Venous thromboembolism (including ...

Venous thromboembolism (including knotty venous thrombosis [DVT] and pulmonary embolism) is the third greatest in quantity common vascular condition, exceeded merely by coronary artery disease and affliction For approximately the past 10 years, the initial treatment for DVT has consisted of heparin plus oral anticoagulation for at least five days. Heparin is discontinued when the anticoagulant has maintained an International Normalized Ratio of 20 to 30 for brace consecutive days. Because low-molecular-weight heparin therapy can be provided at residence hospitalization is no longer required. However, outpatient therapy raises safety affairs Douketis reviewed the literature to identify any subgroup of patients with DVT who should be hospitalized for treatment.

The author's search of electronic databases identified 17 clinical studies of outpatient therapy for DVT Seven of the studies were randomized controll trials and 10 trials were not randomized.

Among the patients who received adequate anticoagulation, 3 to 5 percent discloseed recurrent thromboembolism. The rates of major bleeding during the first three month of treatment were 3 to 5 percent The case-fatality rate in patients with renewed venous thromboembolism is 5 percent

The author identified four risks of criteria for determining if patients should be considered for hospital admission (see accompanying table): (1) does the patient have massive DVT?; (2) does the patient have objectively confirmed symptomatic pulmonary embolism?; (3) is the patient at high risk of anticoagulant-related bleeding complications?; and (4) does the patient have major comorbidity or other factors that might require hospitalization?

Massive DVT is characterized according to severe pain, swelling of the entire limb, acrocyanosis, and ultrasonic findings of involvement of the iliofemoral vein section and/or inferior vena cava. These patients require aggressive pain reign over and may require prolonged use of heparin or unconventional anticoagulation. Patients with iliofemoral DVT who are not treated aggressively are more than twice as likely to expand thrombosis than patients with les methodical DVT (11.2 compared with 53 percent)

Approximately 10 percent of patients with DVT also have symptomatic pulmonary embolism. any studies suggest that hemodynamically stable patients who did not require parenteral analgesia and had oxygen saturations greater than 95 percent forward room air can be treated at household despite evidence of pulmonary embolism. Until further evidence is provided, patients with DVT and symptomatic pulmonary embolism should receive in-hospital anticoagulant therapy for at least the initial pair to three days of treatment.

Between 5 and 10 percent of patients with lately diagnosed DVT have an increased risk of bleeding during anticoagulation. This dispose includes patients with metastatic cancer, gastrointestinal bleeding conditions, coagulation disorders or thrombocytopenia, and patients who have had modern surgery or trauma. Patients in this form into groups require intensive monitoring and quick intervention for those in whom bleeding come into views Hospitalization is required for patients with serious comorbidities and/or limited capacity for domestic circle care.

The author bring to an ends that four criteria can be used to determine if patients with DVT should be considered for in-hospital treatment.

Criteria for Assessing Appropriateness of Outpatient Treatment of DVT *

Does the patient have massive DVT?

Swelling of entire lower limb

Acrocyanosis

Venous limb ischemia

Extension of DVT into iliofemoral veins or inferior vena cava

Does the patient have symptomatic pulmonary embolism?

Requirement for supplemental oxygen or other supportive care

At risk for cardiorespiratory deterioration

Is the patient at high risk for anticoagulant-related bleeding?

Active bleeding (eg active gastrointestinal bleeding source)

new (within four weeks) bleeding episode (eg peptic fester disease)

Recent (within united week) surgery or trauma

Thrombocytopenia (platelet estimate < 100 3 [10.sup.6] through L)

Coagulopathy (INR > 14 or activated PTT > 40 seconds)

Advanced cancer with intracerebral or intrahepatic metastases

Does the patient have major comorbidity or other factors that warrant in-hospital care?

simple pain or discomfort related to DVT that warrants parenteral analgesia

Major comorbidity (eg advanced cancer) that requires in-hospital care

Cognitive impairment or language barrier that obviates outpatient care

Impaired mobility that hinders outpatient visits or laboratory monitoring of anticoagulant activity

DVT = profound venous thrombosis; INR = International Normalized Ratio; PTT = partial thromboplastin time.

*--Presence of undivided or more criteria suggests ne for in-hospital care.

Adapted with permission from Douketis JD Treatment of down-reaching vein thrombosis. What factors determine appropriate treatment? Can Fam Physician 2005;51:220

ANNE D WALLING, MD

Douketis JD Treatment of penetrating vein thrombosis. What factors determine appropriate treatment? Can Fam Physician February 2005;51:217-23

COPYRIGHT 2005 American Academy of Family Physicians

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