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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
Non
Modifiable
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Deep Vein
Thrombosis
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DVT
Deep vein thrombosis, also called deep
venous thrombosis or DVT
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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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
Invasive imaging
Venography
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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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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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Integrated
Diagnostic
Approach
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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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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