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WORKING WITH OUR COLLEAGUES IN NORTHEAST MICHIGAN GREAT LAKES HEART CENTER OF ALPENA
HOME ATRIAL FIBRILLATION DVT VALVULAR HEART DISEASE SURGERY DOSING
Initial treatment of acute leg DVT Initiate anticoagulation with LMWH or UFH (IV or SC) for at least 5 days. UFH can be given SC after a an IV loading dose and17,500 bid to maintain a therapeutic aPTT. Start warfarin concomitantly. Heparin can be discontinued when the PT/INR has been therapeutic for 2 days. Patients should be ambulated as tolerated. Thrombolysis (systemic or catheter delivered) should be used only in selected cases (e.g., massive DVT with gangrene). IVC filter should be reserved for those with contraindications to or complications of anticoagulation (2C).	Chronic management of lower extremity DVT (Choose all tha apply) Is this the first episode? Is there a reversible cause? Does the patient have protein C or S deficiency, factor V Leiden, hyperhomocystenemia, prothrombin gene 20210 gene mutation, elevated factor VIII levels? Does the patient have antiphospholipid antibodies or 2 or more of the above thrombophilic conditions? Does the patient have an underlying malignancy?	Upper extremity DVT Initiate systemic therapy with LMWH or UFH (1C). Thrombolytic therapy in patients with low bleeding risk and acute onset (2C). Catheter extraction or surgical embolectomy in patients who fail anticoagulation or thrombolysis (2C). SVC filter can be considered in patients with contraindications to anticoagulation (2C). Long term therapy of upper extremity DVT Long term anticoagulation as per LE DVT protocol (1C). Elastic bandages for relief of persistent edema and pain (2C).
Initial treatment of pulmonary embolism For non massive PE initiate anticoagulation with LMWH or IV UFH for at least 5 days. Start warfarin concomitantly. Heparin can be discontinued when the PT/INR has been therapeutic for 2 days. Thrombolysis (systemic or catheter delivered) should be used only in selected cases (e.g., massive DVT with gangrene). Catheter extraction or surgical embolectomy for unstable patients unable to receive thrombolysis (2C). IVC filter should be reserved for those with contraindications to or complications of anticoagulation (2C).	Chronic therapy of pulmonary embolism (Choose all tha apply) Is this the first episode? Is there a reversible cause? Does the patient have protein C or S deficiency, factor V Leiden, hyperhomocystenemia, prothrombin gene 20210 gene mutation, elevated factor VIII levels? Does the patient have antiphospholipid antibodies or 2 or more of the above thrombophilic conditions? Does the patient have an underlying malignancy?	Chronic thromboembolic pulmonary hypertension Indefinite anticoagulation with a target INR of 2.5 (range 2.0 - 3.0). Pulmonary thromboendarterectomy(1C) and IVC filter placement (2C) in selected cases. Post thrombotic syndrome Elastic compression stockings (2C) or rutosides (2B) for mild edema. Intermittent compression therapy for severe edema (2B). Superficial thrombophlebitis Topical(1B) or oral (1C) diclofenac for post i.v. superficial thrombophlebitis For spontaneous superficial thrombophlebitis UFH or LMWH at intermidiate doses for 4 weeks (2B)
Grade 1 recommendations - reviewers are very certainthat benefits do, or do not, outweigh risks, burdens, and costs. Grade 2 recommendation - reviewers are less certain of the magnitude of the benefitsand the risks, burdens, and costs, and thus of their relativeimpact. Grade A recommendations - Consistentresults from noted from randomized clinical trials (RCTs). Grade C+ recommendations - recommendations based on observationalstudies with very strong effects or secure generalizations fromrandomized clinical trials. results from RCTs generate Grade B recommendations - RCTs generate inconsistent results. Grade C recommendations - recommendations are based on observational studies.
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