Diagnosis and Treatment of DVT in an Urgent Care Setting
Diagnosis and Treatment of DVT in an Urgent Care Setting
Abstract & Commentary
By Scott C. Elston, MD, Eastern Regional Medical Director, NextCare Urgent Care, Cary, NC, is Associate Editor for Urgent Care Alert.
Dr. Elston reports no financial relationship to this field of study
Synopsis: Venous Thromboembolism is a common condition affecting 7.1 persons per 10,000 person years among community residents. Incidence rates are higher for men and African Americans, and increases substantially with age. It is critical to treat deep venous thrombosis at an early stage to avoid development of further complications such as pulmonary embolism or recurrent deep venous thrombosis.
Source: Snow V, et al. Management of venous thromboembolism: A clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med. 2007;146:204-210.
Recommendations
Recommendation 1: low-molecular-weight heparin (LMWH), rather than unfractionated heparin, should be used whenever possible for the initial inpatient treatment of deep venous thrombosis (DVT). Either unfractionated heparin or LMWH is appropriate for the initial treatment of pulmonary embolism.
Recommendation 2: Outpatient treatment of DVT, and possibly pulmonary embolism, with LMWH is safe and cost-effective for carefully selected patients and should be considered if the required support services are in place.
Recommendation 3: Compression stockings should be used routinely to prevent post-thrombotic syndrome, beginning within one month of diagnosis of proximal DVT and continuing for a minimum of one year after diagnosis.
Recommendation 4: There is insufficient evidence to make specific recommendations for types of anticoagulation management of Venous Thromboembolism (VTE) in pregnant women.
Recommendation 5: Anticoagulation should be maintained for 3 to 6 months for VTE secondary to transient risk factors and for more than 12 months for recurrent VTE. While the appropriate duration of anticoagulation for idiopathic or recurrent VTE is not definitively known, there is evidence of substantial benefit for extended-duration therapy.
Recommendation 6: LMWH is safe and efficacious for the long-term treatment of VTE in selected patients (and may be preferable for patients with cancer).
Commentary
With the availability of more sensitive and sophisticated laboratory testing (ie, d-dimer), as well as refined clinical evaluation tools (ie, Hamilton Criteria), urgent care centers can certainly be of greater assistance in diagnosing DVT. Now with growing evidence regarding the safety and efficacy of LMWH, urgent care centers may be able to further participate in the care of select, low-risk patients presenting with DVT. With careful patient history, skillful examination, and supportive laboratory testing, one can reliably diagnose, and now perhaps initiate, treatment in patients without significant co-morbidities or other risk factors, at least until they can be conveniently referred to the appropriate specialist for continued care.
This approach may further help to spare patients (and their insurers) the time and expense of unnecessary emergency room visits/hospitalizations, thus conserving the resources of all of the above for patients more in need of their specific levels of care.
Recommendation 1: low-molecular-weight heparin (LMWH), rather than unfractionated heparin, should be used whenever possible for the initial inpatient treatment of deep venous thrombosis (DVT). Either unfractionated heparin or LMWH is appropriate for the initial treatment of pulmonary embolism.Subscribe Now for Access
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