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Duration of anticoagulation in VTE The decision is always based

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					Duration of anticoagulation in VTE
 1- The decision is always based on weighing the risk of recurrence
    versus the risk of bleeding.
 2- Sure long term warfarin will reduce the recurrence of VTE
    significantly but the risk of major bleeding will be up to 4 % per
    patient per year.
 3- The risk of VTE recurrence relates to the presence of additional
    prothrombotic factors at the time of the initial event, the number of
    previous events, the specific hpercoagulable states and presence of
    residual PTS.
 4- The best evidence duration of therapy:
    # 3 Months of therapy is indicated in first uncomplicated VTE
    (without PTS) provoked by a major transient risk factor (Major
    surgery).
    # 6-12 Months of therapy is indicated in:
     *First idiopathic event or provoked by minor risk factor (OCP)
     *Heterozygous factor V Leiden, heterozygous factor II mutation,
        Hyperhomocyseinemia, or a reversible secondary
        hypercoagulable state (pregnancy) all without complicated VTE
    # 12-18 Months Persistent V III elevation, protein C deficiency,
        protein S deficiency or residual venous insufficiency.
    # Indefinite anticoagulation is indicated in:
     *Patients with multiple idiopathic VTEs or persistent significant
       risk (severe PTS).
     *Single event in patients with AT III deficiency,
        dysfibrinogenemia, multible hypercoagulable states, or APLA
       syndrome.
     *Single life threatening event or an unusual site (mesenteric or
        cerebral vein).
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October 15, 2007 (table of contents)
Vol. 76 No. 8


      Table 1. Wells Prediction Rule for Diagnosing DVT*
      Clinical characteristic                                                                                          Score
      Alternative diagnosis at least as likely as DVT                                                                  -2
      Active cancer (treatment ongoing, within previous six months, or palliative)                                     1
      Calf swelling 3 cm larger than asymptomatic side (measured 10 cm below tibial                                    1
       tuberosity)
      Collateral superficial veins (nonvaricose)                                                                       1
      Paralysis, paresis, or recent plaster immobilization of the lower extremities                                    1
      Pitting edema confined to the symptomatic leg                                                                    1
      Recently bedridden for more than three days or major surgery within 12 weeks that                                1
       required general or regional anesthesia
      Swollen leg                                                                                                      1


      note: Clinical probability of DVT is low if score is 0 or less; intermediate if 1 or 2; and high if 3 or more.
      *-In patients with symptoms in both legs, the more symptomatic leg is used.
      Adapted with permission from Wells PS, Anderson DR, Bormanis J, Guy F, Mitchell M, Gray L, et al. Value of
       assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet 2002;350:1796.




      Table 2. Wells Prediction Rule for Diagnosing Pulmonary Embolism
      Clinical characteristic                                                                                      Score
      Cancer                                                                                                       1
      Hemoptysis                                                                                                   1
      Heart rate more than 100 bpm                                                                                 1.5
      Previous pulmonary embolism or DVT                                                                           1.5
      Recent surgery or immobilization                                                                             1.5
      Alternative diagnosis less likely than pulmonary embolism                                                    3
      Clinical signs of DVT                                                                                        3


      note: Clinical probability of pulmonary embolism is low if score is 0 to 1; intermediate if 2 to 6; and high if > 6

				
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