Venous thromboembolism (VTE) remains one of the top three major cardiovascular diseases affecting the Australian population trailing only acute coronary syndrome and stroke, despite treatment evolving considerably over the past decade.1
Professor Christopher Ward, head and director of research, Department of Haematology and Transfusion Medicine, Royal North Shore Hospital, Sydney, reminds GPs to have a high degree of suspicion when managing patients at risk of VTE because it’s a significant disease and fatal if the thrombosis progresses to the lung.
“Even in the legs, patients may suffer long-term complications, which can impact on their health,” says Professor Ward, who is also vice president of the Australasian Society of Thrombosis and Haemostatis.
With GPs being the first port of call for patients with or at high risk of VTE,2 here are the top three tips to manage VTE in your practice.
1. Be active in screening patients for risk of VTE
“The interesting thing is, there is no typical patient. You might assume that the people who are going to get a venous thrombosis are overweight, inactive, have other medical problems, but in fact we see a lot of thrombosis in very young, fit people and in that case it’s often in the context of injury, long-haul travel or other external factors like the pill or pregnancy,” says Professor Ward.
VTE will usually present in patients with underlying risk factors including:3,4
- Acute factors like hospitalisation or surgery, trauma, immobilisation, long-haul travel, oestrogen therapy or intravascular devices
- Chronic predisposing factors like age, body weight, cancer, pregnancy, chronic diseases, history of VTE, clotting dysregulation, hereditary factors
2. Use compression ultrasound to diagnose DVT
Diagnosis of DVT can be challenging without objective testing as the symptoms are often non-specific.5,6 Therefore, use compression ultrasound for timely diagnosis of DVT.6
Once diagnosed, examine the patients’ clinical characteristics and history – as well as the risk of bleeding to determine the choice and length of anticoagulation therapy.4,6
“Once someone’s made a diagnosis of a venous thrombosis, there’s a set of questions you have to go through. There’s the location of the clot, because that will determine particularly the duration of therapy, possibly the intensity. Then you have to assess the patient’s risk of anticoagulation,” says Professor Ward. “Probably the most important [risk] is renal function.”
3. Refer quickly if you suspect pulmonary embolism (PE)
The pressure is on when it comes to PE as the risk of mortality is high (>15%).7
Many clinicians fear missing PE and are more successful at excluding PE than correctly diagnosing it.8
Initial diagnosis for referral should be based on a combination of symptoms (which are relatively non-specific and may include difficulty breathing, chest pain or anxiety, rapid pulse and dizziness, among others), and clinical factors, as it rarely presents in the absence of a risk factor.8,9
When PE is suspected, refer immediately for a computed tomography (CT) or lung scan and treatment.7
“The best approach is clearly to take an accurate history, examination, but realise that those things won’t be diagnostic in many cases. It’s important then to move to imaging quickly if you are suspicious….for that [PE] you’ll usually refer someone to hospital …”
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This content was independently developed and produced by Australian Doctor Group and made possible with support from sanofi-aventis australia Pty Ltd. The opinions expressed in this article are the author’s own and do not necessarily represent the views of sanofi-aventis australia Pty Ltd.
References: 1. Cleveland Clinic. Venous thromboembolism (deep vein thrombosis & pulmonary embolism), 2012. Available from: http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/cardiology/venous-thromboembolism/ (accessed 16 April 2017). 2. Institute for Quality Improvement. Patient Safety Toolkit: Primary care and VTE (venous thromboembolism). Available from: https://www.aaahc.org/Global/aaahc_toolkit_workmat_pvvte_FINAL.pdf (accessed 3 May 2017). 3. Ho WK et al. Med J Aust 2005;182(9):476–81. 4. Kearon C et al. Chest 2016;149(2):315–52. 5. Chapman NH et al. Aust Fam Physician 2009;38(1–2):36–40. 6. Ho WK Aust Fam Physician 2010;39(7):468–74. 7. Skinner S Aust Fam Physician 2013;42(9):628–32. 8. Lee CH et al. Med J Aust 2005;182(11):569–74. 9. American Heart Association. Symptoms and diagnosis of venous thromboembolism (VTE). Available from: http://www.heart.org/HEARTORG/Conditions/VascularHealth/Venous…enous-Thromboembolism-VTE_UCM_479057_Article.jsp#.WQiHEaOr1TY (accessed 2 May 2017).