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R20 Respirology
Pulmonary Vascular Disease Toronto Notes 2019
• long-termanticoagulation
■ for most non-pregnant patients who do not have renal insufficiency or active cancer, first-line is
direct oral anticoagulants (rivaroxaban, apixaban, edoxaban, or dabigatran) rather than warfarin ■ warfarin: start the same day as LMWH/heparin – overlap warfarin with LMWH/heparin for at
least 5 d and until INR in target range of 2-3 for at least 2 d (use for patients with severe renal
insufficiency)
■ LMWH instead of warfarin for pregnancy, active cancer, or high bleeding risk patients
• IVthrombolytictherapy
■ if patient has massive PE (hypotension or clinical right heart failure) and no contraindications
■ hastens resolution of PE but may not improve survival or long-term outcome and doubles risk of
major bleeding
• interventionalthrombolytictherapy
■ massive PE may be treated with catheter-directed thrombolysis by an interventional radiologist
■ catheter-directed thrombolysis is not recommended over systemic thrombolysis
• IVCfilter:onlyifrecentproximalDVT+absolutecontraindicationtoanticoagulation • durationoflong-termanticoagulation:individualized,howevergenerally
■ if reversible cause for PE (surgery, injury, pregnancy, etc.): 3-6 mo
■ if PE unprovoked: 6 mo to indefinite
■ if ongoing major risk factor (active cancer, antiphospholipid antibody, etc.): indefinite
Thromboprophylaxis
• mandatoryformosthospitalpatients:reducesDVT,PE,all-causemortality,cost-effective
• start ASAP
• continueatleastuntildischargeorrecommendextendingfor35dpost-operatively,ifmajororthopedic
surgery
Table 22. VTE Risk Categories and Prophylaxis (see Hematology, H35)
Workup for Idiopathic VTE
Thrombophilia Workup: recurrent or idiopathic DVT/PE, age <50, FHx, unusual location, massive
Malignancy Workup: 12% of patients with idiopathic VTE will have a malignancy
The Use of Unfractionated Heparin Should Be Limited to:
• Patients with severe renal dysfunction (CrCl
<30 ml/min) in whom LMWH and novel
oral anticoagulation should be avoided
• Patients at elevated risk of bleeding that
may need rapid reversal of anticoagulation
• Patients who receive thrombolytic therapy
Extended Use of Dabigatran, Warfarin or Placebo in Venous Thromboembolism
NEJM2013;368:709-718
Study: Two double blind, RCTs; one comparing against placebo, the other against active treatment.
Population: 4,199 patients (2,856 in active-control study, 1,343 in placebo-control study) with VTE who had completed at least 3 mo of therapy.
Intervention: In the active-control study, patients randomized to either 150 mg dabigatran or warfarin (INR 2.0-3.0). Patients in the placebo-control study received either 150 mg dabigatran or placebo.
Outcome: Recurrence of VTE, risk of major or clinically relevant bleed.
Results: In the active-control study, there was a hazard ratio (HR) of 1.44 (95% Cl 0.78-2.64 for non-inferiority) of recurrent VTE with dabigatran vs. warfarin. HR of major or clinically relevant bleed was 0.54 (95% Cl 0.41-0.71). In the placebo-control study, the HR of VTE with dabigatran vs. placebo was 0.08 (95% Cl 0.02-0.25). HR of major or clinically relevant bleed was 2.92 (95% Cl 1.52-5.60). Conclusions: Dabigatran appears to be non-inferior to warfarin in the prevention of VTE recurrence. Dabigatran is associated with a lower risk of major or clinically relevant bleed than warfarin, but greater than placebo.
Risk Group
Low Thrombosis Risk
Medical patients: fully mobile
Surgery: <30 min, fully mobile
Moderate Thrombosis Risk
Most general, gynecologic, urologic surgery Sick medical patients
High Thrombosis Risk
Arthoplasty, hip fracture surgery Major trauma, spinal cord injury
High Bleeding Risk
Neurosurgery, intracranial bleed Active bleeding
Prophylaxis Options
No specific prophylaxis Frequent ambulation
LMWH
Low dose unfractionated heparin Fondaparinux
LMWH
Fondaparinux
Warfarin (INR 2-3)
Dabigatran
Apixaban
Rivaroxaban
Low dose unfractionated heparin
TED stockings, pneumatic compression devices
LMWH or low dose heparin when bleeding risk decreases