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Tratamiento del Tromboembolismo Venoso

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El Montany , Seva 2013 Sesi n III: ETEV en las gu as del ACCP 2012: revisi n cr tica basada en los casos cl nicos X Curso de Formaci n Continuada – PowerPoint PPT presentation

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Title: Tratamiento del Tromboembolismo Venoso


1
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

2
(No Transcript)
3
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
4
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
5
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

6
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

7
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).

8
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)
9
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

10
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

11
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
12
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).

13
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) .

14
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
15
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.

16
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

17
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)

18
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

19
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).

20
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

21
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

22
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

23
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)

24
Pregunta caso 3
  • Cuanto tiempo anticoagularías a este paciente?
  • 3 meses
  • 6 meses
  • 1 año
  • Indefinido

25
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) .

26
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.
27
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
28
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).

29
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

30
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
31
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) .

32
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

33
Pregunta caso 5
  • Cuanto tiempo anticoagularías a este paciente?
  • 3 meses
  • 6 meses
  • 1 año
  • Indefinido

34
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) .

35
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)
37
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

38
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) .

39
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

40
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).

41
El Montanyà, Seva 2013
X Curso de Formación Continuada
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