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Deep Vein Thrombosis Assignment Help: Diagnosis & Treatment

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Deep Vein Thrombosis: Diagnosis and Treatment

Diagnosis and Treatment of Deep Vein Thrombosis

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Diagnosis and Treatment of Deep Vein Thrombosis

What Is Deep Vein Thrombosis?

Deep Vein Thrombosis or DVT is a medical condition, characterized by the formation of thrombosis in the deep veins of pelvis or the lower limbs (Osman et al., 2017). This syndrome has gained attention as one of its complications, Pulmonary Embolism, can be fatal. Around 45,000 people in Canada suffer from Deep Vein Thrombosis each year, with an incidence of 1-2 per 1000 persons affected annually. The ability to diagnose Deep Vein Thrombosis accurately is crucial as an early diagnosis prevents thrombus extension, formation of Pulmonary Embolism and facilitation of the early initiation of anti-coagulant therapy, unless otherwise contraindicated (Thrombosiscanada.ca, n.d.).

Diagnosis of Deep Vein Thrombosis (Thrombosiscanada.ca, n.d.)

The diagnosis of DVT is based on the Pre-test probability or clinical suspicion, tested through Wells Score. For the diagnosis of DVT, the three-level and two-level (Unlikely, Likely) Wells score need to be validated. Table 1 indicates two-level Wells’ score criteria and the diagnostic algorithm. Wells’ score of <2 indicates DVT to be “Unlikely”. However, if the Wells score is ≥2, it is “Likely” there.

Two level DVT Wells score

Figure 1 Source: https://www.researchgate.net/figure/Two-level-DVT-Wellsscore_fig2_312279537

The second diagnostic criterion is the Venous Compression Ultrasound (CUS). It involves testing the compressibility of the Femoral and Popliteal veins. Any failure to demonstrate compressibility of the proximal vein in patients without prior history of DVT, is suggestive of DVT.

The third diagnostic criterion is D-Dimer test. It is a non-specific but sensitive marker of thrombosis. D-dimer is commonly elevated in patients with DVT. However, the levels may also rise in cases of malignancy, inflammatory diseases, hospitalization and surgery.

The Diagnostic Strategy used for diagnosing DVT involves incorporation of all the three diagnostic tests. The first step is to get a Wells Score done. Patients who have “Unlikely” pre-test probability from Wells Score undergo D-Dimer testing and managed accordingly, if tested positively. In case of patients with “Likely” pre-test probability, CUS is done as the first-line test. The patients with a negative CUS test then undergo D-Dimer test or repeat CUS after 5-7 days to rule out the possibility of distal DVT that might have extended proximally. Figure 2 shows the algorithm for the diagnosis of DVT.

DVT Diagnosis-01

Source: https://thrombosiscanada.ca/wp-content/uploads/2015/11/DVT-Diagnosis-01-1024x561.png

Treatment of Deep Vein Thrombosis

The patients who are likely to have DVT (except those with high risk of bleeding) should undergo Anti-coagulant therapy before their diagnosis is confirmed. The common medications ordered for DVT include Direct Acting Oral Anticoagulant (DOAC) monotherapy, unfractionated heparin (UFH) or Low molecular weight heparin (LMWH) followed by DOAC or bridging to Warfarin or LMWH monotherapy (Thrombosiscanada.ca, n.d.).

Direct Oral Anticoagulants/ Non – Vitamin K antagonist Oral Anticoagulants The drugs under this category include Apixaban, Rivaroxaban, Dabigatran, Edoxaban. The mechanism of action of DOAC is inhibition of clotting factors Xa or lla (Thrombin), resulting in a reduction of the thrombin-burst during coagulation cascade’s propagation phase (Schwarb and Tsakiris, 2016).

Low molecular weight heparin (LMWH) The drugs under this category include Dalteparin, Enoxaparin, Tinzaparin, and Nadroparin. LMWH binds to anti-thrombin and creates conformational change. This accelerates inhibition of activated factor X in conversion of thrombin to prothrombin thereby prevents conversion of fibrinogen to fibrin strands and clot formation (openanesthesia.org, n.d.). LMWH are generally avoided in cases of people with severe renal insufficiency.

Unfractionated Heparin (UFH) It works by forming a complex with Antithrombin (AT) that acts as an anticoagulant in catalyzing inhibition of blood coagulation factors like thrombin (factor lla), IXa, Xa, XIa, and XIIa and thus, prevent fibrin formation. (Thrombosiscanada.ca, n.d.)

Warfarin It acts as an anti-coagulant by completely inhibiting Vitamin K epoxide reductase complex (VKORC1) that is essential for activating Vitamin K in the human body. Through this mechanism, Warfarin depletes reserves of Vitamin K, thereby reduces synthesis of blood clotting factors (Patel et al., 2021).

References

Osman, A.A. et al. (2018) Deep venous thrombosis: a literature review. Int J Clin Exp Med.

Available at http://www.ijcem.com/files/ijcem0060561.pdf

Openanesthesia.org (n.d.) LMWH: Mechanism of action. Open Anesthesia. Available at

https://www.openanesthesia.org/lmwh_mechanism_of_action/#:~:text=LMWH%20binds%20to%20anti%2Dthrombin,fibrin%20strands%20and%20clot%20formation.

Patel, S. et al. (2021) Warfarin. Statpearls. Available at

https://www.ncbi.nlm.nih.gov/books/NBK470313/

Schwarb, H. and Tsakiris, D. A. (2016) New Direct Oral Anticoagulants (DOAC) and Their Use

Today. Dent J (Basel). doi: 10.3390/dj4010005. Available at

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5851208/#:~:text=The%20mechanism%20of%20action%20of,phase%20of%20the%20coagulation%20cascade.

Thrombosiscanada,org (n.d.) Deep Vein Thrombosis: Diagnosis. Thrombosis Canada.

Available at https://thrombosiscanada.ca/clinicalguides/?search=dvt%20guide#

Thrombosiscanada.org (n.d.) Deep Vein Thrombosis (DVT): Treatment. Thrombosis Canada.