Update on the Management of VTE
• Including Special Populations
Introduction
• • Venous thromboembolism (VTE) includes
DVT & PE
• • Major cause of morbidity and mortality
• • Guidelines update treatment strategies
• • Special populations require tailored
management
Epidemiology
• • Incidence: ~1-2 per 1000 people/year
• • Higher risk in elderly, hospitalized, cancer
patients
• • 3rd most common cardiovascular disorder
• • Significant healthcare burden
Pathophysiology
• • Virchow’s triad: Hypercoagulability, stasis,
endothelial injury
• • Clot formation in deep veins -> embolism
risk
• • PE occurs when thrombus migrates to
pulmonary arteries
• • Inflammatory response worsens condition
Etiology
• • Surgery, trauma, prolonged immobility
• • Cancer, pregnancy, hormonal therapy
• • Genetic thrombophilias (e.g., Factor V
Leiden)
• • Chronic conditions (e.g., CKD, obesity)
Clinical Presentation
• • DVT: Leg swelling, pain, warmth, redness
• • PE: Dyspnea, chest pain, tachycardia,
hemoptysis
• • Asymptomatic cases detected incidentally
• • Severity varies by clot burden & location
Diagnosis
• • D-dimer (high sensitivity, low specificity)
• • Compression ultrasound for DVT
• • CT Pulmonary Angiography (CTPA) for PE
• • Clinical probability scoring (Wells Score,
Geneva Score)
Management – General Approach
• • Rapid risk stratification is crucial
• • Initial anticoagulation (LMWH, DOACs, UFH)
• • Long-term therapy: DOACs, Warfarin
• • Consider mechanical prophylaxis in high-risk
patients
Anticoagulation Therapy
• • DOACs (Apixaban, Rivaroxaban) preferred
• • LMWH for cancer-associated VTE
• • Warfarin for patients with renal impairment
• • Monitor INR if using Warfarin
Duration of Therapy
• • 3-6 months for provoked VTE
• • Extended therapy for unprovoked or high-
risk cases
• • Indefinite anticoagulation in recurrent cases
• • Individualized risk-benefit assessment
Reversal Agents
• • DOAC reversal: Andexanet alfa,
Idarucizumab
• • Warfarin reversal: Vitamin K, PCC, FFP
• • UFH/LMWH reversal: Protamine sulfate
• • Monitor closely for bleeding risk
Special Populations – Pregnancy
• • LMWH preferred (does not cross placenta)
• • Avoid DOACs & Warfarin (teratogenic)
• • Adjust dosing based on weight & trimester
• • Postpartum anticoagulation for at least 6
weeks
Special Populations – Cancer
• • LMWH preferred for cancer-associated
thrombosis
• • DOACs may be used in select patients
• • Consider bleeding risk with gastrointestinal
cancers
• • Duration: At least 6 months, reassess risk
Special Populations – Renal
Impairment
• • Avoid DOACs if CrCl < 30 mL/min
• • Warfarin or LMWH preferred
• • Monitor renal function & adjust dose
• • Increased bleeding risk in CKD
Monitoring & Follow-Up
• • INR monitoring for Warfarin users
• • Periodic renal/liver function tests
• • Assess adherence & bleeding risk
• • Educate patients on signs of recurrence
Emerging Therapies & Guidelines
Update
• • Novel anticoagulants under investigation
• • AI & biomarkers for risk stratification
• • Extended prophylaxis in high-risk groups
• • Updated ACCP & ASH guidelines
Summary
• • VTE management evolving with new
therapies
• • Individualized treatment based on risk
factors
• • Special populations require tailored
approaches
• • Ongoing research shaping future guidelines
References
• • Latest guidelines: ACCP, ASH, ESC
• • Landmark trials: EINSTEIN, Hokusai-VTE
• • Recent systematic reviews & meta-analyses
• • Clinical pharmacology resources
