Approach To Treating Patients With

® Once the diagnosis of VTE has been confirmed with an objective test, promptly start anticoagulation therapy in full therapeutic doses. If there is high clinical suspicion of VTE, anticoagulation therapy can be initiated while waiting for the results of diagnostic tests.17 Initiate therapy with a quick-acting anticoagulant such as UFH (given IV or SC), an LMWH (given SC), or fondaparinux (given SC; Figs. 10-5 and 10-11). In patients with adequate renal function, the LMWHs are preferred over

UFH. Recent evidence also supports the use of SC fondaparinux as an alternative option to UFH or LMWH for the initial treatment of VTE.17 For the long-term treatment phase, warfarin is the preferred approach except for patients with cancer, in whom an LMWH is recommended due to better efficacy in preventing recurrent thromboembolic events. Initiate warfarin on the first day of therapy after the first dose of UFH, LMWH, or fondaparinux is given. Overlap the injectable agent with warfarin therapy for a minimum of 5 days. Warfarin should be dosed to achieve a goal INR range of 2 to 3. Once the INR is stable and above 2, the injectable anticoagulant should be discontinued. Anticoagulation therapy is continuedfor a minimum of 3 months but should be given longer depending on the underlying etiology of the VTE and the patient's risk factors (Table 10 11) 1 '20,21 Use a thrombolytic only if the patient has a massive iliofemoral DVT and is at risk of limb gangrene. In patients with PE, use a thrombolytic if the patient is hemodynamically unstable (i.e., SBP less than 90 mm Hg). If there is a contraindication to anticoagulation therapy or the patient has failed therapy with an anticoagulant, a vena cava filter should be inserted. Encourage

17 20/1

early ambulation as tolerated by the patient during the initial treatment phase. ' ' Patient Encounter 2, Part 1

BA is a 38-year-old female who presents to the emergency department complaining of chest pain, shortness of breath, and lightheadedness. The patient states that her symptoms started with some mild left calf pain approximately 5 days ago. She started feeling short of breath and experiencing chest pain last evening. She could not sleep and her shortness of breath has gotten progressively worse in the last several hours. BA was hospitalized because she was suspected to have a PE.

PMH: Obesity x 12 years; asthma

FH: Mother died of a stroke; paternal grandmother had clots in her legs SH: The patient is a school teacher

Current Meds: Albuterol (salbutamol) metered-dose inhaler as needed; ortho-Tri-Cyclen Lo by mouth daily; echinacea one to two tablets by mouth daily as needed; multivitamin one tablet by mouth daily

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