Expedited Management of Deep Vein Thrombosis and Acute Pulmonary Embolism
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THROMBOSIS (D SLATTERY, SECTION EDITOR)
Expedited Management of Deep Vein Thrombosis and Acute Pulmonary Embolism Stacy A. Johnson • Peter M. Yarbrough
Published online: 6 April 2013 Springer Science+Business Media New York 2013
Abstract Deep vein thrombosis and pulmonary embolism are common diseases with significant morbidity and mortality. Clinical probability assessment reliably identifies low-risk patients, and when paired with a negative D-dimer test, safely excludes venous thromboembolism. Compression ultrasonography confirms the diagnosis of deep vein thrombosis, whereas computed tomography pulmonary angiography is typically used to confirm pulmonary embolism. Risk assessment of acute pulmonary embolism stratifies low-risk patients for outpatient treatment, and high-risk patients for consideration of thrombolytic therapy. The recent approval of rivaroxaban, a novel oral anticoagulant, can simplify and expedite treatment in select patients. Ongoing clinical trials may uncover methods to prevent postthrombotic syndrome and chronic thromboembolic pulmonary hypertension. In this report, we review current diagnostic and management methods for deep vein thrombosis and pulmonary embolism. Keywords Deep vein thrombosis Pulmonary embolism Diagnosis Management Risk stratification Thrombolytic therapy Antithrombotic therapy Novel oral anticoagulant
Introduction Venous thromboembolism (VTE), comprising deep vein thrombosis (DVT) and pulmonary embolism (PE), is the third leading cause of cardiovascular mortality in the USA, responsible for nearly 550,000 hospitalizations annually, with DVT accounting for 60 % of these events [1]. The 30-day mortality rate for PE is 8.2 % with treatment and 20 % with recurrent events [2]. Improved diagnostic techniques recently demonstrated one third of patients with DVT also have occult PE [3, 4]. In addition to disease burden, VTE also carries a significant financial burden for patients and the health care system. In patients with VTE, the 1-year cost is estimated to be $33,531, nearly twice that for matching controls [1]. The cornerstone of VTE treatment remains anticoagulation, which carries a considerable 3-month bleeding risk of 2.1–12.8 % [2, 5••, 6]. The difficulty lies in creating effective diagnostic and treatment strategies that detect VTE without placing patients at undue risk. This review outlines current diagnostic and management strategies for DVT and PE, focusing on established practices and the ever-changing landscape of this disease.
Diagnosis Deep Vein Thrombosis S. A. Johnson (&) P. M. Yarbrough Department of Internal Medicine, University of Utah School of Medicine, 30 N 1900 E, Room 4B120, Salt Lake, UT 84132, USA e-mail: [email protected] P. M. Yarbrough e-mail: [email protected]
Limb swelling, pain, warmth, and erythema can all prompt DVT evaluation. Unfortunately, clinical assessment alone cannot accurately identify DVT [7]. Of all patients evaluated for DVT, only about 20 % have the disease [5••]. Therefore, clinicians r
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