time keeps on tickin’…

 

How long should we treat this patient with a PE?
We all get good at diagnosing and acutely treating PE in the acute care setting.  Often, we turf the decision of how to manage them to the clinic.  But today you are in the clinic and it’s in your lap.  So, what to do?
Our patient is 52 with well controlled hypertension on one medicine. He presented to the ED with chest pain and was found to have a PE.  He was admitted and treated appropriately with Lovenox and Coumadin. He has been following up in Coumadin clinic and is appropriately anticoagulated now.  He wants to know how long he needs this Coumadin.
Well, that depends….
Here’s an article that goes through a lot of these issues, and it is worth a read if you are interested.
But the things to balance are the risk of repeat clot and the risk of bleeding.
Risk of clot 
This has to do with reasons for clot and underlying patient factors.
  • Low risk (3% year): major reversible risk- surgery
  • Intermediate risk (5% year): minor reversible risk- travel, estrogen (Rx or pregnancy), trauma
  • High risk (10%): irreversible risks-  unprovoked clot, untreated malignancy
The various hypercoagulable states all have their own risk levels for repeat clot.
  • Antiphospholipid antibodies and homogyzotes for Factor V Leiden are on the high end of the risk spectrum.  
  • Heterozygotes for Factor V Leiden may have no increased risk of clot, unless they also carry a copy of the prothrombin gene mutation.
Risk of bleeding
There are clinical prediction tools for this.  Here’s one: (RIETE registry: Thromb Haemost 2008; 100:26-31)
Recent major bleed: 2 points
Elevated Creatinine >1.2: 1.5 point
Hemoglobin <13: 1.5 points
Malignancy: 1 point
Overt PE: 1 point
Age >75: 1 point
Add up the points
0=low risk (0.3 per 100 patient trimesters- I admit to not knowing what this means in real life)
1-4= moderate risk (2.6)
>4=high risk (7.3)

 

Expert guidelines
ACCP recommends:
  • First provoked DVT or PE: 3 months
  • First unprovoked DVT or PE: 3-6 months
    • DVT/PE with malignancy: until malignancy is “controlled”
  • Recurrent DVT/PE or thrombophilia: indefinite

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