![Page 1: Dave Duddleston, MD VP and Medical Director Southern Farm ......Pulmonary Embolism Related to Deep Vein Thrombosis (DVT) Lower extremities (trauma, bedrest, previous DVT) Pelvic veins](https://reader034.vdocuments.mx/reader034/viewer/2022043020/5f3c586c8ad4685587710ef6/html5/thumbnails/1.jpg)
Dave Duddleston, MD
VP and Medical Director
Southern Farm Bureau Life
![Page 2: Dave Duddleston, MD VP and Medical Director Southern Farm ......Pulmonary Embolism Related to Deep Vein Thrombosis (DVT) Lower extremities (trauma, bedrest, previous DVT) Pelvic veins](https://reader034.vdocuments.mx/reader034/viewer/2022043020/5f3c586c8ad4685587710ef6/html5/thumbnails/2.jpg)
Sources of Risk for Venous Diseases� Pulmonary embolism (thrombus)
� Bleeding from anticoagulation
� Mortality from underlying disease
� Chronic wounds (venous insufficiency)
� Thrombophilias
![Page 3: Dave Duddleston, MD VP and Medical Director Southern Farm ......Pulmonary Embolism Related to Deep Vein Thrombosis (DVT) Lower extremities (trauma, bedrest, previous DVT) Pelvic veins](https://reader034.vdocuments.mx/reader034/viewer/2022043020/5f3c586c8ad4685587710ef6/html5/thumbnails/3.jpg)
Pulmonary Embolism� Related to Deep Vein Thrombosis (DVT)
� Lower extremities (trauma, bedrest, previous DVT)
� Pelvic veins (inflammatory disease, cancer)
� Upper extremities (intravenous access)
� Virchow’s Triad
� Stasis
� Endothelial injury
� Hypercoagulability
![Page 4: Dave Duddleston, MD VP and Medical Director Southern Farm ......Pulmonary Embolism Related to Deep Vein Thrombosis (DVT) Lower extremities (trauma, bedrest, previous DVT) Pelvic veins](https://reader034.vdocuments.mx/reader034/viewer/2022043020/5f3c586c8ad4685587710ef6/html5/thumbnails/4.jpg)
Why did PE occur?� Trauma
� Bedrest
� Thrombophilia
� Cancer
� Venous disease
![Page 5: Dave Duddleston, MD VP and Medical Director Southern Farm ......Pulmonary Embolism Related to Deep Vein Thrombosis (DVT) Lower extremities (trauma, bedrest, previous DVT) Pelvic veins](https://reader034.vdocuments.mx/reader034/viewer/2022043020/5f3c586c8ad4685587710ef6/html5/thumbnails/5.jpg)
Mortality of Pulmonary Embolism� Leiden University, The Netherlands, 2012
� 5,000 patients with first PE compared to 6,000 controls
� Followed 8 years, using a death index including cause of death
� 2x death rate in patients without malignancy, 17x death rate with malignancy
� Significant risks (cancer, CV disease) are reduced by underwriting
![Page 6: Dave Duddleston, MD VP and Medical Director Southern Farm ......Pulmonary Embolism Related to Deep Vein Thrombosis (DVT) Lower extremities (trauma, bedrest, previous DVT) Pelvic veins](https://reader034.vdocuments.mx/reader034/viewer/2022043020/5f3c586c8ad4685587710ef6/html5/thumbnails/6.jpg)
Figure 1. Kaplan-Meier survival curves for patients and controls.
Flinterman LE, van Hylckama Vlieg A, Cannegieter SC, Rosendaal FR (2012) Long-Term Survival in a Large Cohort of Patients with Venous Thrombosis: Incidence and Predictors. PLoS Med 9(1): e1001155. doi:10.1371/journal.pmed.1001155http://127.0.0.1:8081/plosmedicine/article?id=info:doi/10.1371/journal.pmed.1001155
![Page 7: Dave Duddleston, MD VP and Medical Director Southern Farm ......Pulmonary Embolism Related to Deep Vein Thrombosis (DVT) Lower extremities (trauma, bedrest, previous DVT) Pelvic veins](https://reader034.vdocuments.mx/reader034/viewer/2022043020/5f3c586c8ad4685587710ef6/html5/thumbnails/7.jpg)
Recurrent Pulmonary Embolism� Increases mortality risk over time (table rating)
� The cumulative rate of late recurrence has been reported to be 8 percent at six months, 13 percent at one year, 23 percent at five years, and 30 percent at 10 years
� See also: http://williams.medicine.wisc.edu/vte_recurrence_rosendaal_2010.pdf
![Page 8: Dave Duddleston, MD VP and Medical Director Southern Farm ......Pulmonary Embolism Related to Deep Vein Thrombosis (DVT) Lower extremities (trauma, bedrest, previous DVT) Pelvic veins](https://reader034.vdocuments.mx/reader034/viewer/2022043020/5f3c586c8ad4685587710ef6/html5/thumbnails/8.jpg)
Figure 1. Overall cumulative recurrence rate in 929 patients with a first unprovoked VTE estimated by Kaplan-Meier analysis, with 95% CIs (dotted lines).
Sabine Eichinger et al. Circulation. 2010;121:1630-1636
Copyright © American Heart Association, Inc. All rights reserved.
![Page 9: Dave Duddleston, MD VP and Medical Director Southern Farm ......Pulmonary Embolism Related to Deep Vein Thrombosis (DVT) Lower extremities (trauma, bedrest, previous DVT) Pelvic veins](https://reader034.vdocuments.mx/reader034/viewer/2022043020/5f3c586c8ad4685587710ef6/html5/thumbnails/9.jpg)
Figure 3. Nomogram to compute shrunken risk scores and estimate cumulative recurrence rates of recurrent VTE by use of sex, location of VTE, and D-dimer.
Sabine Eichinger et al. Circulation. 2010;121:1630-1636
Copyright © American Heart Association, Inc. All rights reserved.
![Page 10: Dave Duddleston, MD VP and Medical Director Southern Farm ......Pulmonary Embolism Related to Deep Vein Thrombosis (DVT) Lower extremities (trauma, bedrest, previous DVT) Pelvic veins](https://reader034.vdocuments.mx/reader034/viewer/2022043020/5f3c586c8ad4685587710ef6/html5/thumbnails/10.jpg)
Anticoagulation� Risk from long term anticoagulation (bleeding)
� Warfarin
� Including overanticoagulation
� Direct thrombin/Factor Xa inhibitors
� Risk from underutilization of anticoagulation (where benefit would exceed risk)
![Page 11: Dave Duddleston, MD VP and Medical Director Southern Farm ......Pulmonary Embolism Related to Deep Vein Thrombosis (DVT) Lower extremities (trauma, bedrest, previous DVT) Pelvic veins](https://reader034.vdocuments.mx/reader034/viewer/2022043020/5f3c586c8ad4685587710ef6/html5/thumbnails/11.jpg)
Bleeding: Warfarin� Population-based cohort study of warfarin-treated
patients with atrial fibrillation: incidence of cardiovascular and bleeding outcomes. London, UK –BMJ Open
� 16,500 pts with atrial fibrillation, anticoagulated with warfarin, followed over 5 years, monitored for *hospitalization for bleeding*
� Range was 3.8-4.5 events/100 patient-years for current and recent warfarin, vs. 2.9 for non-use.
BMJ Open 2014;4:e003839. doi:10.1136/bmjopen-2013 003839
![Page 12: Dave Duddleston, MD VP and Medical Director Southern Farm ......Pulmonary Embolism Related to Deep Vein Thrombosis (DVT) Lower extremities (trauma, bedrest, previous DVT) Pelvic veins](https://reader034.vdocuments.mx/reader034/viewer/2022043020/5f3c586c8ad4685587710ef6/html5/thumbnails/12.jpg)
Bleeding: Direct thrombin/Xa
inhibitors� Risk of Bleeding With Dabigatran in Atrial
Fibrillation� Inmaculada Hernandez, PharmD1; Seo Hyon Baik, PhD1; Antonio Piñera, MD2;
Yuting Zhang, PhD1
� 1Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania 2Department of Obstetrics and Gynecology, La Paz University Hospital, Madrid, Spain
� Risk of bleeding in this short term study was about 1.5x that of warfarin, in Medicare patients diagnosed with atrial fib and treated with either agent.
JAMA Intern Med. 2015;175(1):18-24. doi:10.1001/jamainternmed.2014.5398
![Page 13: Dave Duddleston, MD VP and Medical Director Southern Farm ......Pulmonary Embolism Related to Deep Vein Thrombosis (DVT) Lower extremities (trauma, bedrest, previous DVT) Pelvic veins](https://reader034.vdocuments.mx/reader034/viewer/2022043020/5f3c586c8ad4685587710ef6/html5/thumbnails/13.jpg)
Bleeding: Direct thrombin/Xa
inhibitors� Comparative risk of gastrointestinal bleeding
with dabigatran, rivaroxaban, and warfarin: population based cohort study
� BMJ 2015 http://dx.doi.org/10.1136/bmj.h1857 Published 24 April 2015
� Suggests that risk is a bit higher with warfarin in younger to middle age; Thrombin/Xa inhibitors a little riskier at older ages
![Page 14: Dave Duddleston, MD VP and Medical Director Southern Farm ......Pulmonary Embolism Related to Deep Vein Thrombosis (DVT) Lower extremities (trauma, bedrest, previous DVT) Pelvic veins](https://reader034.vdocuments.mx/reader034/viewer/2022043020/5f3c586c8ad4685587710ef6/html5/thumbnails/14.jpg)
Fig 2 Dabigatran versus warfarin in patients with atrial fibrillation: treatment effect by age.
Neena S Abraham et al. BMJ 2015;350:bmj.h1857
©2015 by British Medical Journal Publishing Group
![Page 15: Dave Duddleston, MD VP and Medical Director Southern Farm ......Pulmonary Embolism Related to Deep Vein Thrombosis (DVT) Lower extremities (trauma, bedrest, previous DVT) Pelvic veins](https://reader034.vdocuments.mx/reader034/viewer/2022043020/5f3c586c8ad4685587710ef6/html5/thumbnails/15.jpg)
Fig 3 Rivaroxaban versus warfarin patients with atrial fibrillation: treatment effect by age.
Neena S Abraham et al. BMJ 2015;350:bmj.h1857
©2015 by British Medical Journal Publishing Group
![Page 16: Dave Duddleston, MD VP and Medical Director Southern Farm ......Pulmonary Embolism Related to Deep Vein Thrombosis (DVT) Lower extremities (trauma, bedrest, previous DVT) Pelvic veins](https://reader034.vdocuments.mx/reader034/viewer/2022043020/5f3c586c8ad4685587710ef6/html5/thumbnails/16.jpg)
Venous Ulcers� Leg ulcers from chronic venous insufficiency are
relatively common
� Growth of wound centers
� Most ulcers can be healed
� What are the long term risks?
![Page 17: Dave Duddleston, MD VP and Medical Director Southern Farm ......Pulmonary Embolism Related to Deep Vein Thrombosis (DVT) Lower extremities (trauma, bedrest, previous DVT) Pelvic veins](https://reader034.vdocuments.mx/reader034/viewer/2022043020/5f3c586c8ad4685587710ef6/html5/thumbnails/17.jpg)
Death Related to Venous
Insufficiency is Uncommon� European Journal of Vascular and Endovascular Surgery
Volume 13, Issue 5, May 1997, Pages 500–508
Long-term prognosis for patients with chronic leg ulcers: a prospective cohort study
� Patients with venous ulcers had a survival not significantly different from controls and patients with arterial or other aetiologies had a doubled risk of death.
doi:10.1016/S1078-5884(97)80179-7
![Page 18: Dave Duddleston, MD VP and Medical Director Southern Farm ......Pulmonary Embolism Related to Deep Vein Thrombosis (DVT) Lower extremities (trauma, bedrest, previous DVT) Pelvic veins](https://reader034.vdocuments.mx/reader034/viewer/2022043020/5f3c586c8ad4685587710ef6/html5/thumbnails/18.jpg)
Venous Insufficiency: Outcome of
Ulcers� “We included 11 studies that
reported on mortality. In most of these studies, deaths were rare, occurring in less than 5 percent of patients, and did not differ between intervention groups.” (2014)
![Page 19: Dave Duddleston, MD VP and Medical Director Southern Farm ......Pulmonary Embolism Related to Deep Vein Thrombosis (DVT) Lower extremities (trauma, bedrest, previous DVT) Pelvic veins](https://reader034.vdocuments.mx/reader034/viewer/2022043020/5f3c586c8ad4685587710ef6/html5/thumbnails/19.jpg)
Thrombophilia� Traditional risk factors are more important in
determination of first and recurrent thrombosis, but what is the impact of a thrombophilia found at diagnosis of a venous thrombosis?
� Risk Factors for Venous Thromboembolism
� Samuel Z. Goldhaber, MD
� J Am College of Cardiology 2010;56:1–7
![Page 20: Dave Duddleston, MD VP and Medical Director Southern Farm ......Pulmonary Embolism Related to Deep Vein Thrombosis (DVT) Lower extremities (trauma, bedrest, previous DVT) Pelvic veins](https://reader034.vdocuments.mx/reader034/viewer/2022043020/5f3c586c8ad4685587710ef6/html5/thumbnails/20.jpg)
Thrombophilia Risk� Factor V Leiden
� Prothrombin gene mutation
� Antiphospholipid antibody syndrome (acquired)
� “Thrombophilia workups are expensive and usually add little to patient management.”
![Page 21: Dave Duddleston, MD VP and Medical Director Southern Farm ......Pulmonary Embolism Related to Deep Vein Thrombosis (DVT) Lower extremities (trauma, bedrest, previous DVT) Pelvic veins](https://reader034.vdocuments.mx/reader034/viewer/2022043020/5f3c586c8ad4685587710ef6/html5/thumbnails/21.jpg)
Thrombophilia Risks� More aggressive thrombophilias include:
� Anticardiolipin antibodies, homozygous factor V Leiden, homozygous prothrombin gene mutation, double heterozygote mutations, protein C, protein S, and antithrombin deficiency
![Page 22: Dave Duddleston, MD VP and Medical Director Southern Farm ......Pulmonary Embolism Related to Deep Vein Thrombosis (DVT) Lower extremities (trauma, bedrest, previous DVT) Pelvic veins](https://reader034.vdocuments.mx/reader034/viewer/2022043020/5f3c586c8ad4685587710ef6/html5/thumbnails/22.jpg)
A Case of VTE� Consult: “I’m back on (an Xa inhibitor) for a clot.”
� 28 YO female with DVT and PE 3 years earlier
� Oral contraceptives
� Tobacco
� Heterozygote Factor V Leiden
� Subsequently pregnant, no DVT on an injectable Xainhibitor during pregnancy
![Page 23: Dave Duddleston, MD VP and Medical Director Southern Farm ......Pulmonary Embolism Related to Deep Vein Thrombosis (DVT) Lower extremities (trauma, bedrest, previous DVT) Pelvic veins](https://reader034.vdocuments.mx/reader034/viewer/2022043020/5f3c586c8ad4685587710ef6/html5/thumbnails/23.jpg)
A Case of VTE� Undesired pregnancy and took the “morning after pill”
� Developed leg pain
� CT chest negative for PE
� LLE nonocclusive defect in popliteal vein, favoring a chronic finding
� Your recommendation for treatment?
� Your decision for underwriting?
![Page 24: Dave Duddleston, MD VP and Medical Director Southern Farm ......Pulmonary Embolism Related to Deep Vein Thrombosis (DVT) Lower extremities (trauma, bedrest, previous DVT) Pelvic veins](https://reader034.vdocuments.mx/reader034/viewer/2022043020/5f3c586c8ad4685587710ef6/html5/thumbnails/24.jpg)
A Case of VTE� Patient was seen by an expert hematologist
� Treatment was discontinued
� Would treat prophylactically during a high risk event such as pregnancy, injury, bedrest
� Her risk of another VTE?
� Her risk of death?
![Page 25: Dave Duddleston, MD VP and Medical Director Southern Farm ......Pulmonary Embolism Related to Deep Vein Thrombosis (DVT) Lower extremities (trauma, bedrest, previous DVT) Pelvic veins](https://reader034.vdocuments.mx/reader034/viewer/2022043020/5f3c586c8ad4685587710ef6/html5/thumbnails/25.jpg)