Updates in Medical Management of Pulmonary Embolism and Deep Vein Thrombosis. By: Justin Youtsey, Elliott Reiff, William Montgomery, Grant Finlan

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1 Updates in Medical Management of Pulmonary Embolism and Deep Vein Thrombosis By: Justin Youtsey, Elliott Reiff, William Montgomery, Grant Finlan

2 Objectives Describe the prevalence of PE and DVT as it relates to physical therapy Describe the symptoms of both PE and DVT Describe medical interventions/treatments for PE and DVT Be familiar with new research for PE and DVT

3 Deep Vein Thrombosis and Pulmonary Embolism DVT: often in the legs, veins of the arms, the splanchnic veins, and cerebral veins PE: A sudden blockage in a lung artery, blockage is usually caused by a blood clot that travels to the lung from a vein in the leg.

4 Post Thrombotic Syndrome (PTS) Chronic complication following a DVT due to venous hypertension and damage or inflammation of the vein. Symptoms occur 6 months to 2 years following a DVT and include: chronic aching pain intractable edema limb heaviness leg ulcers Prevention Measures: Pneumatic Compression Sleeves Exercise Regularly Medication Compliance

5 MEDICAL EMERGENCIES Medical Concern: 10 million global cases reported yearly 3 rd leading vascular disease after myocardial infarction and strokes United States Healthcare yearly cost: $7-10 Billion Rising incidents of DVT and PE due to: increasing aging population, comorbities such as obesity, cancer, and heart failure. Higher incidence in African Americans compared to Caucasians and Asians. Risk does not differ by sex Heritable risk factors: V Leiden Prothrombin gene mutation

6 Risk factors for venous thromboembolism Knowledge of risk factors has increased over the past decades, but over 33% of venous thromboembolism episodes do not have an identifiable provoking factor. Provoked risk factors include: After childbirth After heart attack, heart surgery or stroke After surgery most commonly joint, bone or brain surgery After severe injuries, burns or fracture of hip or thigh During or after long car ride or plane ride Oncology diagnosis (20%) During bed rest or long periods of immobilization (15%)

7 Annual Incidence According to the Centers of Disease Control and Prevention annual incidence: 2 cases per 1000 patients Recurrence rate within 10 years: 33% Mortality rate: 60, ,000 per year Over 50% of patients diagnosed with DVT will have long term complications including postthrombotic syndrome and venous ulcers.

8 Signs and Symptoms of DVT & PE DVT Swelling, usually in one leg (or arm) Leg pain or tenderness Reddish or bluish skin discoloration Leg (or arm) warm to touch Dyspnea PE Angina that gets worse with deep breaths Tachycardia Coughing with expectoration of blood

9 Differential Diagnosis of VTE Muscle Hematoma Muscle or tendon tear Muscle Cramp Superficial Thrombophlebitis Cellulitis Sciatica External Venous Compression What screening tool can physical therapists use if you suspect a patient has a VTE? What diagnostic test is used to rule out a DVT?

10 Wells Clinical Screening Tool

11 Vitamin K Antagonists vs. Novel Oral Anticoagulants Current standard of care for VTE treatment and prevention. low molecular weight heparin vitamin K antagonists What does research say about Vitamin K Antagonists? Warfarin is high maintenance Narrow therapeutic window Numerous Drug Interactions Delayed onset New research suggests the use of Novel Oral Anticoagulants may be more beneficial than Vitamin K Antagonists!

12 Novel Oral Anticoagulants (NOACS) Edoxaban, Apixaban, Dabigatran and Rivaroxaban Apixaban Treatment: associated with the most favorable safety profile. Reduced risk of major or clinically relevant non-major bleeding NOACS are more Predictable! Not impacted by dietary Vitamin K More consistent Pharmacokinetics Fewer drug interactions Quick onset of action Do not require routine coagulation monitoring

13 NOACS Continued Disadvantages: increased cost compared to Vitamin K Antagonists Not approved to use for: Children Patients that are pregnant Patients with mitral valve issues Patients with hepatic disease Advantages: safe and effective for long-term prevention Ease of administration and drug management may enable earlier discharge and outpatient treatment in low-risk patients and alleviate the demands put on emergency-care infrastructures.

14 Novel In-Bed Active Leg Exercise Apparatus DVT prevention exercise machine for increasing venous blood flow. Benefits: increased patient compliance and motivation to exercise compared to performing active ankle exercises. Research Results: Leg Exercise Apparatus (LEX) vs. Active Ankle Exercises Exercise using the LEX increased lower leg venous blood flow and blood vessel diameter more than active ankle exercises.

15 Physical Therapy Takeaways Follow the Clinical Practice Guidelines for VTE Decrease the incidence of VTE Improve diagnosis of LE DVT Ensure compliance with medication management Reduce the long term complications of LE DVT EDUCATE patients and other healthcare professionals

16 References Di Nisio, M., van Es, N., & Büller, H. R. (2016). Deep vein thrombosis and pulmonary embolism. Tanaka, K. et al. (2016). The use of a novel in-bed active Leg Exercise Apparatus (LEX) for increasing venous blood flow. Journal of Rural Medicine Hillegass E, et al. Role of Physical Therapists in the Management of Individuals at Risk for or Diagnosed With Venous Thromboembolism: Evidence-Based Clinical Practice Guideline. February 2016 Cohen, A. T., et al. (2015). Comparison of the novel oral anticoagulants apixaban, dabigatran, edoxaban, and rivaroxaban in the initial and long-term treatment and prevention of venous thromboembolism: systematic review and network metaanalysis.