MANAGEMENT OF PATIENTS WITH DEEP VEIN THROMBOSIS (DVT) IN THE COMMUNITY SETTING & ANTICOAGULATION CLINICS THE PAST, PRESENT AND THE FUTURE Dr. Riaz JanMohamed Consultant Haematologist The Hillingdon Hospital Foundation Trust
Acute deep vein thrombosis It has an incidence of which most studies place at around 1:1000patients per year, the incidence increasing with age (Winter et al, 2005). Pulmonary embolism, which is now generally regarded as part of the same spectrum of disease, occurs at about half this frequency (Booth, F 2003).
RISK FACTORS FOR DVT Recent surgery Recent injury or trauma Previous DVT Recent immobility (> 24 hours) Long haul air flight Obesity or excess weight Oestrogen therapy Underlying malignant disease Family history thrombosis Known prothrombotic tendency.
Common Presenting Features Pain or tenderness of the leg Swelling of calf or leg Pitting oedema Palpable venous thrombosis Increased temperature in the leg Fever Discoloration or erythema of the leg Venous distension
SUITABILITY for COMMUNITY BASED OUTPATIENT MANAGEMENT FOR DVT. Patients with a calf vein DVT. Patients with a proximal DVT (above popliteal vein and into the femoral vein) that is not compromising the leg, and which is not associated with pulmonary embolus. Patients who are able to understand the instructions for anticoagulation or who have carers who can manage this for them
D Dimer testing D Dimers are a specific breakdown product of cross linked fibrin, released during clot dissolution or fibrinolysis. Receiver operating characteristic (ROC) curves are used in medicine to determine a cut off value for a clinical test. For example, the cut off value of 250mg/L has been determined for the D Dimer test. Patients with D Dimers less than 250mg/L are unlikely to have venous thrombosis. (98% confidence.) Patients with D Dimers >250 mg/l may have venous thrombosis specificity is 39.4%
Clinical Probability Scoring Tool (Wells, 1998). Paralysis, paresis, or recent orthopaedic casting of a lower extremity Recently bedridden for longer than three days or major surgery within the past four weeks Localized tenderness in the deep vein system +1 Swelling of an entire leg +1 Calf swelling 3 cm greater that the other leg, measured 10 cm below the tibial tuberosity Pitting edema greater in the symptomatic leg +1 Collateral non-varicose superficial veins +1 Active cancer or cancer treated within six months +1 Previously documented DVT +1 Alternative diagnosis more likely than DVT -2 +1 +1 +1 TOTAL HIGH= >3 MODERATE= 1-2 LOW= 0
TREATMENT FOR DVT Low molecular weight heparin until INR therapeutic Oral anticogulation with warfarin INR 2 3 6 weeks for provoked (surgical DVT) 12 weeks for unprovoked (medical DVT) 26 weeks for proximal DVT/PE
CONTRA INDICATIONS for MANAGEMENT of DVT IN THE COMMUNITY SETTING Patients with a thrombus extending ABOVE the femoral vein Patients presenting with pulmonary embolus Patients with risk factors for anticoagulation therapy, i.e. patients with a known history of bleeding disorders Patients who are totally immobile which precludes ambulatory care at home Patients with other medical conditions necessitating admission
Factor Higher risk of recurrence Lower risk of recurrence Cause of 1 st VTE Idiopathic Transient (e.g. surgery) Thrombophilia Present Absent Malignancy Present Absent Gender Male Female Race Caucasian Hispanic/ African American Site of thrombosis Iliofemoral Femoral/ popliteal Residual thrombosis Present Absent Quality of Poor Good anticoagulant control (especially INR <1.5) D-dimer Raised Within reference range APTT Shortened Within reference range Thrombin generation Peak >400nm Peak <400nm Hormonal status 1 st VTE not related to altered hormonal status 1 st VTE related to OCP, pregnancy, HRT.
. Hirsh J, Hoak J Circulation 1996;93:2212-2245 Copyright American Heart Association
Average Age of Patients Attending The Clinics Year Mean Age (Female) Mean Age (Male) Mean Age (Unknown) 2007 71.7 69.6 67.5 2008 72.6 70.4 69.2 2009 72.6 70.6 70.3 2010 73.6 71.5 71.2 2011 73.8 71.8 72.3
2007 2011 2016
Incidence rates of atrial fibrillation by age and gender (100,000 person-years) 2007 2011 2016
Number of Patients attending the anticoagulation clinics at The Hillingdon Female Male Unknown Total % increase in a year 2007 401 537 70 1008 2008 473 644 104 1221 20 2009 564 758 126 1448 18 2010 657 898 132 1687 18 2011 831 1121 143 2095 24 From 2007 to 2011 number of patients attending anticoagulation clinics have doubled!!!!!!!!
Numbers and Diagnosis of Patients Attending Anticoagulation Clinic Diagnosis 2007 2008 2009 2010 2011 TOTAL PTS 1008 1221 1448 1687 2095 AF 630 782 918 1072 1328 62% 64% 63% 63% 63% PE 14 23 28 35 73 1.3% 1.8% 1.9% 2.0% 3.4% Rec PE 73 83 117 137 153 1.3% 1.8% 8.0% 8.1% 7.3% DVT 34 38 42 54 76 3.3% 3.1% 2.9% 3.2% 3.4% Rec DVT 72 81 112 131 148 7.1% 6.6% 7.7% 7.7% 7.0%
Clotting Cascade AJHP 2004;61:S7.
Why new drugs? Warfarin is underused in pts who need it most: Only 47% of patients with afib are taking warfarin This is often due to hemorrhagic contraindications Convenience issues due to the need for frequent monitoring Difficulty in maintaining optimal anticoagulation
IDEAL ANTICOAGULANT Effective (Superior to Warfarin) Fixed dose Wide therapeutic range Acceptable bleeding risks No need for monitoring No drug interactions No dietary restrictions No side effects Once or max twice daily Reversible Cheap
Emerging Therapies Am J Health Syst Pharm;65:1520
Some of the newer anticoagulants on the market awaiting NICE approval Drug Dabagatran Rivaroxaban Apixaban Target Thrombin Xa Xa Extended prophylaxis yes yes Yes DVT No Yes No AF Side effects Renal excretion Superior to Warfarin Indigestion Increased minor GI bleeding MI Equivalent to Warfarin Increased minor GI bleeding 80% 66% 25% Superior to Warfarin Less major and minor bleeding Monitoring LFTs None None Frequency bd od bd Antidote No No No
Who should receive the newer anticoagulants Patients on short term anticoagulation Bridging, Non valvular AF for cardioversion, Distal DVT Unstable patients Not able to maintain INR in therapeutic range Those unable to attend for monitoring travelling Warfarin resistance/side effects (alopecia/rash) OR EVERYBODY???? AWAIT NICE GUIDELINES!!!!!
THANK YOU FOR YOUR ATTENTION ANY QUESTIONS???