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LEARNING OBJECTIVES

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LEARNING OBJECTIVES

Upon completion of the chapter, the reader will be able to:

  1. Identify risk factors and signs and symptoms of deep vein thrombosis (DVT) and pulmonary embolism (PE).

  2. Describe the processes of hemostasis and thrombosis, including the role of the vascular endothelium, platelets, coagulation cascade, and thrombolytic proteins.

  3. Determine a patient's relative risk (low, moderate, or high) of developing venous thrombosis.

  4. Formulate an appropriate prevention strategy for a patient at risk for DVT.

  5. State at least two potential advantages of newer anticoagulants (i.e., low molecular weight heparins, fondaparinux, oral direct thrombin inhibitors, and oral direct factor Xa inhibitors) over traditional anticoagulants (i.e., unfractionated heparin and warfarin).

  6. Select and interpret laboratory test(s) to monitor antithrombotic drugs.

  7. Identify factors that place a patient at high risk of bleeding while receiving antithrombotic drugs.

  8. Manage a patient with an elevated international normalized ratio (INR) with or without bleeding.

  9. Identify warfarin drug–drug and drug–food interactions.

  10. Formulate an appropriate treatment plan for a patient who develops a DVT or PE, and develop a comprehensive education plan for a patient who is receiving an antithrombotic drug.

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KEY CONCEPTS

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  • Image not available. Antithrombotic therapies (thrombolytics and anticoagulants) require precise dosing and meticulous monitoring, as well as ongoing patient education. Well-organized anticoagulation management services improve the quality of patient care and reduce the overall cost.

  • Image not available. The risk of venous thromboembolism (VTE) is related to several identifiable factors including age, prior history of VTE, major surgery (particularly orthopedic procedures of the lower extremities), trauma, malignancy, pregnancy, estrogen use, and hypercoagulable states. These risks are additive.

  • Image not available. The symptoms of DVT or PE are nonspecific, and it is extremely difficult to distinguish VTE from other disorders on clinical signs alone. Therefore, objective tests are required to confirm or exclude the diagnosis.

  • Image not available. At the time of hospital admission, all patients should be evaluated for their risk of VTE, and strategies to prevent VTE appropriate for each patient's level of risk should be routinely used. Prophylaxis should be continued throughout the period of risk.

  • Image not available. In the absence of contraindications, the treatment of VTE should initially include a rapid-acting anticoagulant (e.g., unfractionated heparin [UFH], low molecular weight heparin [LMWH], or fondaparinux) overlapped with warfarin for at least 5 days and until the patient's international normalized ratio (INR) is greater than 2 and stable. Anticoagulation therapy should be continued for a minimum of 3 months. However, the duration of anticoagulation therapy should be based on the patient's risk of VTE recurrence and major bleeding.

  • Image not available. Due to significant variability in interpatient response and changes in patient response over time, UFH requires close monitoring and periodic dose adjustment.

  • Image not available. Bleeding is the most common adverse effect associated with antithrombotic drugs. A patient's risk of major hemorrhage is related to the intensity and stability of therapy, age, concurrent drug use, history of GI bleeding, risk of falls or trauma, and recent surgery.

  • Image not available. Most patients with an uncomplicated deep vein thrombosis (DVT) can be managed safely at ...

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