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Tuesday, January 30, 2007

New Guidelines for Thromboembolic disease

New guidelines for DVT and PE are appearing in the Feb. Annals Internal Medicine and the Journal of Family Practice and a overview of is found here.

Here are some of the highlights.

1.Low molecular weight heparin (LMWH) is preferable to unfactionated heparin (UFH). UFH is history for that application.
2.It is o.k. to treat DVT as an outpatient.Not everyone , of course, but for those patients who have the wherewith all to do the necessary things, such as take the LMWH injections and travel to where ever to get INRS-(coumadin and LMWH typically started simultaneously), etc. Further, in selected patients maybe you can treat PEs as out patients. This may give older docs a little heartburn and again this is not for all patients.
3.Three to six months is probably long enough for a provoked DVT.
4.For recurrent DVT -more than 12 months is recommended.
5.Use of Prediction Rules ( like the Wells Rule) is encouraged. Caveat-this is for uncomplicated cases, i.e. younger patients without co-morbidities.I have expressed my reservations about decision "rules" before.
6.The D-dimer is ready for prime time and with low pre-test probability ( probably as indicated by a prediction rule) and a negative high sensitivity D-dimer, further testing can be eliminated. Caveat-this may not apply to older patients with co-morbidities.
7.A negative ultra sound does not rule out a calf DVT.Ultra sounds do better for proximal DVTs.
8.Compression stockings are important in an effort to decrease the likelihood of post thrombosis syndrome.Begin use within one week and continue for a year.

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