Meagan Wong, MD
Brandon Fainstad, MD
David Garcia, MD – expert review (hematologist, University of Washington)
Objectives
- Determine IF a venous thromboembolism warrants anticoagulation versus further evaluation.
- Determine WHERE anticoagulation should be initiated, inpatient or outpatient.
- Select WHICH anticoagulation agent to use.
- Develop a framework for determining HOW LONG to anticoagulate.
Teaching Instructions
Preparation
Plan to spend at least 30 minutes preparing for this talk. It is designed to be delivered on a chalkboard/whiteboard, but could easily be projected on a display instead. This chalk talk uses 4 cases to highlight the If, WHERE, WHICH and HOW LONG decisions in the initial anticoagulation management of VTE. Each segment could be presented on its own, and we have provided expected presentation times for each. The entire chalk talk will take 40-50 minutes to deliver.
Print the VTE Teacher’s Guide for your personal reference. Draw the “Board Set-up” on the whiteboard along with abridged learning objectives before starting the presentation. Organize the learners into four groups so they can work one of the four cases together. Print out enough copies of the VTE Learner’s Handout on double-sided paper so each learner can have at least one case. You will give one of the four cases to each learner or small group. Ask them not to look at the back. They will read the clinical vignette within the group and discuss the first question then come back together as a large group to explain their decision to the rest of the learners. You will repeat this process for all four ‘stages’ and fill in the “chalk talk” as you go. The back page is a copy of the final chalkboard for their reference…but, you should really recommend they just come back to teachIM.org as a reference.
Introduction
Initial management of venous thromboemboli (VTE) depends on vascular location, an individual’s ongoing thrombosis risk and their risk of bleeding. We will work through four separate cases and in the process, answer four basic questions:
- IF the thrombus should be treated with anti-coagulation
- WHERE the anti-coagulation should be initiated
- WHAT is the most appropriate long-term agent
- HOW LONG to anti-coagulate.
Printouts
Interactive Boards
For Teaching
Use for Presenting – Warning, this is not an interactive PowerPoint but just a series of slides for the stages of this talk. We recommend reproducing a version of this on a whiteboard rather than using the PowerPoint for this talk.
Take Home Point
- Low risk below the knee DVT may be re-evaluated with repeat duplex in 1-2 weeks before starting anticoagulation.
- An uncomplicated PE with a PESI score below 85 may be managed as an outpatient.
- DOACs are first-line treatment of stable VTEs, including most cancer-related VTEs.
- Unprovoked VTEs without high bleed risk should receive indefinite anticoagulation.
References
Kearon, Clive, et al. “Antithrombotic Therapy for VTE Disease.” Chest, vol. 149, no. 2, 2016, pp. 315–352., doi:10.1016/j.chest.2015.11.026.
Aujesky, Drahomir, et al. “Derivation and Validation of a Prognostic Model for Pulmonary Embolism.” American Journal of Respiratory and Critical Care Medicine, vol. 172, no. 8, 2005, pp. 1041–1046., doi:10.1164/rccm.200506-862oc.
Stevens, Scott M., et al. “Guidance for the Evaluation and Treatment of Hereditary and Acquired Thrombophilia.” Journal of Thrombosis and Thrombolysis, vol. 41, no. 1, 2016, pp. 154–164., doi:10.1007/s11239-015-1316-1.
Raskob, G. E., et al. “Edoxaban for the Treatment of Cancer-Associated Venous Thromboembolism.” New England Journal of Medicine,378(7), 2018, pp. 615-624. doi:10.1056/nejmoa1711948
Young, Annie M., et al. “Comparison of an Oral Factor Xa Inhibitor With Low Molecular Weight Heparin in Patients With Cancer With Venous Thromboembolism: Results of a Randomized Trial (SELECT-D).” Journal of Clinical Oncology, vol. 36, no. 20, Oct. 2018, pp. 2017–2023., doi:10.1200/jco.2018.78.8034.
