As a #medicine resident you'll come across 👇🏻 scenario often.
Your #surgery colleagues want you to opine on the type and duration of ANTICOAGULATION and also want to know why it occured in the first place🤷♂️
Let's dig deeper 👇🏻
1/24
#MedTwitter #DVT
Your #surgery colleagues want you to opine on the type and duration of ANTICOAGULATION and also want to know why it occured in the first place🤷♂️
Let's dig deeper 👇🏻
1/24
#MedTwitter #DVT
Yeah, this is obviously a Deep Vein Thrombosis (DVT) !
It's fairly common, develops in about 1/1000 people 😮
Remember, DVT+PE = VTE
PE= pulm embolism
VTE= venous thromboembolism
⭐1/3 DVT develop PE⭐
The PE is what can lead to mortality!
Preventing PE is IMPORTANT 🙏🏻
2/24
It's fairly common, develops in about 1/1000 people 😮
Remember, DVT+PE = VTE
PE= pulm embolism
VTE= venous thromboembolism
⭐1/3 DVT develop PE⭐
The PE is what can lead to mortality!
Preventing PE is IMPORTANT 🙏🏻
2/24
DVT is not less of a monster !
Many w/ DVT will develop post thrombotic syndrome 😮 That's a lot of morbidity, leg pain, swelling, ulceration and all 😭
But
🔸Why does VTE occur ?
🔸Who's at risk of developing it ?
🔸Can we prevent it ?
🔸How does one treat it ?
3/24
Many w/ DVT will develop post thrombotic syndrome 😮 That's a lot of morbidity, leg pain, swelling, ulceration and all 😭
But
🔸Why does VTE occur ?
🔸Who's at risk of developing it ?
🔸Can we prevent it ?
🔸How does one treat it ?
3/24
Before we proceed any further, does anyone recognise 👇🏻 gentleman??
4/24
4/24
Yes, he's Dr Rudolf Carl Virchow, a 🇩🇪 physician/pathologist.
He coined the terms "thrombosis" & "embolism" amongst others!
The first to propose that clots in the lower limbs "embolize" to the lungs, back in 1856.
THE Virchow after whom Virchow nodes are named!
5/24
He coined the terms "thrombosis" & "embolism" amongst others!
The first to propose that clots in the lower limbs "embolize" to the lungs, back in 1856.
THE Virchow after whom Virchow nodes are named!
5/24
Ok, so a clot forms when there's:
1️⃣Bad blood (hypercoag)
2️⃣Bad vessel (vessel wall injury)
3️⃣Lazy blood (stasis)
So, these are the risk factors for VTE:
1. Surgery
2. Immobilization
3. Cancer
4. Pregnancy/post partum
5. Obesity
6. ⤴️Age
7. Bad blood (thrombophilia)
6/24
1️⃣Bad blood (hypercoag)
2️⃣Bad vessel (vessel wall injury)
3️⃣Lazy blood (stasis)
So, these are the risk factors for VTE:
1. Surgery
2. Immobilization
3. Cancer
4. Pregnancy/post partum
5. Obesity
6. ⤴️Age
7. Bad blood (thrombophilia)
6/24
Most of these causes affect >1 of the Virchow triad factors !
As an example, cancer causes stasis + bad blood (cancer procoagulant) + bad vessel 😭
Ok, enough with the history and bad blood etc 🤣
7/24
#MedTwitter
As an example, cancer causes stasis + bad blood (cancer procoagulant) + bad vessel 😭
Ok, enough with the history and bad blood etc 🤣
7/24
#MedTwitter
What does a busy resident need to know 🤷♂️
🔸How to diagnose?
🔸How to treat?
There is something known as the Wells score !! It predicts the PRE-TEST PROBABILITY of DVT but I rarely use it.
So what do I use ?
🔸D-dimer
🔸Compression ultrasound (CUS)
8/24
#MedTwitter
🔸How to diagnose?
🔸How to treat?
There is something known as the Wells score !! It predicts the PRE-TEST PROBABILITY of DVT but I rarely use it.
So what do I use ?
🔸D-dimer
🔸Compression ultrasound (CUS)
8/24
#MedTwitter
The D-dimer is a fibrin degradation product. It is ⤴️ when the body tries to lyse a clot !!
DVT isn't the only cause of an ⤴️D-dimer. It's also ⤴️ in:
🔸Pregnancy
🔸Malignancy
🔸Liver disease
So we can't use D-dimer to diagnose DVT in these conditions !!
#MedTwitter
9/24
DVT isn't the only cause of an ⤴️D-dimer. It's also ⤴️ in:
🔸Pregnancy
🔸Malignancy
🔸Liver disease
So we can't use D-dimer to diagnose DVT in these conditions !!
#MedTwitter
9/24
The D-dimer is NOT SPECIFIC for DVT but it is QUITE SENSITIVE !
What I mean to say is that it can RULE OUT a DVT ✅
Normal D-dimer=⤵️probability of DVT
⬇️
If the D-dimer is ➕ get a compression ultrasound (CUS)
10/24
#MedTwitter
What I mean to say is that it can RULE OUT a DVT ✅
Normal D-dimer=⤵️probability of DVT
⬇️
If the D-dimer is ➕ get a compression ultrasound (CUS)
10/24
#MedTwitter
There are other imaging modalities to diagnose DVT, like CT/MR venography !
But CUS is easy, cheap and accurate.
If a vein doesn't compress when the probe presses on it = thrombus ✅
#MedTwitter
11/24
But CUS is easy, cheap and accurate.
If a vein doesn't compress when the probe presses on it = thrombus ✅
#MedTwitter
11/24
CUS is good for picking up proximal DVT, not so much for distal DVT.
PROXIMAL = above the knee
PROXIMAL = ilio-femoral-popliteal veins
What you need to recognise clinically are the limb threatening signs 😮
Why?
Because, in addition to anticoag you will need to lyse the clot!
PROXIMAL = above the knee
PROXIMAL = ilio-femoral-popliteal veins
What you need to recognise clinically are the limb threatening signs 😮
Why?
Because, in addition to anticoag you will need to lyse the clot!
What are these LIMB THREATENING SIGNS?
🔸Absent pulse
🔸Cyanosis
🔸Gangrene
This is what we call PHELGMASIA CERULEA DOLENS (PCD) 👇
PCD is the ONLY indication of thrombolysis/ thrombectomy.
And catheter directed is always better than systemic thrombolysis 👍🏻
13/24
🔸Absent pulse
🔸Cyanosis
🔸Gangrene
This is what we call PHELGMASIA CERULEA DOLENS (PCD) 👇
PCD is the ONLY indication of thrombolysis/ thrombectomy.
And catheter directed is always better than systemic thrombolysis 👍🏻
13/24
Let's summarise what we've learnt till now !
🔸DVT is bad/morbid
🔸Risk ⤴️ w/ ⤴️age
🔸Hospitalisation/SX is a risk factor
🔸Virchow triad messed up
🔸D-dimer negative = DVT unlikely
🔸CUS is good to pick it up
🔸PCD needs thrombolysis !!
#MedTwitter
14/24 phew 🤣
🔸DVT is bad/morbid
🔸Risk ⤴️ w/ ⤴️age
🔸Hospitalisation/SX is a risk factor
🔸Virchow triad messed up
🔸D-dimer negative = DVT unlikely
🔸CUS is good to pick it up
🔸PCD needs thrombolysis !!
#MedTwitter
14/24 phew 🤣
How do we treat run of the mill DVT ??
ANTICOAGULATION obviously 🤷♂️
But,
🔸Which one ?
🔸For how long ?
For DVT, I can now safely say 👇🏻
⭐NOAC > VKA/Heparin⭐
NOAC include:
🔸ApiXaban
🔸RivaroXaban
🔸EdoXaban
🔸Dabigatran
Xa = Factor Xa inhibitors
#MedTwitter
15/24
ANTICOAGULATION obviously 🤷♂️
But,
🔸Which one ?
🔸For how long ?
For DVT, I can now safely say 👇🏻
⭐NOAC > VKA/Heparin⭐
NOAC include:
🔸ApiXaban
🔸RivaroXaban
🔸EdoXaban
🔸Dabigatran
Xa = Factor Xa inhibitors
#MedTwitter
15/24
Dosing NOACs:
-ApiXAban:10mg BD x 7d➡️5mg BD
-RivaroXaban:15mg BD x 21d➡️20 OD
-EdoXaban: 60mg OD
-Dabigatran: 150mg BD
Can these be used in patients w/ cancer asso. thrombosis ?
YES ✅✅ (avoid in GI malignancies)
No money for NOAC, no problem. Use VKA, monitor INR !!
16/24
-ApiXAban:10mg BD x 7d➡️5mg BD
-RivaroXaban:15mg BD x 21d➡️20 OD
-EdoXaban: 60mg OD
-Dabigatran: 150mg BD
Can these be used in patients w/ cancer asso. thrombosis ?
YES ✅✅ (avoid in GI malignancies)
No money for NOAC, no problem. Use VKA, monitor INR !!
16/24
Next important question 👇🏻
That depends on whether the DVT was provoked or unprovoked ??
Provoked = Risk factor identified
Let's recap the risk factors:
Pregnancy
Surgery
OCP
Long distance travel
Immobilization
Cancer
Obesity
Provoked = 3 months of anticoagulation
Unprovoked = Tricky business 🤷♂️
See 👇🏻
Provoked = Risk factor identified
Let's recap the risk factors:
Pregnancy
Surgery
OCP
Long distance travel
Immobilization
Cancer
Obesity
Provoked = 3 months of anticoagulation
Unprovoked = Tricky business 🤷♂️
See 👇🏻
To answer this we must remember that we need to balance the risk vs benefit of anticoagulation!
Risk=bleeding risk
Benefit=preventing recurrent clots
So who has ⤴️risk of recurrent clots?
-previous h/o VTE
-♂️
-Obese
-thrombophilia✅
May consider longer duration rx here!
19/24
Risk=bleeding risk
Benefit=preventing recurrent clots
So who has ⤴️risk of recurrent clots?
-previous h/o VTE
-♂️
-Obese
-thrombophilia✅
May consider longer duration rx here!
19/24
LONGER DURATION 🤷♂️
What does that even mean ??
ANYTHING >3 MONTHS. Sometimes lifelong, sometimes till there is resolution of the underlying "provoking" factor !!
20/24
#MedTwitter
What does that even mean ??
ANYTHING >3 MONTHS. Sometimes lifelong, sometimes till there is resolution of the underlying "provoking" factor !!
20/24
#MedTwitter
Next question 👇🏻
I've heard so much about these IVC filters, what's all that about ??
I almost never recommend it!
The only indication is:
Acute, proximal leg vein DVT and an ABSOLUTE CONTRAINDICATION to ANTICOAGULATION !
If necessary, place it for the shortest possible time!
I've heard so much about these IVC filters, what's all that about ??
I almost never recommend it!
The only indication is:
Acute, proximal leg vein DVT and an ABSOLUTE CONTRAINDICATION to ANTICOAGULATION !
If necessary, place it for the shortest possible time!
Summary slide for those lazy to read the whole thread 🤷♂️
-DVT is common
-⤴️Risk during hospital stay/SX/🤰
-Normal D-dimer can rule it out
-CUS is a good test, sensitive✅
-DOAC > VKA/heparin
-LWMH = DOAC for cancer asso VTE
-NOAC not safe in pregnancy !
22/24
#MedTwitter
-DVT is common
-⤴️Risk during hospital stay/SX/🤰
-Normal D-dimer can rule it out
-CUS is a good test, sensitive✅
-DOAC > VKA/heparin
-LWMH = DOAC for cancer asso VTE
-NOAC not safe in pregnancy !
22/24
#MedTwitter
The most important point 👇🏻
⭐⭐NOT EVERY DVT NEEDS A FULL THROMBOPHILIA WORKUP ⭐⭐
No factor V Leiden, Protein C/S/AT/APLA et al 🛑
There are a lot of other "provoking" factors like obesity, immobility, smoking, surgery, drugs like OCP. Plz take a detailed history
23/24
⭐⭐NOT EVERY DVT NEEDS A FULL THROMBOPHILIA WORKUP ⭐⭐
No factor V Leiden, Protein C/S/AT/APLA et al 🛑
There are a lot of other "provoking" factors like obesity, immobility, smoking, surgery, drugs like OCP. Plz take a detailed history
23/24
If you have read the whole thread, THANK YOU 💪🏼👍🏻
If you have read just the summary slides, I still THANK YOU 🤣
Share, retweet if you found this useful !
24/24 🙏🏻
#MedTwitter
If you have read just the summary slides, I still THANK YOU 🤣
Share, retweet if you found this useful !
24/24 🙏🏻
#MedTwitter
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