heart and blood vessel disorders
Deep Vein Thrombosis (DVT)
Treatment of Deep Vein Thrombosis
Anticoagulant drugs (sometimes called blood thinners) Sometimes, clot-dissolving drugs For deep vein thrombosis, a doctor’s main goal is to prevent Pulmonary Embolism (PE) . Hospitalization may be necessary at first, but most people with deep vein thrombosis can be treated at home. Bed rest is unnecessary except to help relieve symptoms. People may be as active as they want. Physical activity does not increase the risk that a blood clot will break loose and cause a pulmonary embolism. Treatment usually consists of Anticoagulant medications (most common) Clot-dissolving drugs Rarely, a clot-blocking filter (umbrella) People with deep vein thrombosis may be as active as they want. Physical activity does not increase the risk that a blood clot will break loose and cause pulmonary embolism. Anticoagulants are sometimes called blood thinners. They decrease the blood’s ability to clot, so they can prevent new clots from forming and can stop existing clots from getting bigger. They do not break up or dissolve clots that have already formed. All people with deep venous thrombosis are given anticoagulants. Doctors usually use an injectableheparin(unfractionated or low molecular weight) orfondaparinux, also given by injection under the skin (subcutaneously), followed by longer term treatment with an anticoagulant medication that can be taken by mouth. The injectable medication works immediately, but if people are going to usewarfarin, it takes several days to be fully effective, and the person must start taking it while still receiving the injectable anticoagulant. Once thewarfarinhas taken effect, people stop taking the injectable medication. Direct oral anticoagulants (DOAC) are an alternative towarfarin.Rivaroxaban,apixaban,edoxaban, anddabigatranare DOACs. These medications have a faster anticoagulant effect thanwarfarinand are as effective aswarfarinfor the treatment of blood clots. However, several days of treatment with the injectables are needed before starting some of the DOACs. For people whose clots are thought to be related to cancer, many doctors prefer to use the injectable medications or a DOAC rather thanwarfarin. However,warfarinis a reasonable alternative for such cases. How long people continue anticoagulants (withwarfarinor an injectable medication) varies according to the degree of risk. People whose deep vein thrombosis resulted from a specific, temporary cause (such as surgery or a medication they have stopped taking) usually continue anticoagulants for 3 to 6 months. When a specific cause is not found, people are usually on anticoagulants for at least 6 months.Anticoagulants should be continued indefinitely if the cause is not temporary (for example, a blood clotting disorder) or if people have had two or more episodes of deep vein thrombosis. Use ofanticoagulants increases the risk of bleeding, both internally and externally. To minimize this risk, people takingwarfarinmust have periodic blood tests to see how much their blood is anticoagulated. Doctors then use the blood test result to adjust the dose ofwarfarin. The blood tests are usually done once or twice a week for 1 or 2 months, and then every 4 to 6 weeks thereafter. (see also Drug Interactions ). Some medications and foods The effect of DOACs on people's blood is more predictable than the effect ofwarfarin. Therefore, unlike people takingwarfarin, people taking DOACs do not need to have frequent blood tests to adjust the dose. Also, DOACs tend to cause fewer episodes of serious bleeding thanwarfarin. However, bleeding caused by DOACs can be harder to stop because antidotes for these medications are not as widely available as antidotes forwarfarin. Excessive bleeding,which may be life-threatening, is the most common complication of anticoagulants. Risk factors for excessive bleeding include being age 65 years or older or having A recent Acute Coronary Syndromes (Heart Attack; Myocardial Infarction; Unstable Angina) , Diabetes Mellitus (DM) None Overview of Kidney Failure None For people who are takingwarfarin, doctors can give vitamin K, transfusions of plasma (which contains clotting factors), or prothrombin complex concentrate to reverse the effects of thewarfarinand stop the bleeding. For people who are takingheparin, doctors can giveprotamineto partially reverse the effects. For people taking some of the DOACs, doctors can give andexanet alfa or prothrombin complex concentrate to reverse the effects of the DOACs and stop the bleeding. Very rarely, as an alternative to Anticoagulant medications , doctors place a filter (formerly called an umbrella) inside a large vein between the heart and the area affected by deep vein thrombosis, such as the inferior vena cava. The inferior vena cava is a large vein that returns blood to the heart from the lower part of the body. The filter can trap emboli, preventing them from reaching the lungs. However, unlike Anticoagulant medications , filters do not prevent new clots from forming. Filters are usually reserved for people in whom anticoagulant therapy is not possible or not effective. In people who have deep vein thrombosis, a blood clot may break loose from an affected vein in the leg and travel through the bloodstream. A clot that breaks loose is called an embolus. The embolus travels toward the heart and passes through the right atrium and ventricle and into one of the pulmonary arteries, which carry blood to the lungs. The clot may lodge in an artery in a lung and block blood flow, resulting in pulmonary embolism. Pulmonary embolism may be life threatening, depending on how large the embolus is and the size of the blocked artery. To prevent pulmonary embolism, doctors usually use medications that limit blood clotting (anticoagulants, or blood thinners). However, for some people, doctors may recommend that a filter (formerly called an umbrella) be temporarily or permanently placed in the inferior vena cava. The inferior vena cava is a large vein that returns blood to the heart from the lower part of the body. The filter typically is recommended when anticoagulants cannot be used, for example, when a person is also having bleeding. The filter can trap emboli before they reach the heart but allow blood to flow through freely. Emboli that are trapped sometimes dissolve on their own. However, filters do not completely eliminate the risk of emboli. Sometimes other veins from the legs enlarge, allowing blood and emboli to bypass the filter. Also, filters can break loose or become blocked by a clot. Filters are much less effective at preventing pulmonary embolism than treatment with anticoagulants. Doctors only occasionally use intravenous medications, such asalteplase, to dissolve venous blood clots. These medications (also called thrombolytic, fibrinolytic, or clot-busting drugs) may be given to a person with extensive blood clots if the blood clot has been present for less than 48 hours and the person does not have risk factors for excessive bleeding. After 48 hours, scar tissue begins to develop in the blood clot, making it less likely to dissolve. Clot-dissolving drugs have a higher risk of bleeding complications. Doctors sometimes use clot-dissolving drugs in combination with mechanical removal methods in people who have large clots in their upper leg. In such cases, doctors may put a small, flexible tube (catheter) into the blocked vein, remove as much clot as possible with an instrument, and administer the clot-dissolving drug through the catheter. If Treatment occurs, treatment usually includes oxygen (usually given by a face mask or nasal prongs), analgesics to relieve pain, and In some cases, the veins never completely recover after deep vein thrombosis develops. Elastic compression stockings worn below the knee may be helpful if Chronic Venous Insufficiency and Post-Thrombotic Syndrome develops. If painful skin ulcers ( Chronic Venous Insufficiency and Post-Thrombotic Syndrome ) develop, properly applied compression bandages can help. When these bandages are applied carefully once or twice a week, the ulcer almost always heals because blood flow in the veins improves. The ulcers can become infected, and pus and a foul-smelling discharge can appear on the bandage each time it is changed. The pus and discharge can be washed off the skin with soap and water. Skin creams, balms, and skin medications of any kind have little effect. Once blood flow in the veins has improved, the ulcer heals by itself. After it has healed, wearing an elastic stocking daily can prevent a recurrence. The stocking must be replaced as soon as it becomes too loose. If possible, the person should purchase 7 stockings or pairs of stockings (if both legs are involved)—one for each day of the week so that stockings remain effective considerably longer. Rarely, ulcers that do not heal require skin grafting. After grafting, an elastic stocking must be worn to prevent ulcers from returning. 