Tratamiento del Tromboembolismo Venoso

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El Montanyà, Seva 2013
Sesión III ETEV en las guías del ACCP 2012
revisión crítica basada en los casos clínicos
X Curso de Formación Continuada

• Tratamiento del Tromboembolismo Venoso

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(No Transcript)
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Resumen de indicaciones sobre duración de la
anticoagulación con AVK en el TEV, realizado a
partir de las recomendaciones o sugerencias de la
9ª edición de las Guías de Tratamiento
Antitrombótico del ACCP.
Factor de riesgo Riesgo hemorrágico Duración
TVP proximal EP Cirugía 3 meses
TVP proximal EP Transitorio no-quirúrgico 3 meses
TVP proximal EP No provocada (1ra o recurrente) Bajo o moderado extendida
TVP proximal EP No provocada (1ra o recurrente) Alto 3 meses
TVP distal Transitorio 3 meses
TVP distal No provocada 3 meses
TEV Cáncer extendida (HBPM)
TEV incidental como sintomática
La mayoría de las recomendaciones son de grado 1B
o 2B La intensidad recomendada es de un INR 2-3
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Apuntes sobre recomendaciones en la duración de
la anticoagulación en el TEV según el SCC de la
ISTH

• Recomendamos que los pacientes con una EP o una
  TVP proximal no-provocada deben ser tratados
  durante 3 a 6 meses.
• Recomendamos que en mujeres con TEV asociado a
  tratamiento hormonal no se requieren
  anticoagulaciones superiores a 3 meses, siempre
  que el tratamiento hormonal haya sido suspendido
  en el momento del diagnóstico.
• Recomendamos que las mujeres con TEV asociado a
  terapia hormonal interrumpan el tratamiento
  hormonal (anticonceptivos orales y terapia
  estrogénica substitutiva) antes de suspender la
  terapia anticoagulante. Sin embargo, en las
  mujeres premenopáusicas debe utilizarse una
  anticoncepción alternativa eficaz para evitar la
  toxicidad potencial de la exposición fetal
  temprana a la warfarina.
• Sugerimos que en pacientes seleccionadas la
  terapia hormonal puede ser continuada si hay una
  fuerte indicación clínica para dicho tratamiento.
  En estos casos la terapia anticoagulante se debe
  continuar durante el período de mantenimiento de
  la terapia hormonal.

Baglin. JTH 2012 10 698
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Caso 1

• Mujer 24 años, sana, obesa 106kg,
  anticonceptivos orales
• 7 días antes viaje transoceánico unas semanas
  antes del vuelo refirió molestias sin limitación
  funcional de EEII
• Motivo de consulta molestias y aumento del
  perímetro MID
• DD 990 ng/mL (nlt234)
• ECOdoppler TVP femoral superficial, poplítea y
  distal MID

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Probabilidad clínica de TVP (Wells)
Criterio clínico Puntuación
Cáncer activo (en tratamiento en la actualidad o en los 6 meses previos o paliativo) 1
Parálisis, paresia o reciente inmovilización con férula de las extremidades inferiores 1
Reciente Inmovilización en cama gt3 días, o cirugía mayor bajo anestesia general o regional los 3 últimos meses 1
Dolor a la palpación localizada en el trayecto del sistema venoso profundo 1
Edema global de la pierna 1
Aumento del diámetro de la pantorrilla afecta gt3cm respecto de la asintomática (medida 10cm debajo de la protuberancia tibial) 1
Edema con fóvea limitado a la pierna sintomática 1
Venas (no-varicosas) colaterales superficiales 1
Antecedente de TVP bien documentada 1
Diagnostico alternativo tanto o más probable que el de TVP -2
Probabilidad clínica
lt1 BAJA lt1 IMPROBABLE 1 2 INTERMEDIA gt2
PROBABLE gt2 ALTA

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Lo que dicen las guías

• 3.3 In patients with a moderate pretest
  probability of first lower extremity DVT, we
  recommend one of the following initial tests (i)
  a highly sensitive D-dimer or (ii) proximal CUS,
  or (iii) whole-leg US rather than (i) no testing
  (Grade 1B for all comparisons) or (ii) venography
  (Grade 1B for all comparisons) . We suggest
  initial use of a highly sensitive D-dimer rather
  than US (Grade 2C).
• 3.4. In patients with a high pretest probability
  of first lower extremity DVT, we recommend either
  (i) proximal CUS or (ii) whole-leg US over no
  testing (Grade 1B for all comparisons) or
  venography (Grade 1B for all comparisons).

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Técnicas de dímero D especificidad y
sensibilidad en el diagnóstico de TEV
Técnica Sensitivity (95 CI) Specificity (95 CI)
highly sensitive Enzyme-linked immunofluorescence assays 96 (89-98) 46 (31-61)
microplate enzyme-linked immunosorbent assays (ELISAs) 94 (86-97) 53 38-68)
quantitative latex or immunoturbidimetric assays 93 (89-95) 53 (46-61)
moderately sensitive whole blood D-dimer assay 83 (67-93) 71 (57-82)
latex semiquantitative assays 85 (68-93)
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Caso 1

• Stop anticonceptivos orales

Día INR HBPM AVK
0 1.04 Enoxaparina 1.4 mg qd
7 1.05 Enoxaparina 1.4 mg qd warfarina
10 1.1 Enoxaparina 1.4 mg qd warfarina
14 1.41 Enoxaparina 1.4 mg qd warfarina
18 2.15 warfarina
25 2.8 warfarina

• Metrorragia a los 7 días de inicio de HBPM
• A las 2 semanas inicio progesterona

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Pregunta caso 1

• El día que presentó la metrorragia, cual hubiese
  sido la mejor actuación respecto de la
  anticoagulación con HBPM?
• Mantener la misma dosis de HBPM
• Reducir la HBPM a dosis de profilaxis
• Suspender alguna dosis de HBPM
• Suspender la HBPM
• Suspender la HBPM e iniciar AVK

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Systematic review case-fatality rates of
recurrent VTE and major bleeding events among
patients treated for VTE
Carrier y col. Ann Intern Med 2010 152 578
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Lo que dicen las guías

• 2.1. In patients with acute DVT of the leg
  treated with vitamin K antagonist (VKA) therapy,
  we recommend initial treatment with parenteral
  anticoagulation (low-molecular-weight heparin
  LMWH, fondaparinux, IV unfractionated heparin
  UFH, or subcutaneous SC UFH) over no such
  initial treatment (Grade 1B).
• 2.4. In patients with acute DVT of the leg, we
  recommend early initiation of VKA (eg, same day
  as parenteral therapy is started) over delayed
  initiation, and continuation of parenteral
  anticoagulation for a minimum of 5 days and until
  the international normalized ratio (INR) is 2.0
  or above for at least 24 h (Grade 1B).
• 2.5.2. In patients with acute DVT of the leg
  treated with LMWH, we suggest once- over
  twice-daily administration (Grade 2C) .
• Remarks This recommendation only applies when
  the approved once-daily regimen uses the same
  daily dose as the twice-daily regimen (ie, the
  once-daily injection contains double the dose of
  each twice-daily injection). It also places value
  on avoiding an extra injection per day.
• 2.7. In patients with acute DVT of the leg and
  whose home circumstances are adequate, we
  recommend initial treatment at home over
  treatment in hospital (Grade 1B).

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Lo que dicen las guías

• 2.14. In patients with acute DVT of the leg, we
  suggest early ambulation over initial bed rest
  (Grade 2C).
• Remarks If edema and pain are severe, ambulation
  may need to be deferred. We suggest the use of
  compression therapy in these patients.
• 3.1.2. In patients with a proximal DVT of the leg
  provoked by a nonsurgical transient risk factor,
  we recommend treatment with anticoagulation for 3
  months over (i) treatment of a shorter period
  (Grade 1B) , (ii) treatment of a longer
  time-limited period (eg, 6 or 12 months) (Grade
  1B) , and (iii) extended therapy if there is a
  high bleeding risk (Grade 1B) . We suggest
  treatment with anticoagulation for 3 months over
  extended therapy if there is a low or moderate
  bleeding risk (Grade 2B).
• 3.1.4. In patients with an unprovoked DVT of the
  leg (isolated distal see remark or proximal),
  we recommend treatment with anticoagulation for
  at least 3 months over treatment of a shorter
  duration (Grade 1B) . After 3 months of
  treatment, patients with unprovoked DVT of the
  leg should be evaluated for the risk-benefit
  ratio of extended therapy.
• 3.1.4.1. In patients with a first VTE that is an
  unprovoked proximal DVT of the leg and who have a
  low or moderate bleeding risk, we suggest
  extended anticoagulant therapy over 3 months of
  therapy (Grade 2B) .

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Systematic review case-fatality rates of
recurrent VTE and major bleeding events among
patients treated for VTE
Carrier y col. Ann Intern Med 2010 152 578
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Lo que dicen las guías

• 3.2. In patients with DVT of the leg who are
  treated with VKA, we recommend a therapeutic INR
  range of 2.0 to 3.0 (target INR of 2.5) over a
  lower (INR , 2) or higher (INR 3.0-5.0) range for
  all treatment durations (Grade 1B).
• 3.3.1. In patients with DVT of the leg and no
  cancer, we suggest VKA therapy over LMWH for
  long-term therapy (Grade 2C) . For patients with
  DVT and no cancer who are not treated with VKA
  therapy, we suggest LMWH over dabigatran or
  rivaroxaban for long-term therapy (Grade 2C).
• 4.1. In patients with acute symptomatic DVT of
  the leg, we suggest the use of compression
  stockings (Grade 2B).
• Remarks Compression stockings should be worn for
  2 years, and we suggest beyond that if patients
  have developed PTS and find the stockings helpful.

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Caso 2

• Mujer 24 años,
• Parto eutócico 15 días antes
• Acude por dolor región gemelar MID
• Ligero edema MID y empastamiento muscular
• Dímero-D 800ng/mL
• ECOdoppler no se aprecia trombosis
• Tratamiento sintomático

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Lo que dicen las guías

• 3.4. In patients with a high pretest probability
  of first lower extremity DVT, we recommend either
  (i) proximal CUS or (ii) whole-leg US over no
  testing (Grade 1B for all comparisons) or
  venography (Grade 1B for all comparisons).
• In patients with a negative proximal CUS, we
  recommend additional testing with a highly
  sensitive D-dimer or whole-leg US or repeat
  proximal CUS in 1 week over no further testing
  (Grade 1B for all comparisons) or venography
  (Grade 2B for all comparisons) . We recommend
  that patients with a single negative proximal CUS
  and positive D-dimer undergo whole-leg US or
  repeat proximal CUS in 1 week over no further
  testing (Grade 1B) or venography (Grade 2B) . In
  patients with negative serial proximal CUS, a
  negative single proximal CUS and negative highly
  sensitive D-dimer, or a negative whole-leg US, we
  recommend no further testing over venography or
  additional US (Grade 1B for negative serial
  proximal CUS and for negative single proximal CUS
  and highly sensitive D-dimer Grade 2B for
  negative whole-leg US).
• We recommend that in patients with high pretest
  probability, moderately or highly sensitive
  D-dimer assays should not be used as standalone
  tests to rule out DVT (Grade 1B)

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Caso 2

• A las 24h acude, de nuevo, a urgencias por
  progresión del dolor en MID
• Dolor agudo a la palpación región gemelar
• ECodoppler TVP gemelar MID
• Tratamiento tinzaparina 170 UI/kg qd

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Lo que dicen las guías

• 2.3.1. In patients with acute isolated distal DVT
  of the leg and without severe symptoms or risk
  factors for extension, we suggest serial imaging
  of the deep veins for 2 weeks over initial
  anticoagulation (Grade 2C).
• 2.3.2. In patients with acute isolated distal DVT
  of the leg and severe symptoms or risk factors
  for extension (see text), we suggest initial
  anticoagulation over serial imaging of the deep
  veins (Grade 2C).
• Remarks Patients at high risk for bleeding are
  more likely to benefit from serial imaging.
  Patients who place a high value on avoiding the
  inconvenience of repeat imaging and a low value
  on the inconvenience of treatment and on the
  potential for bleeding are likely to choose
  initial anticoagulation over serial imaging.
• 3.1.3. In patients with an isolated distal DVT of
  the leg provoked by surgery or by a nonsurgical
  transient risk factor (see remark), we suggest
  treatment with anticoagulation for 3 months over
  treatment of a shorter period (Grade 2C) and
  recommend treatment with anticoagulation for 3
  months over treatment of a longer time-limited
  period (eg, 6 or 12 months) (Grade 1B) or
  extended therapy (Grade 1B regardless of bleeding
  risk).

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Pregunta caso 2

• En una puérpera lactante con un TEV, cual crees
  que es la mejor estrategia anticoagulante?
• HBPM seguida de AVK
• HBPM
• Rivaroxaban
• 1 y 2 son correctas

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Caso 3

• Mujer de 38 años, fumadora, S. ansioso-depresivo,
  endometriosis. Anticonceptivos orales (inicio 6
  meses antes)
• 2d antes dolor y aumento del perímetro
  infrapoplíteo MII
• Es atendida por episodio sincopal, vegetatismo,
  disnea de inicio súbito posterior.
• RS, TA 100/60mmHg, FC110 lpm,
• ECG S1Q3T3, DD 10000 ng/mL,
• Enoxaparina 1mg/kg y remisión a Hospital de
  referencia

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Caso 3
En Hospital de referencia

• TA 100/60 mmHg, FC 105 lpm
• SaO2 99, FGgt60mL/min
• Troponina I 0.86ug/L (nlt0.2)
• AngioTC TEP masivo bilateral, signos sobrecarga
  D, signos sugerentes TVP poplítea bilateral
• ECOcar TT VD dilatado, ratio VD/VI 1.2,
  disfunción TAPSE 10mm
• ECOdoppler VFS-P ocupación de luz sin
  no-compresibilidad bilateral

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Caso 3
Tratamiento

• Angiografía pulmonargt trombectomía (PAm33gt32) no
  trombolisis
• HNF (bolo 80 U/kg gtperfusión 18 U/kg/hgtajustada a
  TTPa 1.5-2.5)
• A los 2 días tinzaparina 175 U/kg qd
• A los 5 días inicio warfarina
• A los 20 días stop tinzaparina (INR 2.02)

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Pregunta caso 3

• Cuanto tiempo anticoagularías a este paciente?
• 3 meses
• 6 meses
• 1 año
• Indefinido

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Lo que qué dicen las guías

• 5.2.1. In patients with a high clinical suspicion
  of acute PE, we suggest treatment with parenteral
  anticoagulants compared with no treatment while
  awaiting the results of diagnostic tests (Grade
  2C).
• 5.4.1. In patients with acute PE, we suggest LMWH
  or fondaparinux over IV UFH (Grade 2C for LMWH
  Grade 2B for fondaparinux) and over SC UFH (Grade
  2B for LMWH Grade 2C for fondaparinux) .
• Remarks Local considerations such as cost,
  availability, and familiarity of use dictate the
  choice between fondaparinux and LMWH.
• LMWH and fondaparinux are retained in patients
  with renal impairment, whereas this is not a
  concern with UFH.
• In patients with PE where there is concern about
  the adequacy of SC absorption or in patients in
  whom thrombolytic therapy is being considered or
  planned, initial treatment with IV UFH is
  preferred to use of SC therapies.
• 5.5. In patients with low-risk PE and whose home
  circumstances are adequate, we suggest early
  discharge over standard discharge (eg, after
  first 5 days of treatment) (Grade 2B) .

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Criterios de Wells.

• Síntomas clínicos de TVP 3,0
• Otros diagnósticos menos probables 3,0
• Frecuencia cardiaca mayor de 100 l.p.m. 1,5
• Inmovilización o cirugía en las últimas 4
  semanas 1,5
• Antecedentes de TVP o TEP 1,5
• Hemoptisis 1,0
• Cáncer 1,0

Probabilidad Clínica de TEP.
Baja lt 2 Intermedia 2-6 Alta gt 6
Wells PS y cols. Ann Intern Med 2001.
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Escala de riesgo pronóstico PESI simplificado

• Edad gt 80 años 1 punto
• Historia de cáncer 1 punto
• Historia de insuficiencia cardiaca o EPOC 1
  punto
• Pulso gt 110 lpm 1 punto
• Presión arterial sistólica lt 100 mmHg 1 punto
• Saturación de O2 lt 90 1 punto

Recomendación

• Bajo riesgo 0 puntos Alta precoz /
  hospitalización domiciliaria
• Alto riesgo gt1 Ingreso hospitalario.
• Elevación de Troponina y/o disfunción de VD
  (ecocardiograma) valorar UCI

Jimenez D et al. Chest 2007
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Lo que dicen las guías

• 5.6.1.1. In patients with acute PE associated
  with hypotension (eg, systolic BP , 90 mm Hg) who
  do not have a high bleeding risk, we suggest
  systemically administered thrombolytic therapy
  over no such therapy (Grade 2C).
• 5.6.1.2. In most patients with acute PE not
  associated with hypotension, we recommend against
  systemically administered thrombolytic therapy
  (Grade 1C).
• 5.6.1.3. In selected patients with acute PE not
  associated with hypotension and with a low
  bleeding risk whose initial clinical
  presentation, or clinical course after starting
  anticoagulant therapy, suggests a high risk of
  developing hypotension, we suggest administration
  of thrombolytic therapy (Grade 2C).
• 5.7. In patients with acute PE associated with
  hypotension and who have (i) contraindications to
  thrombolysis, (ii) failed thrombolysis, or (iii)
  shock that is likely to cause death before
  systemic thrombolysis can take effect (eg, within
  hours), if appropriate expertise and resources
  are available, we suggest catheter-assisted
  thrombus removal over no such intervention (Grade
  2C).
• 6.3.1. In patients with a first VTE that is an
  unprovoked PE and who have a low or moderate
  bleeding risk, we suggest extended anticoagulant
  therapy over 3 months of therapy (Grade 2B).

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Caso 4

• Varón de 45 años, HTA, fumador, sin antecedentes
  familiares de TEV
• Desde hace 4 semanas dolor centrotorácico sin
  vegetatismo y dísnea progresivagtactualmente de
  reposo
• Hipotenso, mal perfundido, FC125 lpm.
• SpO2 95 (Mónagan), PAO2/FIO2 145 (ngt300),DD 2152
  ng/mL, troponina I 0.20 ug/L ECG S1Q3T3
• ECOcar TT dilatación disfunción VD
• AngioTAC TEP masivo bilateral, sobrecarga cav.
  D, área vidrio deslustrado base , posible TVP.
• ECOdoppler TVP FP MII
• OD TEP Neumonía

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Caso 4

• Arteriografíagttrombectomía fibrinolisis local

Puente de la Constitución
Día INR HBPM/HNF Warfarina (mg)
0 HNF
3 Tinzaparina 175 UI/kg qd
17 1 Tinzaparina 175 UI/kg qd 5-5-5
20 2.75 2.5-2.5-2.5
23 6.5 0-0-2.5-2.5-2.5-0
29 3.37 2.5
30 6.3 0-0-2.5-0
34 4.4 0-2.5 alternos
41 3.29 1 diario
Vacaciones de Navidad
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Lo que dicen las guías

• 5.6.2.1. In patients with acute PE, when a
  thrombolytic agent is used, we suggest short
  infusion times (eg, a 2-h infusion) over
  prolonged infusion times (eg, a 24-h infusion)
  (Grade 2C).
• 5.6.2.2. In patients with acute PE when a
  thrombolytic agent is used, we suggest
  administration through a peripheral vein over a
  pulmonary artery catheter (Grade 2C) .
• 5.9.1. In patients with acute PE who are treated
  with anticoagulants, we recommend against the use
  of an IVC filter (Grade 1B) .

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Caso 5

• Varón 84 años, HTA, DLP, DM-II, BNCO, Cardiopatía
  isquémica (IAM hace años), I. renal crónica
  (creat 140), dependiente, movilización muy
  limitada
• AAS, pravastatina, insulina, haloperidol,
  omeprazol, O2 domiciliario
• Historia de 4 días de febrícula, expectoración
  purulenta, dísnea
• TA 130/60, FC 81,
• Sat O2 98, DD6500, Troponina T lt0.03 µg/L
  (nlt0.014)
• TAC con contraste TEP ramas segmento ant. LSD,
  condensación LID
• ECOcar FE 45 hipocinesia septal
• HBPMgtacenocumarol

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Pregunta caso 5

• Cuanto tiempo anticoagularías a este paciente?
• 3 meses
• 6 meses
• 1 año
• Indefinido

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Lo que dicen las guías

• 6.3.2. In patients with a first VTE that is an
  unprovoked PE and who have a high bleeding risk,
  we recommend 3 months of anticoagulant therapy
  over extended therapy (Grade 1B) .

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Factores de riesgo de hemorragia en el
tratamiento del TEV con AVK (9ª ed guía ACCP)
Edad gt 65 años Edad gt 75 años Sangrado previo Cáncer Cáncer metastático Insuficiencia renal Insuficiencia hepática Trombocitopenia Ictus previo Diabetes Anemia Tratamiento antiagregante Mal control de la anticoagulación Comorbilidades y capacidad funcional reducida Cirugía reciente Caídas frecuentes Enolismo
Puntuación
Riesgo Nº factores de riesgo
Bajo Moderado Elevado 0 1 gt 2
36
(No Transcript)
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Caso 6

• Mujer 74 años, HTA, DM, DLP, TVP MII
  post-histerectomía hace 20 años gt acenocumarol 4
  años, antecedentes en familiares 1er orden de TEV
• Dianben, Omeprazol
• Acude por dolor y aumento del perímetro de MII
• MII caliente, empastamiento gemelar, asimetría
• DD 1200
• ECOdoppler TVP IFP MII

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Lo que dicen las guías

• 3.1.4.4. In patients with a second unprovoked
  VTE, we recommend extended anticoagulant therapy
  over 3 months of therapy in those who have a low
  bleeding risk (Grade 1B), and we suggest extended
  anticoagulant therapy in those with a moderate
  bleeding risk (Grade 2B) .
• 3.1.4.5. In patients with a second unprovoked VTE
  who have a high bleeding risk, we suggest 3
  months of anticoagulant therapy over extended
  therapy (Grade 2B) .

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Caso 7

• Varón de 72 años
• Cáncer ductal infiltrante de mama, metástasis
  óseas, estadio IV (6/11)
• TEP bilateral incidental (7/11) durante tto
  tamoxifeno/zometa gttinzaparina 175 UI/kg qd 6
  mesesgtAVK
• Progresión M1 óseas y progresión biológica gt
  decapeptyl/letrozol/zometa

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Lo que dicen las guías

• 6.4. In patients with PE and active cancer, if
  there is a low or moderate bleeding risk, we
  recommend extended anticoagulant therapy over 3
  months of therapy (Grade 1B) , and if there is a
  high bleeding risk, we suggest extended
  anticoagulant therapy (Grade 2B) .
• Remarks In all patients who receive extended
  anticoagulant therapy, the continuing use of
  treatment should be reassessed at periodic
  intervals (eg, annually).
• 6.7. In patients with PE and cancer, we suggest
  LMWH over VKA therapy (Grade 2B) . In patients
  with PE and cancer who are not treated with LMWH,
  we suggest VKA over dabigatran or rivaroxaban for
  long-term therapy (Grade 2C).
• 6.9. In patients who are incidentally found to
  have asymptomatic PE, we suggest the same initial
  and long-term anticoagulation as for comparable
  patients with symptomatic PE (Grade 2B).

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El Montanyà, Seva 2013
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