Professional Documents
Culture Documents
Migration
PE
Embolus
Thrombus
DVT
VTE is a leading cause of death worldwide
VTE is estimated to cause >500,000 deaths
Europe every year1
An estimated
300,000
VTE-related
deaths occur in
the US VTE is estimated to cause at least
each year2 3 million deaths a year worldwide
1. Cohen AT et al. Thromb Haemost 2007; 2. Heit JA et al. Blood 2005
VTE is a major cause of death in Europe
600,000 Deaths resulting from VTE
543,454
500,000
Number of deaths per annum
400,000
300,000
Combined deaths
209,926
200,000 Transport accident
Prostate cancer
100,000
Breast cancer
AIDS
0
p=0.38
N=14,108
$14,722
p=0.006 $14,146
Total average cost
per patient (US$)
$11,862
$9,805
0 5 10 15 20 25
Incidence of DVT per 10,000
hospital patients
1
Woo KS, et all. Singapore Med J.1988 Aug:Aug29(4)357-359
2
Lee LH. New Insights and unresolved issue in the prevention of DVT/VTE in Asia. March 2001.Phuket.Thailand
In Asia
40
35
30
25
20
15
10
0 DVT
No DVT
Circulatory
Stasis
Left ventricular dysfunction
Immobility or paralysis
Venous insufficiency or varicose veins
Venous obstruction from tumour, obesity or pregnancy
Virchow R, ed. Gesammelte Abhandlungun zur Wissenschaftichen Medicin. Von Meidinger Sohn, Frankfurt, 1856;
Blann AD, Lip GYH. BMJ 2006; Geerts WH et al. Chest 2004; Bennett PC et al. Thromb Haemost 2009
Provoked and unprovoked VTE
Transient/
Continuing/
reversible factors No identifiable
irreversible factors
e.g. surgery or cause
e.g. cancer
hospitalization
Unprovoked
Provoked VTE (idiopathic)
VTE
50
30 9
40 9
50 9
60 9
70 9
9
20 9
10 9
0
2
3
4
5
6
7
1
0
8
Age
1. Anderson FA, Jr et al. Arch Intern Med 1991; 2. Torbicki A et al. Eur Heart J 2008
The diagnosis of symptomatic VTE is
often delayed
Patients enrolled in the MASTER registry (N=2,047)
>10 days from onset
of symptoms (%)
Diagnosis of VTE
23% 16%
DVT: multiple signs or symptoms, pain and previous VTE are associated
with earlier diagnosis
PE: only multiple signs or symptoms and transient risk factors are
associated with an earlier diagnosis
Agnelli G et al. Thromb Res 2008; Ageno W et al. Thromb Res 2008
Clinical presentations of DVT
DVT occurs when clots form in the deep veins within the muscles of
the leg1
Less commonly, clots may form in the upper extremities as well2
DVT-related symptoms may include:1,3
Leg pain
Tenderness of the leg
Cramping that intensifies over several days
Erythema
Warmth at the site of DVT
Edema
DVT is often asymptomatic, sometimes revealed only after
diagnostic tests4
1. Blann AD, Lip GY. BMJ 2006; 2. Spencer FA. J Gen Intern Med 2006 3. Goldhaber SZ, Morrison RB. Circulation 2002;
4. Anderson FA et al. Center for Outcomes Research, University of Massachusetts Medical Center 1998
Distal or proximal
Proximal
DVT can be:
Distal External iliac
Below the knee in the deep
veins of the calf
Deep femoral
Proximal
Above the knee, primarily in the Great saphenous
popliteal and femoral veins
Popliteal
DVT usually begins distally
Distal
A thrombus may grow and extend to
the proximal veins Anterior tibial
and embolize1 Posterior tibial
1. Anderson FA, et al. Center for Outcomes Research, University of Massachusetts Medical Center; 1998
DVT PROBABILITY : WELLS SCORE SYSTEM
Active cancer (treatment ongoing, within previous 6 +
months, palliative) 1
Paralysis, paresis or recent plaster immobilization of the +
lower extremities 1
Recently bedridden > 3 days, or major surgery within 12 +
weeks requiring 1
general or regional anesthesia
Localized tenderness along the distribution of the deep +
venous system 1
Entire leg swollen +
1
Calf swelling > 3 cm compared to asymptomatic leg +
(measured 10 cm 1
below
0 : tibial
LOWtuberosity)
1Pitting
or 2 edema
: INTERMEDIATE
confined to the symptomatic leg +
3 : HIGH 1
Collateral superficial veins (non-varicose)
Venous Thromboembolism +
Diagnosis & Treatment Guideline. Group Health. 2
PEMERIKSAAN KONFIRMASI DIAGNOSTIK
1. USG Doppler
2. Venografi
3. D-Dimer
APPROACH TO SUSPECTED DVT
Sign &
symptoms
Wells score
probability
test
1. Goldhaber SZ. N Engl J Med 1998; 2. Goldhaber SZ, et al. Circulation 2002; 3. Stein PD et al. Chest 2001
Classification of PE
The European Society of Cardiology (ESC) guidelines stratify PE
into levels of risk of early death
Defined as 30-day risk of death
PE and risk of early death
High-risk PE (>15% mortality risk)
Intermediate-risk PE (315% mortality risk)
Low-risk PE (<1% mortality risk)
Clinical markers are:
Shock or hypotension
Right ventricular dysfunction
Markers of myocardial injury
1. CT pulmonary angiography
2. V/Q (ventilation-perfusion) lung scan
3. D-Dimer
APPROACH
Clinical symptoms
TO
SUSPECTE Wells probability test
D PE
Low Intermediate High
DVT complications:1,2
PE
Damage to valves in the deep veins
Venous reflux
Post-thrombotic syndrome (PTS)
Goal of treatment
Prevent embolization to the lungs
Prevent extension into larger veins
Prevent recurrence
Avoid the chronic complications
1. Kearon C. Circulation 2003; 2. Ginsberg JS, et al. Arch Intern Med 2000
Chronic thromboembolic
pulmonary hypertension
Serious complication of PE
Up to 5% of patients with PE are
reported to develop chronic
thromboembolic pulmonary
hypertension (CTPH)1
Initial phase of disease often
asymptomatic and followed by
progressive dyspnoea and
hypoxaemia2
Right heart failure can frequently
occur2
Progressive condition associated
with mortality rates of 420%2
Chest axial with a clot on the left (patients right side); a
tongue of white contrast can be seen extending into the
clot (PE)
Reproduced with permission from Professor AT Cohen
1. Kearon C. Circulation 2003; 2. Torbicki A et al. Eur Heart J 2008
Post-thrombotic syndrome
Occurs in nearly one-third of
patients within 5 years after
idiopathic DVT1
PTS is characterized by:2
Pain
Oedema
Hyperpigmentation
Eczema
Varicose collateral veins
Venous ulceration
Severe PTS can lead to
intractable, painful venous
leg ulcers requiring ongoing
nursing and medical care3
Reproduced with permission from Dr AT Cohen and Dr T Urbanek
1. Prandoni P et al. Ann Intern Med 1996; 2. Kahn SR. J Thromb Thrombolysis 2006;
3. Kahn SR, et al. J Gen Intern Med 2000
Conclusion
VTE incidence year by year to be increased
DVT diagnosis starting from clinical symptoms, Wells probability
test, and confirmed diagnosis
PE diagnosis starting from clinical symptoms, Wells probability
test, and confirmed diagnosis
VTE is not merely a western disease its also rise number in Asia
Data from Indonesia showed high rate of VTE, when patients
undergoing major orthopedic surgery were not given
thromboprophylactic. Also high prevalence of VTE among cancer
and bedridden patients