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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.

  3. Determine a patient’s relative risk of developing venous thrombosis.

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

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

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

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

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

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

  10. Formulate an appropriate treatment plan for a patient who develops a DVT or PE.




Venous thromboembolism (VTE) is one of the most common cardiovascular disorders in the United States. VTE is manifested as deep vein thrombosis (DVT) and pulmonary embolism (PE) resulting from thrombus formation in the venous circulation (Figure 10–1).1,2 It is often provoked by prolonged immobility and vascular injury and most frequently seen in patients hospitalized for a serious medical illness, trauma, or major surgery. VTE can also occur with little or no provocation in patients who have an underlying hypercoagulable disorder.

FIGURE 10–1.

Venous circulation. (From Witt DM, Clark NP. Venous thromboembolism. In: DiPiro JT, Talbert RL, Yee GC, et al., eds. Pharmacotherapy: A Pathophysiologic Approach, 9th ed. New York, NY: McGraw-Hill, 2014:246.)

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Although VTE may initially cause few or no symptoms, the first overt manifestation of the disease may be sudden death from PE, which can occur within minutes, before effective treatment can be given.2,3 A history of VTE is a significant risk factor for recurrent thromboembolic events.4,5,6,7 Postthrombotic syndrome (PTS) is a complication of VTE that occurs due to damage to the vein caused by a blood clot and leads to development of symptomatic venous insufficiency such as chronic lower extremity swelling, pain, tenderness, skin discoloration, and ulceration.


The treatment of VTE is fraught with substantial risks.8 KEY CONCEPT Antithrombotic therapies (thrombolytics and anticoagulants) require precise dosing and meticulous monitoring, as well as ongoing patient assessment and education.4,9,10 Well-organized anticoagulation management services improve quality of care and reduce overall cost. A systematic approach to drug therapy management reduces risks, but bleeding remains a common and serious complication.10,11 Therefore, preventing VTE is paramount to improving outcomes. When VTE is suspected, a rapid and accurate diagnosis is critical to making appropriate treatment decisions. The optimal use of antithrombotic drugs requires ...

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