Article Figures & Data
Figures
- Figure 1.
Recommended evaluation of Dyspnea post PE.* Abbreviations: AC, anticoagulant; CTED, chronic thromboembolic disease; CTEPH, chronic thromboembolic pulmonary hypertension; PE, pulmonary embolism; RHC = right heart catheterization; TTE, transthoracic echocardiogram; V/Q, ventilation/perfusion; VTE, venous thromboembolism. Algorithm is based on recommendations from the authors and is an original figure.
- Figure 2.
Decision tree for anticoagulation management after initial 3 months of treatment.* Abbreviations: AC, anticoagulant; APS, antiphospholipid antibody syndrome; DVT, deep vein thrombosis; Pdvt, proximal DVT; PE, pulmonary embolism; VTE, venous thromboembolism. Major transient risk factors (within 3 months before the VTE diagnosis) include surgery with general anesthesia for > 30 minutes, bed immobilization in-hospital for 3 or more days, and cesarean section. Minor transient risk factors occurring within 2 months of VTE diagnosis include surgery with general anesthesia < 20 minutes, hospitalization for < 3 days with an acute illness, estrogen therapy, pregnancy/puerperium, bed rest out of the hospital for 3 or more days with an acute illness, and leg injury with reduced mobility for at least 3 days. Persisting risk factors include A) active cancer that has i) not been treated, ii) is recurrent or progressing, or iii) is actively being treated, or B) active inflammatory bowel disease.35 *Flow chart is based on recommendations from the authors and is an original figure.
Tables
- Table 1.
Checklist of Important Management Decisions That Should Be Addressed after the Initial 3 Months of Anticoagulation Treatment
Essential Issues That Must Be Addressed ☐Assess if signs and symptoms of the recent VTE event have resolved. ☐Decide if anticoagulation therapy should be discontinued vs continued (see Table 2). ☐If continued, select the duration and the dose of the anticoagulant. ☐Educate the patient. ☐Address patient concerns, which likely include the risk of recurrent VTE, the risk of bleeding, indications for VTE prophylaxis in the future, and the benefits of direct oral anticoagulant (DOAC) agents vs warfarin. ☐Review signs and symptoms of recurrent VTE. ☐Inform the patient about the radiation risks associated with repeated chest CT scanning. Inform patients about the usefulness of D-dimer testing. Ancillary Issues ☐Consider testing for antiphospholipid antibody syndrome if the results will affect future patient management. ☐Order the retrieval of an inferior vena cava filter (if the patient has a deployed retrievable filter). ☐Consider whether a work-up for an underlying malignancy needs to be undertaken or completed. ☐Consider re-imaging the affected venous segments (upper or proximal lower extremity compression ultrasound) if the index event was a DVT and consider obtaining a D-dimer to further prognosticate the risk of VTE recurrence. ☐For complex cases, is a formal thrombosis/anticoagulation consultation needed? CT, computed tomography; DVT, deep vein thrombosis; VTE, venous thromboembolism.
*Table is based on recommendations from the authors.
- Table 2.
Current Recommendations Regarding the Duration of Anticoagulation Therapy for DVT and PE
Three Months of anticoagulation recommended Indefinite Anticoagulation Recommended Patients treated for isolated calf-vein thrombosis
Patients with a provoked proximal DVT or PE (transient risk factor was present)
Patients with an unprovoked VTE who are at high risk for bleeding
Caucasian women with an unprovoked VTE who have 1 or fewer points using the HERDOO2 decision rule #5Patients with first-time proximal DVT or PE in the setting of a persisting risk factor (eg, active cancer)
Men who have a first-time unprovoked proximal DVT or PE
Caucasian women with first-time unprovoked VTE and 2 or more points using the HERDOO2 decision rule #5
Patients who meet the criteria for having antiphospholipid antibody syndrome
Patients being evaluated for CTEPH because of ongoing dyspnea.
Until further research has been completed, the use of the HERDOO2 decision rule to risk-stratify women with unprovoked VTE should be applied only to Caucasian women.CTEPH, chronic thromboembolic pulmonary hypertension; DVT, deep vein thrombosis; PE, pulmonary embolism; VTE, venous thromboembolism.
*Information adapted from the following sources: Rodger MA, Kahn SR, Wells PS, et al. Identifying unprovoked thromboembolism patients at low risk for recurrence who can discontinue anticoagulant therapy. Can Med Assoc J. 2008;179(5):417-426; Konstantinides S, Meyer G, Becattini C, et al. 2019 ESC guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J. 2019. doi:10.1093/eurheartj/ehz405.
How likely they will develop another blood clot if they continue vs discontinue anticoagulation
The magnitude of the long-term risk of bleeding associated with anticoagulant therapy
The advantages, disadvantages, and costs of the available anticoagulants
The radiation risks associated with repeatedly undergoing CT scanning
The availability of a D-dimer test (when the result is normal) to confirm no new formations of a blood clot
CT, computed tomography.
↵* Table is based on recommendations from the authors and is an original table.
