DVT



Well's scoring / criteria

Present

Score

Lower limb trauma or surgery or immobilisation in a plaster cast+1
Bed ridden for more than three days or surgery within the last four week+1
Tenderness along line of femoral or popliteal veins (NOT just calf tenderness)+1
Entire limb swollen+1
Calf more than 3cm bigger circumference, 10cm below tibial tuberosity+1
Pitting oedema+1
Dilated collateral superficial veins (on-varicose)+1
Past Hx of confirmed DVT+1
Malignancy (including treatment up to six months previously)+1
Alternative diagnosis is more likely than DVT-2

Rivaroxaban Special populations

Renal impairment

  • Xarelto is to be used with caution in these patients.
  • Please check BNF or medicines.ie

Hepatic impairment

  • Rivaroxaban is contraindicated in patients with hepatic disease associated with coagulopathy and clinically relevant bleeding risk including cirrhotic patients with Child Pugh B and C.

Elderly population

  • No dose adjustment.

Body weight

  • No dose adjustment

Gender

  • No dose adjustment.

Children

  • Xarelto is not recommended for patients <18 years.

DDx

Not suitable for home treatment

  • Unable to walk, frail or in severe pain.
  • Unable to understand the instructions.
  • Unable to understand the importance of compliance with the treatment.
  • Unable to return for the scan next morning - if awaiting scan.

Bleeding risk:

  • Liver disease
  • active peptic ulcer
  • alcohol abuse.

Management Proven VTE

Provoked leg DVT

Anticoagulate for 3 months.

Unprovoked DVT

Increased risk of occult malignancy so:

  • A thorough physical exam., including breast and PR, ± pelvic exam.
  • Check FBC, ESR, LFT, U&E, CXR, Ca++, urinalysis.
  • Men > 40 yo - request PSA.
  • All patients diagnosed with unprovoked DVT or PE who are not already known to have cancer should have an abdomino-pelvic CT scan (and a mammogram for women) (NICE 2012)
  • The CT-TAP should be arranged by the admitting team or my our AMU colleagues (for those discharged to ambulatory care). Please ensure the GP (and patient) are aware these tests will be arranged by another team of clinicians.

Isolated calf DVT

Overall risk of PE = 1 in 50. If anticoagulated, risk of PE = 1 in 25. But, anticoagulation has risk so.... please follow the ACCP guidelines (2012):

Severe symptoms: anticoagulate x3/12.

No, mild or moderate symptoms (and no risk factors for clot extension) – re-scan in 1-2 weeks (15% propagate).


Thrombophilia screen

Considered in those

  • Patients with a known FHx of thrombophilia
  • Under 45 years old with VTE, no ppt cause
  • Recurrent thromboses
  • Thrombosis in an unusual site,
  • FHx of thrombosis or
  • FHx of recurrent (2 or more) VTE
  • Past Hx of of recurrent foetal loss

Request

  • Antithrombin
  • Protein S, Protein C
  • APC resistance
  • Factor V Leiden mutation
  • Lupus anticoagulant
  • Anticardiolipin antibodies

British Journal of Haematology 2010: 149 (2) 209-220 Clinical guidelines for testing for heritable thrombophilia (www.bcshguidelines.com)



Content by Dr Íomhar O' Sullivan 11/03/2004. Reviewed by Dr ÍOS 13/07/2004, 15/11/2004, 19/07/2005, 05/03/2007.   Last review Dr ÍOS 13/11/18.