1b) BTW, Dr. Arya is Theme Leader for #VTE at the upcoming #ISTH2022 congress in London that kicks off this weekend. It will be the most important international meeting of the year in the field of #thrombosis and #hemostasis and we are proud to have our faculty among the leaders!
— cardio-met (@cardiomet_CE) July 5, 2022
3) Anticoag duration decisions involve weighing up the risk of #VTE recurrence vs. bleeding. When considering recurrence, it can be helpful to use the ‘recurrence triangle’ ➡️the influence of risk factors & helps explain recurrence risk to patients.
— cardio-met (@cardiomet_CE) July 5, 2022
🔓https://t.co/XGykqtkXPt pic.twitter.com/L0BiIM1ilx
5) Patients with VTE usu receive at least 3 mos of anticoagulation, based on early studies showing that 3 mos was better to⬇️VTE recurrence than 4 weeks. These studies started to explore the benefit of using risk stratification to determine recurrence.
— cardio-met (@cardiomet_CE) July 5, 2022
🔓https://t.co/soISgKQ7Ej pic.twitter.com/jqnLHqETtL
7) WHAT happened? The most important determinant of recurrence is presence/absence of provoking factors at presentation. Up to 50% of 1st VTEs are unprovoked. Recurrence is⬆️after an unprovoked event relative to VTE after a major transient risk factor. https://t.co/g56hpkl0X1 pic.twitter.com/oLGpOqKow6
— cardio-met (@cardiomet_CE) July 5, 2022
9a) WHERE was the clot? The SITE of VTE is important too. Recurrence risk of isolated distal DVT is half that of proximal DVT/PE. These are usually treated for 3 months.
— cardio-met (@cardiomet_CE) July 5, 2022
10) The site of the initial event can also predict site of recurrence. Patients presenting with PE are 3❌ more likely to suffer recurrence as PE than patients presenting with DVT ❗
— cardio-met (@cardiomet_CE) July 5, 2022
🔓https://t.co/rtwvYBH1VZ
12) Let’s put all this into practice with our 1st case! 76 y/o ♀️ with right hip #NOF after a fall. She undergoes right hip hemiarthroplasty within 24 h of admission. Her clinical course is complicated by pneumonia and SIADH. pic.twitter.com/T2lcuxntOK
— cardio-met (@cardiomet_CE) July 5, 2022
14) She is reviewed in the thrombosis clinic after 6 weeks of treatment. She is fine on anticoagulation with no bleeding/side effects. Her breathing is back to normal. How long should she continue anticoagulation?
— cardio-met (@cardiomet_CE) July 5, 2022
16) Moving on to Case 2: 52 y/o ♂️ referred to DVT Clinic with 7 days worsening right leg swelling; O/E 7 cm difference in leg circumference. No previous or family history VTE. No provoking factors. pic.twitter.com/UjlWNi42ng
— cardio-met (@cardiomet_CE) July 5, 2022
18) You review him in the thrombosis clinic at 10 weeks. He feels well with resolution of his leg swelling. He is back to his normal activities including regular visits to the gym.
— cardio-met (@cardiomet_CE) July 5, 2022
20) Mark your response and RETURN TOMORROW for the correct answer and more education on optimizing #duration of #anticogulation for #VTE!
— cardio-met (@cardiomet_CE) July 5, 2022
👏to @bhwords @ProfMakris @MaryCushmanMD @fniainle @NTConnell @KingsCollegeNHS @MarcCarrier1 @ThrombosisUK @connors_md @aakonc @KurtMahan
22) Did you answer yesterday’s concluding #quiz? It was in tweet 19 and if you didn’t COMMIT, scroll back ⤴️in this 🧵now and make your case! pic.twitter.com/ktfxSQa9kB
— cardio-met (@cardiomet_CE) July 6, 2022
24) He tells you he understands the rationale for continuing but his preference is to stop anticoagulation after 6 months. He asks:
— cardio-met (@cardiomet_CE) July 6, 2022
🙋 can he have a scan to ‘make sure the clot has gone’ and
🙋are there blood tests that could help predict his risk of recurrence?
25b) Some studies found a positive correlation between RVT and VTE recurrence, but there is not enough evidence to support routinely assessing RVT.
— cardio-met (@cardiomet_CE) July 6, 2022
🔓https://t.co/Awff2xhbyH
27) However, a negative D-dimer does not necessarily mean that it is safe to remain off anticoagulation 😐. Recurrence rates of 6.7% per pt-year overall (9.7% in ♂️!) were seen in pts who remained off anticoagulation after repeatedly negative D-dimers.
— cardio-met (@cardiomet_CE) July 6, 2022
🔓https://t.co/buhdZF220v
29) Testing for heritable #thrombophilia 👪is not recommended and it would not alter decision making. After a 1st #VTE episode, recurrence rates were shown to be no different in the presence or absence of heritable thrombophilia. https://t.co/g56hpkl0X1
— cardio-met (@cardiomet_CE) July 6, 2022
31) The answer is No❎! Anticoagulation generally does not interfere with testing for anticardiolipin or anti-β2GP1 testing (serological antibody assays are not coagulation-based).
— cardio-met (@cardiomet_CE) July 6, 2022
33) Which lupus anticoagulant test might be useful in a patient on anticoagulation?
— cardio-met (@cardiomet_CE) July 6, 2022
A. Dilute Russell Viper Venom Test (DRVVT)
B. Taipan Snake Venom Test (TSVT)
35) Unlike Russell viper venom in the DRVVT (which activates Factor X and is affected by VKAs & DOACs), Taipan snake venom directly activates #prothrombin and can be used for LAC testing on warfarin (and even on Xa-inhibitors when at trough levels) pic.twitter.com/Js0FTN8pzp
— cardio-met (@cardiomet_CE) July 6, 2022
37) The DVT nurse starts her on a DOAC. The patient asks about her HRT. Should she be advised to:
— cardio-met (@cardiomet_CE) July 6, 2022
A. 🛑oral HRT immediately
B. Continue the HRT pending review by her GP
C. Be reassured HRT is unlikely to have contributed to the DVT
D. Switch to a different oral HRT formulation
38b) There is no need to urgently discontinue oral #HRT. She can visit her GP to discuss alternative HRT options.
— cardio-met (@cardiomet_CE) July 6, 2022
🔓https://t.co/IMfjnKzvgj
40) This is backed up by lab studies🔬, which also show an absence of a #prothrombotic effect with transdermal #HRT unlike oral HRT.
— cardio-met (@cardiomet_CE) July 6, 2022
🔓https://t.co/oqz1lUQbEy pic.twitter.com/DcPT13Rqi6
42) The answer depends on how ‘strong’ a provoking factor we consider the #HRT to be for #VTE. Currently, combined hormonal #contraceptives and oral HRT are classed as ‘intermediate or minor’ with an annual recurrence risk of ~5%.
— cardio-met (@cardiomet_CE) July 6, 2022
🔓https://t.co/UcjjlIdJYP pic.twitter.com/bZS5fyjne8
44a) It would be OK to anticoagulate for 3-6 mos. @ASH_hematology classes hormone use as a minor transient factor so long term anticoagulation is an option.
— cardio-met (@cardiomet_CE) July 6, 2022
45) So please RETURN TOMORROW for one last case, a wrap-up of our program on optimizing #durtaion of #anticoagulation after #VTE, and your link for 0.75h 🆓CE/#CME for #physicians #physicianassociate #nurses #nursepractitioners #pharmacists pic.twitter.com/L8vQrA2DPV
— cardio-met (@cardiomet_CE) July 6, 2022
47) OK, here’s our last case. 58 y/o nurse attends ED with 72h history of worsening shortness of breath. D-dimer 6461 ng/ml. #CTPA: multiple #PE. No previous or family history of #VTE. No evidence of right heart strain and she is discharged on a #DOAC. pic.twitter.com/FnunQ5D66m
— cardio-met (@cardiomet_CE) July 7, 2022
49) Not so easy when patients are not at the top or bottom of the recurrence 🔺(tweet 3), is it?! 🙋She asks whether there are risk scores that could help decide if she really needs anticoagulation. Good question!
— cardio-met (@cardiomet_CE) July 7, 2022
51) The risk scores differ in terms of the populations studied, the predictive variables used, and how points are assigned. For example, age >65 scores in one model, but age <50 in another 😕.
— cardio-met (@cardiomet_CE) July 7, 2022
🔓https://t.co/8ZP4cZpyjK pic.twitter.com/bqLf0kYoGT
52b) . . . but those with a score of ≥2 (and all men!) have a high risk of recurrence and should continue anticoagulation long-term.
— cardio-met (@cardiomet_CE) July 7, 2022
🔓https://t.co/amVBNrf1hH pic.twitter.com/Bab2m1lnNy
54) As it happens, this patient has a normal BMI and has a D-dimer measured on anticoagulation, which is negative. She chooses to stop anticoagulation after completing 6 months. So the correct answer for HER is B.
— cardio-met (@cardiomet_CE) July 7, 2022
55b)
— cardio-met (@cardiomet_CE) July 7, 2022
👉Consider extended anticoag for unprovoked VTE, especially in men
👉Intermediate group = individualised approach
57) This table lays out the estimates for ⬇️in recurrent #VTE, ⬆️ in major bleeding and ☠️🪦 with extended #anticoagulation vs no anticoagulation in different patient groups.
— cardio-met (@cardiomet_CE) July 7, 2022
🔓https://t.co/bX99a34vtU pic.twitter.com/2j6BzQXjJD
59a) Just one last thing to cover! In those who go on extended #anticoagulation the lower dose option with both #apixaban & #rivaroxaban is attractive for many patients after first 6/12 of treatment . . .
— cardio-met (@cardiomet_CE) July 7, 2022
60) Final recap – points to consider in the clinic
— cardio-met (@cardiomet_CE) July 7, 2022
👉 WHAT, WHERE, recurrence vs bleeding?
👉 Stop @ 3/12 or need to carry on?
👉 If for extended #anticoag – how about low-dose #DOAC?
61) And that's it! You just earned 0.75h 🆓CE/#CME on your only 🏡for #accredited #serialized #tweetorials in #cardiometabolic medicine. Thank you for joining us–from @AryaRoopen & @czuprynska_j. Claim your credit NOW at https://t.co/s9o8PxWlAM & FOLLOW US for more programs! pic.twitter.com/PWB2kAoGrt
— cardio-met (@cardiomet_CE) July 7, 2022