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Posted on 3/01/10
A 72-year-old male presented at the hospital complaining of severe pain in his left leg, shortness of breath, and pleuritic type chest pain following a long drive from Connecticut to Florida with minimal stopping. The patient had a history of pulmonary embolism, degenerative joint disease, and previously was a chronic smoker. His vital signs were: temperature 38.4 °C, pulse 98 bpm, respiratory rate 20 breaths per minute, and blood pressure 138/89 mm Hg. Basic metabolic panel and complete blood count values were within the normal range. He had been taking hydrocodone/acetaminophen 5/325 mg one tablet orally every 6 hours as needed for pain, tiotropium handihaler 18 mcg one inhalation daily, and albuterol two inhalations as needed for chronic obstructive pulmonary disease (COPD).
The chest 1 view on radiography confirmed COPD and computed tomography (CT) scanning showed bilateral pulmonary emboli. Venous Doppler ultrasound of the lower extremities also revealed extensive deep venous thrombosis in his left lower leg.
Venous thromboembolism (VTE) results from clot formation within the venous circulation and typically manifests as deep vein thrombosis (DVT) and pulmonary embolism (PE). It can strike young healthy adults, but more frequently occurs in patients who sustain multiple traumas, have major surgery, are immobile for a lengthy period of time, or have hypercoagulable disorders.¹ An estimated 2 million people in the United States develop VTE each year; of these approximately 600,000 are hospitalized, and 60,000 die.¹ The estimated annual direct medical costs are well over a $1 billion US dollars.¹ The incidence of VTE nearly doubles in each decade of life after the age of 50 years and is slightly higher in men. Patients who sustain multiple traumas or undergo an orthopedic procedure involving a lower extremity are at higher risk, with an incidence often exceeding 50% in the absence of effective prophylactic measures (administration of anticoagulants or sequential compression devices). Patients undergoing major surgeries not involving the lower extremities have an incidence of VTE of 20% to 40% when one or more other risk factors are present. The long-term incidence of VTE among patients who have a prior history of VTE and who have metastatic cancer is also high.¹
A number of factors increase the risk of VTE, and these factors are additive. A prior history of VTE is the strongest risk factor for recurrent VTE, because of the destruction of valves and obstruction of blood flow caused by the initial event.¹ Valves in the deep veins of the legs and contraction of the calf and thigh muscles, facilitate blood flow back to the heart and lungs; therefore, damage to the venous valves and prolonged periods of immobility leads to venous stasis.
The American College of Chest Physicians provides prophylactic recommendations for long-distance travel-associated VTE in their Antithrombotic and Thrombolytic Therapy Evidence-Based Clinical Practice Guidelines.² For example:
- For travelers who are taking flights >8 hours, the following general measures are recommended: avoidance of constrictive clothing around the lower extremities or waist, maintenance of adequate hydration, and frequent calf muscle contraction (Grade 1C). Grade 1C is defined as a strong recommendation, although it has relatively low-quality evidence.
- For long-distance travelers with additional risk factors for VTE, the general measures listed above are recommended. If active thromboprophylaxis is considered because of a perceived high risk of VTE, the use of properly fitted, below-knee graduated compression stockings (GCS), providing 15-30 mm Hg of pressure at the ankle (Grade 2C), or a single prophylactic dose of low-molecular-weight heparin (LMWH), injected prior to departure (Grade 2C) are suggested. Grade 2C is a weak recommendation, with low or very low-quality evidence.
- For long-distance travelers, the use of aspirin for VTE prevention is not recommended (Grade 1B). Grade 1B is a strong recommendation, with moderate-quality evidence.
Case study (cont'd)
In this case, the 72-year-old patient had additive risk factors for VTE: age, history of pulmonary embolism and venous stasis after a long drive from Connecticut to Florida. He didn't receive active thromboprophylaxis and developed a second VTE episode which may have been preventable. As a result, treatment of acute DVT and PE was initiated in this patient.
The American College of Chest Physicians also provides recommendations for the treatment of VTE in their Antithrombotic Therapy for Venous Thromboembolism Disease Evidence-Based Clinical Practice Guidelines.³ For example:
- In acute DVT and PE, initial treatment with low molecular weight heparin (LMWH), unfractionated heparin (UFH) or fondaparinux (factor-Xa antagonist) is indicated for at least 5 days. Vitamin K antagonists (eg, warfarin) can be initiated together with LMWH, UFH, or fondaparinux on the first treatment day, and heparin preparations should be discontinued when the international normalized ratio (INR) is ≥ 2.0 for at least 24 hours. Vitamin K antagonists should be continued and the INR monitored until the INR goal is reached (2.0-3.0).
- If intravenous (IV) UFH is chosen, an initial IV bolus (80 units/kilogram or 5,000 units) should be followed by a continuous infusion (initially at a dose of 18 units/kg/hr or 1,300 units/hr) with dose adjustment to achieve and maintain an activated partial thromboplastin time (aPTT) prolongation that corresponds to a plasma heparin level of 0.3 to 0.7 international units (IU)/mL anti-Xa activity.
- If monitored SC UFH is chosen, an initial dose of 17,500 units or a weight-adjusted dose of approximately 250 units/kg twice a day is recommended, with dose adjustment to achieve and maintain an aPTT prolongation that corresponds to plasma heparin levels of 0.3 to 0.7 international units/milliliter anti-Xa activity when measured 6 hours after injection.
- If fixed-dose, unmonitored SC UFH is chosen, an initial dose of 333 units/kg followed by 250 units/kg twice a day is recommended.
- If LMWH is chosen rather than UFH, a dose of 1 mg/kg SC twice a daily or 1.5 mg/kg SC daily is recommended.
- The synthetic pentasaccharide fondaparinux has also been evaluated for the short-term treatment of DVT and PE. The once-daily SC dose of fondaparinux is 7.5 mg for a person with a body weight of 50 to 100 kg, 5.0 mg if body weight is <50 kg, and 10 mg if >100 kg.
It should be noted that patients who have hemodynamic compromise as evidenced by significant hypotension (systolic BP ≤ 90 mm Hg) or severe right ventricular strain because of a large clot burden may benefit from thrombolytic therapy with tissue plasminogen activator (tPA).1
Andrelis Mclean from the University of Florida College of Pharmacy is acknowledged for her contributions to the development of this case study.
1. Haines ST, Witt DM, and Nutescu EA. "Venous Thromboembolism." Pharmacotherapy A Pathophysiologic Approach (Pharmacotherapy (Dipiro)). 7th ed. Access Pharmacy Website: http://accesspharmacy.com. Accessed: 02/08/10.
2. Geerts WH, Bergqvist D, Pineo GF, et al.; American College of Chest Physicians. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133(6 Suppl):429S-433S. Website: http://chestjournal.chestpubs.org/content/133/6_suppl/71S.short?rss=1&ssource=mfc#sec-83. Accessed: 02/08/10.
3. Kearon C, Kahn SR, Agnelli G, et al.; American College of Chest Physicians. Antithrombotic Therapy for Venous Thromboembolic Disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008; 133; 454S-545S. Website: http://chestjournal.chestpubs.org/content/133/6_suppl/454S.full. Accessed: 02/08/10.
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