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In last week’s newsletter, I talked about the risk factors that can lead to venous thromboembolism.
In today’s newsletter, let’s talk about the management of acute deep vein thrombosis and pulmonary embolism.
First, let’s talk about WHY we need to initiate urgent treatment for VTE. Urgent treatment of DVT and PE with anticoagulation is preferred as it reduces mortality and morbidity, prevents clot extension and decreases the risk of recurrence.
PEs carry the risk of strain on the right ventricle which can then inturn cause the Left ventricle to be strained and this can lead to cardiovascular collapse (massive PEs or high-risk pulmonary emboli). Deep vein thrombi can migrate/extend toward the heart (especially proximal DVTs- clots in popliteal vein and above) and carry similar risk of morbidity.
Thrombolysis or clot-busting is considered if there is hemodynamic compromise or the DVT is so extensive that it affects the venous outflow and can cause compartment-syndrome-like condition called phlegmasia cerulea dolens (see image)
Phlegmasia cerulea dolens
Image credit: NEJM
The following are the most common anticoagulant choices available for treatment
Unfractionated heparin: pros-cheap, easily reversible, short half-life, ability to monitor. Cons- needs IV infusion/admission and needs monitoring
Low-molecular weight heparin : Pros- very effective, strong evidence for cancer-associated VTE. Cons- needs to be self-injected
Direct oral anticoagulants (DOACs): Pros- effective, don’t need monitoring. Cons- can be expensive, can have drug-drug interactions that one needs to be mindful of, reversing the effect of a DOAC is unpredictable and expensive
Vitamin K antagonists: Pros- cheap, ability to monitor, cons- need significant lifestyle changes, needs constant monitoring
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