A 55-year-old male needs treatment for venous thromboembolic disease.
What is the loading dose of unfractionated heparin to be administered if his weight is 75kg?
Correct Answer E:
Initial DVT treatment with unfractionated heparin (UFH):
You are treating a 53-year-old female for a deep-vein thrombosis in her left leg.
The use of compression stockings for this problem has been shown to:
Correct Answer D:
Post-thrombotic syndrome (PTS) is a complication of acute deep-vein thrombosis (DVT), and is characterized by chronic pain, swelling, and skin changes in the affected limb. Within 5 years of experiencing a DVT, one in three patients will develop PTS. A Cochrane review identified three randomized, controlled trials examining the use of compression therapy in patients diagnosed with a new DVT. The use of elastic compression stockings was associated with a highly statistically significant reduction in the incidence of PTS, with an odds ratio of 0.31 (confidence interval of 0.20-0.48). A separate trial cited in the Cochrane review documented no increased incidence of pulmonary embolism, and a reduction in pain and swelling in the treatment group. The studies did not examine the rates of recurrent DVT. Compression stockings should be started after anticoagulant therapy, within two weeks of the diagnosis, and continued for two years.
A 30-year-old female who had a deep venous thrombosis in her left leg during pregnancy has an uneventful delivery. During the pregnancy she was treated with low molecular weight heparin. Just after delivery her left leg is pain free and is not swollen. She plans to resume normal activities soon.
Which one of the following would be most appropriate with regard to anti-coagulation?
Correct Answer C:
The risk of pulmonary embolism continues in the postpartum period, and may actually increase during that time. For patients who have had a deep-vein thrombosis during pregnancy, treatment should be continued for 6 weeks after delivery, with either warfarin or low molecular weight heparin.
Risk factors for venous thromboembolism include which one of the following?
There are many risk factors for thromboembolism, including polycythemia vera, oral contraceptive use, obesity, advanced age, and spinal cord injury. Spinal cord injury induces immobility, as do obesity and advanced age. Oral contraceptives make blood more coagulable, particularly in patients with clotting factor abnormalities such as factor V Leiden. Polycythemia vera increases sludging of blood cells and increases the risk of forming clots. Clot risk is not increased by oral hypoglycemic agents, low BMI, youth, or anemia.
A 45-year-old woman comes to you after an episode of calf pain that began after arriving from a 16 hour flight. She is a non-smoker with no relevant personal or family history, and takes no medications. Her vital signs are stable and you find an area of erythema and induration on the affected leg. After a Doppler venous study of the lower limb you confirm the diagnosis of Deep Venous Thrombosis.
What would be the preferred management in this patient?
When any of the following is present, a patient should be managed on inpatient basis:
Patients who have none of the mentioned criteria (as in this patient) are safe to be managed in the outpatient setting.
Low Molecular Weight Heparin, rather than Warfarin alone or Unfractionated Heparin, is the preferred initial agent for the outpatient management of Deep Venous Thrombosis. Warfarin should be started at the same time with Low Molecular Weight Heparin when not contraindicated. Compression stockings are recommended for at least 1 year in symptomatic DVT for the prevention of post-thrombotic syndrome.
→ This patient has no indications for inpatient management (choices A, B, and C). Her management should include Low Molecular Weight Heparin, Warfarin and Compression Stocks. Compression stockings are recommended for at least 1 year in symptomatic DVT for the prevention of post-thrombotic syndrome.
Key point:
It is important to know when a patient with DVT can be managed in the outpatient setting. It is also important to consider the use of compression stockings (additional to the treatment with LMWH and warfarin) to prevent post-thrombotic syndrome.
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