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2 Eka Fithra Elfi

Eka Fithra Elfi

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Refferences

Agneli. NEJM. 2010;363(3):266-274

Huisman. J. Thromb. Haemost 2013;11:412-422
Tapson. NEJM.
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Perhatian
Bahan ajar ini hanya sebagai panduan dan rangkuman
dasar dari materi kuliah pakar. Sebagai sumber
pengetahuan dan bahan untuk ujian silahkan membaca
referensi tersebut diatas.

Eka Fithra Elfi

Penulis
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Introduction
 Venous Thromboembolism (VTE) constitute one of
three cardiovascular killer, along with MI and stroke
 VTE consist of
 Deep Vein Thrombosis (DVT)
 Pulmonary embolism (PE)
 VTE have high morbidity and mortality rate
 It’s a common problem, yet it may difficult to diagnose
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Epidemiology
 Incidence of VTE 1.5 per 1000 person-year
 Case-fatality rate of DVT and PE ranging from 1% in
young patients up to 10% in older patients
 One year mortality up
to 21.6%, largely caused
by cancer
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Risk Factors
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Risk Factors : Modifiable

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Risk
Factors
Non
Modifiable
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Pathogenesis : Virchow Triad

Venous stasis or sluggish blood flow

Endothelial damage Primary or acquired hypercoagulability

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Risk Factor for Venous Embolism

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Deep Vein
Thrombosis
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Lower Extremities Vein

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DVT
 Deep vein thrombosis, also called deep
venous thrombosis or DVT

 DVT is a blood clot (thrombus) in a

deep vein.

 It usually affects the leg veins, such as

the femoral vein or the popliteal vein.
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DVT epidemiology
 Deep-vein thrombosis occurs in about 1 in 1000 people
per year.
 About 1-5% will die from the complications of a DVT
like pulmonary embolism (lung blood clots).
 Dr Virchow noticed an association between venous
thrombosis in the legs and pulmonary embolism.
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Wells’ Score
Prediction
Model for
Likelihood of
DVT
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Factors that increase the risk of DVT

 major surgery under general anesthesia, especially if it involves
leg joints or a hip
 obesity
 varicose veins
 prolonged bed rest and immobility
 heart or lung problems that require hospitalization
 major injuries
 cancer
 leg paralysis
 pregnancy and childbirth
 estrogen containing contraceptive pills, patch, or vaginal ring
 estrogen replacement therapy
 long-distance travel
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Clinical Examination
 Classic symptoms  swelling, pain, and discoloration
in the affected extremity.
 Physical examination  palpable cord of a
thrombosed vein, unilateral edema, warmth, and
superficial venous dilation.
 Classic signs of DVT, :
 Homans sign (pain on passive dorsiflexion of the foot),
 edema, tenderness, and warmth; can occur in other
conditions such as musculoskeletal injury, cellulitis, and
venous insufficiency.
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DVT
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Diagnostic Modality
 Laboratory :
 d-dimer  degradation
product of cross-linked fibrin
 Cut off value >500

 Non Invasive imaging :

 Vascular Doppler ultrasound

 Invasive imaging
 Venography
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Doppler ultrasound Venography

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Pulmonary Embolism (PE)

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Epidemiology of PE
 Fatality rate up to 7%
 Mostly emboli originating from DVT (3-fold risk of
PE)
 Other non vascular cause :
 Air embolism
 Fat embolism
(discussed elsewhere)
 Long term complication such as recurrent VTE,
CTEPH (Chronic thromboembolism pulmonary
hypertension), and post thrombotic syndrome
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Complication of PE
 Right ventricular dysfunction
 Pulmonary infarction
 Pathophysiological effect :
 Vascular obstruction   pulmonary vascular
resistance   alveolar dead space  impaired gas
exchange  hypoxemia and impaired carbon monoxide
transfer bronchoconstriction  increased airway
resistant  lung edema, hemorrhage, loss of surfactant
  pulmonary compliance
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Right ventricular failure due to PE

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PE Classification
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Diagnostic approach
 Difficult, it’s a great masquerade.
 no diagnostic test for PE has utility unless PE is
considered as diffential diagnosis
Signs Symptoms
Tachypnea Unexplained dyspnea
Tachycardia Chest pain, pleuritic or atypical
hemoptysis Anxiety
Low-grade fever cough
Left parasternal lift
Tricuspid regurgitant murmur
Accentuated P2
Leg edema, erythema,
tenderness
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Diagnostic Approach
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Diagnostic Approach
 ECG : S I, Q III, T III
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Diagnostic Approach
 Other ECG sign :
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Diagnostic Approach
IMAGING :
 Chest radiography
 Westermark sign (focal oligemia) or peripheral wedged-shaped
density
 Lung scanning (pulmonary radionuclide perfusion
scintigraphy)
 Ventilation-perfusion mismatch
 Echocardiography
 Detection RV overload and RV failure (Mc Connel Sign)
 Venous Doppler ultrasound
 Investigation DVT for source of emboli
 Pulmonary CT-scan  gold standard
 Pulmonary angiography  invasive imaging
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Chest X Ray
CT-scan

Echocardiography
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Well’s Score Clinical Likelihood of PE

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Integrated
Diagnostic
Approach
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Treatment Approach for PE

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Therapeutic Options for VTE

 Reperfusion :
 Fibrinolysis
 Catheter-based embolectomy
 Surgical embolectomy
 Anticoagulant
 Heparin, LMWH, Fondaparinux, Warfarin
 Prevention for future VTE
 Long term anticoagulant
 Vena cava filter
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Reperfusion
 Fibrinolysis
 For selected unstable or high risk patients
 Agents : r-TPA, streptokinase
 Cathether based embolectomy
 Using contrast enhanced fluoroscopy for patients with
contraindication of fibrinolysis or
failed fibrinolysis
 Surgical embolectomy
 For patients with massive PE
and contraindicated for
fibrinolysis
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Anticoagulant for VTE

 Heparin with Racke Normogram
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Anticoagulant for VTE

 LMWH and Fondaparinux
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Anticoagulant for VTE

 Warfarin
 A vitamin K antagonist which prevents activation factor
II, VII, IX, X
 For long term therapy
 Overlapping with heparin for at least 5 days
 Monitoring INR to target 2-3
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Anticoagulant for VTE

 Optimal Duration
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Anticoagulant for VTE

 Optimal Duration for secondary prevention
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Prevention of VTE
 Long term anticoagulant
 Provoked VTE event : at least 3 months
 Unprovoked VTE event with low-moderate bleeding
risk : extend over 3 months
 Patients with cancer : extend over 3 months
 Monitoring INR every 1-2 months with target 2-3
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Prevention of VTE
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Prevention
of VTE