How long to continue anticoagulation after DVT?

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1 How long to continue anticoagulation after DVT? Dr. Nihar Ranjan Pradhan M.S., DNB (Vascular Surgery), FVES(UK) Consultant Vascular Surgeon Apollo Hospital, Jubilee Hills, Hyderabad (Formerly Faculty in vascular surgery at CMC Hospital,Vellore, NIMS-Hyderabad) Mobile : drniharpradhan@yahoo.co.in

2 VTE DVT and PE are a single clinical entity Risk of early death in DVT + PE is 18 X higher than in DVT alone ¼ of PE cases present with sudden death Other predictors of poor survival in DVT are older age, male gender, confinement to hospital, CHF, chronic lung disease, neurological disease and active malignancy.

3 PE Predictors of poor survival in PE: Syncope Arterial hypotension Right sided HF ( clinically or by plasma markers levels or echocardiography) These should receive aggressive anticoagulation +/thrombolytic therapy.

4 Long Term Complications of VTE Recurrence PTS

5 Complications of VTE 1. Recurrence Prandoni et al found the risk after cessation of anticoagulation 24.8% at 5 years and 30.3% at 8

6 14. Ref: Schulman S et al. The duration of oral anticoagulant therapy after a second episode of venous thromboembolism. The Duration of Anticoagulation Trial Study Group. N Engl J Med 1997;336:393-8 Short-term primary prevention of deep vein thrombosis/pulmonary embolism with anticoagulant therapy is today common practice for patients undergoing orthopaedic surgical procedures. Patients with confirmed deep vein thrombosis, irrespective of the underlying cause, typically receive anticoagulant treatment for 3 to 6 months, depending on the location of the thrombosis and on other risk factors that the patient may have. For pulmonary embolism the duration of treatment is often 6 months. However, the optimal length of therapy is the subject of debate. Patients are at increased risk of suffering from a new episode of venous thromboembolism once anticoagulant therapy is completed. The next embolus may well prove to be fatal. There is a marked difference in the cumulative probability of a new episode of venous thromboembolism between the patients receiving indefinite treatment and those in the 6-month group.

7 Complications of VTE Risk of recurrence increased with Male gender Increased age Increased BMI Neurological disease Paresis Active malignancy Idiopathic VTE APS Prt C,S and AT deficiency Persistent residual DVT Consider prolonged prophylaxis in the above

8 Complications of VTE Factors not predictive of recurrence: VTE in pregnancy, CCP and gynecological surgery Recent surgery, trauma or fracture. Recent immobilzation Hormonal therapy (Tamoxifen) Failed prophylaxis Distal DVT, deep muscular DVT Short term oral anticoagulation considered

9 Recurrent PE Risk of 7 day case mortality is significantly higher (34%) in recurrent PE, compared to recurrent DVT(4%) alone Consider prolonged anticoagulation, especially if compromised cardiopulmonary functions

10 Complications of DVT 2- Post- thrombotic syndrome Develops in 20-30% of DVT Valvular damage or scarring leading to incompetence / residual venous obstruction due to incomplete clearance Systemic thrombolytic therapy wasn t found to reduce incidence of PTS. Catheter- directed thrombolysis may hold potential but not recommended routinely.

11 Complications of DVT Risk factors for PTS Inadequate initial anticoagulation Recurrent DVT Higher BMI Distal vein thrombosis Recently, persistently elevated D- dimers Not impact for long term anticoagulation.

12 16. Post-thrombotic syndrome; leg ulcer Considerable numbers of patients suffer from post-thrombotic syndromes with, in severe cases, leg ulcers. Venous thromboembolism is an underestimated disease with huge socio-economic implications.

13 Management of VTE Aim of Management: Initially : to prevent propagation of thrombus Chronic anticoagulation to allow fibrinolysis and recanalization.

14 Management of VTE Heparin / LMH immediately and for at least 5 days VKA started on the 2nd day Newer oral anticoagulants Failure to achieve optimum treatment early on leads to recurrence rates of 20 %

15 Haemostasis: generation of thrombin and clot formation

16 Indirect thrombin inhibition Heparin/antithrombin/thrombin complex Thrombin Antithrombin Heparin

17 Clinical Assessment for DVT Suitable for Outpatient Management Yes No DVT confirmed Yes Patient analgesia Support stocking Medical assessment Need for medical follow- up Refer to hemostasis nurse Anticoagulant treatment Liaise with general practitioner No

18 Imberti et al, 2006 Journal of Thrombosis & Haemostasis

19 Duration of Anticoagulation Plan designed clearly for each patient individually at the start of anticoagulation

20 Long-term treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE)* Patient categories Dru Duration g (months) Comments First episode of DVT or PE secondary to a transient (reversible) risk factor VK/ 3 ne w Recommendation applies to both proximal and calf vein thrombosis First episode of idiopathic DVT or PE VK/ 6 12 ne w Continuation of anticoagulant therapy after 6 12 months may be considered First episode of DVT or PE and cancer LM 3 6 WH Continuation of LMWH is recommended indefinitely or until the cancer is resolved First episode of DVT or PE with a documented thrombophilic abnormality VK/ 6 12 ne w Continuation of anticoagulant therapy after 6 12 months may be considered First episode of DVT or PE with documented antiphospholipid antibodies or two or more thrombophilic abnormalities VK/ 12 ne w Continuation of anticoagulant therapy after 12 months may be considered VKA, vitamin K antagonist; LMWH, low molecular weight heparin., newer oral anticoagulant *Based on the Seventh ACCP Conference document (13).

21 Duration of Thromboprophylaxis Indefinite anticoagulation recommended Two or more spontaneous thromboses One spontaneous thrombosis in case of AT deficiency or the APS One life- threatening thrombosis One spontaneous thrombosis at an unusual site One spontaneous thrombosis in the presence of multiple genetic thrombophilia defects