SMALL FEEDINGS IN VENOUS THROMBOEMBOLISM ACP CHAPTER MEETING TURF VALLEY, FEBRUARY, 2012 Daniel J. Brotman, MD, FACP, FHM Director, Hospitalist Program, Johns Hopkins Hospital Associate Professor of Medicine
Case-based topics to touch on Beware of devices that sit in veins. Asymptomatic PE management conundrum. nd Should we be testing for hypercoagulability?
30 y/o M with paraplegia History of MVA 6 months prior to admission Bilateral DVTs IVC Filter bilateral iliac vein stents. Admitted now for bilateral lower extremity swelling
IVC Filters Show of Hands What percent of your patients with pulmonary embolism get IVC filters? (a) > 40% (b) 15-40% (c) 5-15% (d) <5%
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Clinical course Recurrent thromboses of iliac venous stents, anticoagulation failure, repeat catheter directed attempts at thrombolysis No intervention ti with IVC filter or the stents **Beware of venous stents** IVC filters don t always stay where they are supposed to
Indications for IVC filter -Acute VTE plus contraindication to anticoagulation (including patients t who need surgery with recent VTE) --Ethically impossible to study in randomized fashion - Failed antithrombotic therapy (eg, clinically fragile patient with suspected ongoing emboli despite anticoagulation-- I ve never recommended this; if that fragile, consider thrombolysis.)
Possible indications for filters (show of hands )?Bariatric surgery??trauma patients??massive/submassive PE? Try to avoid in patients with catastrophic thrombophilia (eg, bad antiphospholipid antibody syndrome)
Retrievable versus Permanent IVC filter? Is the contraindication to anticoagulation likely to be permanent, recurrent, or temporary? Is patient likely to return for a 2 nd procedure, and do you want the patient to have a 2 nd procedure?
J Hosp Med. 2009 Sep;4(7):441-8. Retrievable vena cava filters: a clinical review. Tschoe M, Kim HS, Brotman DJ, Streiff MB.
Do retrievable filters have to be removed? NO So why not put them in everybody who needs a filter? That may be where we re heading
Temporary filters vs permanent filters Permanent Temporary Cheaper (now minimal) Avoid a 2 nd procedure Tried and True (more evidence suggests comparable efficacy / safety) Can remove a potentially thrombogenic device from the patient s body Will you need to put one back in??
Retrievable Filter? Often retrievable filters are never removed: Anticoagulation contraindication persists A 2 nd procedure (with dye) is needed Loss of follow-up o Patient preference Thrombus present in IVC at angio Failed attempt at removal
Do patients with IVC filters need lifelong l anticoagulation? Answer: Need to individualize NO?: Systematic review (Ray CE, Jr., (Ray CE, Jr., Prochazka A; The need for anticoagulation following inferior vena cava filter placement: systematic review. Cardiovasc Intervent Radiol. 2008;31:316-324.) 324.) YES?: Mainly a conceptual argument: Patients t who get filters usually have had thrombosis DeCousus data: 2-fold increased risk for DVT BUT: other factors have similar relative risk for recurrence: Male sex, Residual thrombus.
Switching gears Incidental PE
70 y/o M with bladder cancer resection, recent ankle fracture, ongoing chemotherapy Routine abdominal film for follow-up
Incidental pulmonary embolism
Incidental PE Real risk factors Asymptomatic Radiographically unambiguous Should there be any discussion about anticoagulation?
Paraphrasing this (articulate) patient: So doc. Let me get this right. I just happened to come in for a CT scan to follow-up on my cancer. The scan shows a clot in my lung. And now you want to put me on blood thinning treatment for 6 months, and perhaps lifelong??? l What would have happened had I never had the scan???
Answer to patient: 2 Possibilities: We might have been blissfully unaware of your pulmonary embolism and you would have done fine without treatment OR You d get symptoms and we d either find out in time to save you from serious consequences or you d be one of the unfortunate (approximately 1/6 th ) of patients who dies of PE without making it to the hospital
The decision: Standard anticoagulant treatment: Who is comfortable with outpatient treatment with enoxaparin (or an alternate LMWH heparin)?? Who would keep him in the hospital?? I discharged him home on enoxaparin that day Should it matter if the patient t is symptomatic??
What happened: Phone call 2 days later: Doc I ve got this pain in my chest, on the right side, and a new cough I m coughing up small flecks of blood What would you ask him? Not short of breath Not tachycardic What would you do?
Well I guess we made the right call in deciding to anticoagulate you. Let s hold the course.
Another patient 79 y/o F with advanced COPD and SCC of supraglottis and associated dysphagia/aspiration Also with big AAA Admitted d for pneumonia Then got PEG/trach in preparation for chemo-xrt Post-op still op still with ronchi/wheezing
House officer decides risk of PE high enough to justify CT: Do you agree? Is a CT warranted?
Proximal PAs looked good
Assess for thrombus burden: Negative duplex of bilateral lower extremities
Anticoagulate? Show of hands YES? High risk for morbidity; sick cancer patient NO? Least of her worries; bigger fish to fry; incidental finding
Decision: Hard to say no Standard of care conundrum; bad COPD; fragile But: can argue for serial US (thrombus burden assessment) if risks of anticoagulation are deemed to be substantial Are small PEs a fact of life? THIS IS A STUDY THAT NEEDS TO BE DONE
Aneurysm (3mo progression) 7cm 8.5cm 10.5cm
JAMA, 2007, Anderson et al:
Results: 701 patients were randomized to CTPA and 716 to V/Q scanning. Of these, 133 patients (19.2%) in the CTPA group vs 101 (14.2%) in the VQ scan group were diagnosed as having pulmonary embolism in the initial evaluation period and were treated t with anticoagulant therapy. (P <0.01) Clinical outcomes were comparable in patients treated and in those not treated in both groups
Interpretation Approx 20% of CTs positive Approx 15% of VQs positive Reliance on CT 1/3 more PE diagnoses, 1/3 more anticoagulated patients; similar outcomes Further research is required to determine whether all pulmonary emboli detected by CTPA should be managed with anticoagulant t therapy.
JTH, 2010, Carrier et al:
Meta-analysis analysis of 2 RCTs plus 20 prospective cohorts Concept: Better CT scanners more ISOLATED subsegmental PEs diagnosed 2657 PEs, all received ed anticoagulation at o Single-detector CTs: 4.7% of PE patients with isolated subsegmental PE Multi-detector CTs: 9.4% Approx 5% under- (or over)-diagnosis
3 Month VTE rates among those with suspected PE who were ruled out 0.9% (0.4-1.4) for single-detector 1.1% 11%(07-1 (0.7 14)formulti-detector 1.4) Inferential conclusion: The PEs not diagnosed by single-detector CTs did not increase rates of recurrence in the single- detector group (if, say, 20% of those 5% with undiagnosed subsegmental PEs in the single-detector group had recurrence, there would have been about a 2% recurrence rate rather than 1%)
Changing gears once more THROMBOPHILIA TESTING
To test or not to test? A 53 year-old man with a history of treated HTN and GERD is admitted to your service with an acute right leg DVT (diagnosed after he came to the ED for acute pain and swelling; occlusive, up to iliac). Enjoys jogging g and swimming No recent surgeries, illnesses, or trauma. Travels for business (in USA only), last flight 6 weeks ago. No bleeding history. No FH of VTE. Up-to-date, age-appropriate appropriate CA screening
Should you test for thrombophilia? FVL Prothrombin gene 20210A mutation Antiphospholipid antibodies drvvt aptt with mixing i Cardiolipin abs Anti-β2-Glycoprotein
Show of Hands Test for thrombophilia Don t test for thrombophilia Key question: Will it change management of this patient??
Predictive value of factor V Leiden and prothrombin G20210A in adults with venous thromboembolism and in family members of those with a mutation: a systematic review. Segal JB, Brotman DJ, Necochea AJ, Emadi A, Samal L, Wilson LM, Crim MT, Bass EB. JAMA.. 2009 Jun 17;301(23):2472-85. Background: Population-based studies demonstrate a consistently elevated risk for first VTE among those who carry these mutations Question: Does the same apply to recurrent VTE
FVL Heterozygotes (OR 1.56)
FVL Homozygotes OR = 2.65
Prothrombin mutation heterozygotes
Asymptomatic family members: 3.4 for heterozygotes, 17.8 for homozygotes
Idiopathic events
So what s going g on? The stronger the precipitant, the less likely there is to be an underlying thrombophilia About 70% of patients with multiple long-bone fractures get VTE (how many of them have bad hypercoagulability?) With no precipitant, p there MUST be something wrong with the patient s blood (even if we can t find it)
Hypercoagulability Intrinsic (Mutations, APLA, Undiagnosed risk factors; TEMPORALLY STATIC) Extrinsic (Trauma, illness, cancer, hormones TEMPORALLY VARIABLE) THROMBUS
Postoperative VTE Intrinsic Extrinsic THROMBUS
Postoperative VTE (FVL may push you over the edge) Intrinsic (FV Leiden) Extrinsic THROMBUS
Idiopathic VTE THROMBUS Intrinsic i Extrinsic
Idiopathic VTE THROMBUS Intrinsic i Extrinsic (FV Leiden + SOMETHING ELSE)
Idiopathic VTE THROMBUS Intrinsic i Extrinsic (SOMETHING ELSE)
QUESTIONS/COMMENTS?