elective hip replacement surgery and what do we use? (3 options)

• LMWH for 10 days then 75mg aspirin for 28 days

• LMWH for 28 days + stockings until discharge

• Rivaroxaban. If unsuitable, apixaban or dabigatran

How long do we continue VTE prophylaxis post elective knee replacement surgery and what do we use? (3 options)

• 75mg aspirin for 14 days

• LMWH for 14 days + stockings until discharge

• Rivaroxaban. If unsuitable, apixaban or dabigatran

What is used for pharmacological prophylaxis in pregnancy and for how long?

LMWH during hospital admission.

Continue until no risk of VTE or until discharged.

When should thromboprophylaxis be started after birth, miscarriage or termination and how long should it be continued?

Start LMWH 4-8 hours after the event and continue for a minimum of 7 days.

When should mechanical thromboprophylaxis be considered in pregnancy?

Additional mechanical thromboprophylaxis in women who are immobilised and continue until sufficiently mobile or discharged from hospital.

How is VTE treated in pregnancy? How does treatment change if high risk of haemorrhage?

LMWH to be given immediately.

Unfractionated heparin if patient is at high risk of haemorrhage