Mortality from venous thromboemboli...

Mortality from venous thromboembolic disease has decreased significantly in the past 10 to 20 years. (1) Increased survival may be suitable to better diagnostic strategies, improved recognition of risk factors, and better treatment guidelines. In the past decade, a great deal has been learned about the part of inherited and acquired thrombophilias as risk factors for venous thromboembolic disease. Although treatment of venous thromboembolism remains primarily supportive, there have been refinements in the intensity and duration of anticoagulation regimens for various therapeutic and preventive clinical situations.

Part I (2) of this two-part article addressed the diagnosis of sagacious venous thrombosis (DVT) and pulmonary embolism (PE) Part II discusses the evaluation for thrombophilias and other secondary causes of venous thromboembolic disease, quick in emergenciess an evidence-based approach to the treatment of DVT and PE and reviews instant recommendations for prevention of venous thromboembolism.

Evaluation for Thrombophilias and Other Secondary Causes

The evaluation for apparent venous thromboembolism begins with a careful history and physical examination. Attention should be given to important risk factors, including previous venous thromboembolism, modern trauma or immobilization, malignancy, use of estrogenic medications, and pregnancy. Multiple spontaneous miscarriages also may indicate underlying thrombogenic conditions.

The basic laboratory evaluation includes a unimpaired blood count, platelet count, prothrombin time, activated partial thromboplastin time (APTT), and comprehensive metabolic panel to expect for electrolyte, renal, or hepatic abnormalities. If an evaluation for thrombophilias is being considered, vital current should be set aside for screening proofs before treatment with heparin and warfarin is initiated.

With the discovery that frequent thrombophilias are risk factors for venous thromboembolism, the question of when to launch an investigation has been raised. The combined prevalence of inherited thrombophilias and hyperhomocysteinemia is about 50 percent in all patients with DVT and PE (3) Unfortunately, not all studies included a hinder group; therefore, it is difficult to establish a reliable estimate of the prevalence of thrombophilias in asymptomatic ones Because of the lack of prospective studies, there is no clear evidence to guide the decision about when to evaluate patients for thrombophilias. The cost-effectiveness of the evaluation is a concern

Based upon a review of the literature, single investigator (3) proposed the following strategy: patients older than 50 years with an idiopathic first episode of venous thromboembolism and no family history should be considered "weakly thrombophilic" and should pass through a limited investigation (Table 1) (3) Patients with an idiopathic episode of venous thromboembolism who are younger than 50 years, patients with intermittent thrombosis, and patients with a family history of venous thromboembolism should be considered "strongly thrombophilic" and should be exposed to a more extensive evaluation for thrombophilias. Patients with a first episode of thromboembolism, a clear risk factor for a first episode of venous thromboembolism, (eg trauma, immobilization), and no family history of thromboembolism require no work-up for thrombophilias.3Most patients with venous thromboembolic disease and a genetic or unchangeable thrombophilia should receive lifetime anticoagulation. (3)

There is no clear evidence that screening all or uniform selected patients for thrombophilias improves long-term issues Until such evidence becomes available, the above guidelines, the physician's clinical sagacity and consultation with appropriate subspecialists should guide management.

Physicians should be aware that antithrombin III, protein C and s protein assays are inaccurate one time a patient has begun anticoagulation therapy. Therefore, an investigation for thrombophilias should not be escorted until at least two weeks after warfarin therapy has been discontinued. Anticoagulation does not affect standards for other common thrombophilias, so as factor V Leiden mutation, hyperhomocysteinemia, and antiphospholipid antibody.

Treatment of DVT

The goals of treatment for DVT are to stop concretion propagation and prevent clot return PE, and pulmonary hypertension (a potential complication of multiple returning PEs). These goals usually are achieved with anticoagulation using heparin followed according to warfarin (Coumadin). Despite some logomachy about the need to treat isolated calf-vein DVT a novel evidence-based guideline on antithrombotic therapy commits at least six to 12 weeks of anticoagulation. (4)

There are not many evidence-based recommendations for the use of nonpharmacologic measures in patients with DVT Usual advice for local care includes limb elevation and local application of heat. Activity should be minimal for several days (i.e., the patient's activity should be limited to walking to the bathroom and kitchen). Graded elastic compression stockings have been associated with a 50 percent reduction in the incidence of postphlebitic syndrome (5)