Establish the presence of DVT
- Achieve the following objectives with minimal side effects and inconvenience.
- Risk Stratification.
- Prevent death from PE.
- Prevent post-thrombotic syndrome.
- Prevent recurrent PE or VTE.
- Oxygen supplementation.
- Pain relief.
- Temporary mechanical ventilation.
- Inotropic agents.
- Thrombolytic therapy.
- Surgical Embolectmy.
- Vitamin K antagonists (warfarin)
- Oral small-molecule direct thrombin inhibitor
- Initial treatment with heparin is necessary.
- Induction period with heparin therapy for 10 days and can be reduced to 5 days.
- LMWH can replace heparin and is now treatment of choice.
- Optimal therapeutic range with warfarin is an INR of 2.0 to 3.0.
- Continued treatment following hospital discharge is necessary.
- Optimal duration of warfarin therapy still to be established.
LMWH: A Major Advance:
Factors That May Influence Duration of Oral Anticoagulation:
- Weight-adjusted subcutaneous dosing predictable.
- Once-daily subcutaneous dosing effective in DVT.
- Treatment of PE effective and safe.
- Less osteopenia than UFH.
- Less HIT than UFH.
- Outpatient treatment effective and safe.
Unstable anticoagulant response
Fear of recurrence or bleeding
VTE presentation (eg, massive PE)
Poor cardiopulmonary reserve
Severe post-thrombotic syndrome
Potential Indications for Indefinite Anticoagulant Therapy:
- Inherited Thrombophilia: AT (= antithrombin), protein C and S deficiency
- Antiphospholipid syndrome.
- Recurrent idiopathic VTE.
- Thromboembolic pulmonary hypertension.
New Anticoagulants for Treatment of DVT:
- Hirudin (recombinant;lepirudin) is effective for treating thrombosis associated with HIT.
- The new oral small-molecule direct thrombin inhibitor appears promising in multiple clinical trials.
- Pentasaccharide has been evaluated in phase 2 studies and is being tested in phase 3 studies.
Exogenously administered drugs:
- Streptokinase - bacterial product - continuous use - immune reaction
- Urokinase - human tissue derived - no immune response (best for PE in Egypt)
plasminogen activator (tPA) - genetically
cloned - no immune reaction – (EXPENSIVE)
N.B: Angikinase( 500,00 I.U ) Available in
Management Strategy and Prognosis for
Pulmonary Embolism (MAPPET):
- 719 patients without carcinogenic shock
- 169 received thrombolytic therapy: 30-day mortality 4.7%;
recurrent PE 7.7%; major bleeding 21.9%
- 550 received heparin: 30-day mortality 11.1%; recurrent
PE 18.7%; major bleeding 7.8%
Randomized Trial of Caval Interruption:
- Initial benefit in preventing PE offset by excess of
recurrent DVT in the longer term in the
absence of anticoagulant.
- Therefore, caval filter not recommended for this
patient population in the long term.
- Can be life saving in patients with massive PE.
- In consecutive series of 96 patients, mortality was 37% (Meyer et al, 1991).
- Cardiac arrest and associated cardiopulmonary disease were independent predictors of death.
- Elective pulmonary embolectmy was life saving in
selected patients with chronic
thrombo-embolic pulmonary hypertension (Moser et al, 1990).
Recommended Treatment of Acute PE:
Massive PE with shock or syncope.
- Thrombolysis or surgery.
Major PE with right-ventricular dysfunction.
- Thrombolysis (Goldhaber).
Major PE without right-ventricular dysfunction.