Tratamiento del Tromboembolismo Venoso

Presentación del tema: "Tratamiento del Tromboembolismo Venoso"— Transcripción de la presentación:

1 Tratamiento del Tromboembolismo Venoso
El Montanyà, Seva 2013 Sesión III: ETEV en las guías del ACCP 2012: revisión crítica basada en los casos clínicos X Curso de Formación Continuada Tratamiento del Tromboembolismo Venoso

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3 Resumen de indicaciones sobre duración de la anticoagulación con AVK en el TEV, realizado a partir de las recomendaciones o sugerencias de la 9ª edición de las Guías de Tratamiento Antitrombótico del ACCP. Factor de riesgo Riesgo hemorrágico* Duración TVP proximal EP Cirugía 3 meses Transitorio no-quirúrgico No provocada (1ra o recurrente) Bajo o moderado extendida Alto TVP distal TEV Cáncer extendida (HBPM) TEV incidental como sintomática La mayoría de las recomendaciones son de grado 1B o 2B La intensidad recomendada es de un INR 2-3

4 Apuntes sobre recomendaciones en la duración de la anticoagulación en el TEV según el SCC de la ISTH
Recomendamos que los pacientes con una EP o una TVP proximal no-provocada deben ser tratados durante 3 a 6 meses. Recomendamos que en mujeres con TEV asociado a tratamiento hormonal no se requieren anticoagulaciones superiores a 3 meses, siempre que el tratamiento hormonal haya sido suspendido en el momento del diagnóstico. Recomendamos que las mujeres con TEV asociado a terapia hormonal interrumpan el tratamiento hormonal (anticonceptivos orales y terapia estrogénica substitutiva) antes de suspender la terapia anticoagulante. Sin embargo, en las mujeres premenopáusicas debe utilizarse una anticoncepción alternativa eficaz para evitar la toxicidad potencial de la exposición fetal temprana a la warfarina. Sugerimos que en pacientes seleccionadas la terapia hormonal puede ser continuada si hay una fuerte indicación clínica para dicho tratamiento. En estos casos la terapia anticoagulante se debe continuar durante el período de mantenimiento de la terapia hormonal. Baglin. JTH 2012: 10: 698

5 Caso 1 Mujer 24 años, sana, obesa: 106kg, anticonceptivos orales
7 días antes: viaje transoceánico; unas semanas antes del vuelo refirió molestias sin limitación funcional de EEII Motivo de consulta: molestias y aumento del perímetro MID DD: 990 ng/mL (n<234) ECOdoppler: TVP femoral superficial, poplítea y distal MID

6 Probabilidad clínica de TVP (Wells)
Criterio clínico Puntuación Cáncer activo (en tratamiento en la actualidad o en los 6 meses previos o paliativo) 1 Parálisis, paresia o reciente inmovilización con férula de las extremidades inferiores Reciente Inmovilización en cama >3 días, o cirugía mayor bajo anestesia general o regional los 3 últimos meses Dolor a la palpación localizada en el trayecto del sistema venoso profundo Edema global de la pierna Aumento del diámetro de la pantorrilla afecta >3cm respecto de la asintomática (medida 10cm debajo de la protuberancia tibial) Edema con fóvea limitado a la pierna sintomática Venas (no-varicosas) colaterales superficiales Antecedente de TVP bien documentada Diagnostico alternativo tanto o más probable que el de TVP -2 Probabilidad clínica: <1: BAJA <1: IMPROBABLE 1 – 2: INTERMEDIA >2: PROBABLE >2: ALTA

7 Lo que dicen las guías 3.3 In patients with a moderate pretest probability of first lower extremity DVT, we recommend one of the following initial tests: (i) a highly sensitive D-dimer or (ii) proximal CUS, or (iii) whole-leg US rather than (i) no testing (Grade 1B for all comparisons) or (ii) venography (Grade 1B for all comparisons) . We suggest initial use of a highly sensitive D-dimer rather than US (Grade 2C). 3.4. In patients with a high pretest probability of first lower extremity DVT, we recommend either (i) proximal CUS or (ii) whole-leg US over no testing (Grade 1B for all comparisons) or venography (Grade 1B for all comparisons).

8 especificidad y sensibilidad en el diagnóstico de TEV
Técnicas de dímero D: especificidad y sensibilidad en el diagnóstico de TEV Técnica Sensitivity (95% CI) Specificity (95% CI) highly sensitive Enzyme-linked immunofluorescence assays 96% (89%-98%) 46% (31%-61%) microplate enzyme-linked immunosorbent assays (ELISAs) 94% (86%-97%) 53% 38%-68%) quantitative latex or immunoturbidimetric assays 93% (89%-95%) (46%-61%) moderately sensitive whole blood D-dimer assay 83% (67%-93%) 71% (57%-82%) latex semiquantitative assays 85% (68%-93%)

9 Caso 1 Stop anticonceptivos orales
Día INR HBPM AVK 1.04 Enoxaparina 1.4 mg qd 7 1.05 warfarina 10 1.1 14 1.41 18 2.15 25 2.8 Metrorragia a los 7 días de inicio de HBPM A las 2 semanas inicio progesterona

10 Pregunta caso 1 El día que presentó la metrorragia, ¿cual hubiese sido la mejor actuación respecto de la anticoagulación con HBPM? Mantener la misma dosis de HBPM Reducir la HBPM a dosis de profilaxis Suspender alguna dosis de HBPM Suspender la HBPM Suspender la HBPM e iniciar AVK

11 Systematic review: case-fatality rates of recurrent VTE and major bleeding events among patients treated for VTE Carrier y col. Ann Intern Med 2010; 152: 578

12 Lo que dicen las guías 2.1. In patients with acute DVT of the leg treated with vitamin K antagonist (VKA) therapy, we recommend initial treatment with parenteral anticoagulation (low- molecular-weight heparin [LMWH], fondaparinux, IV unfractionated heparin [UFH], or subcutaneous [SC] UFH) over no such initial treatment (Grade 1B). 2.4. In patients with acute DVT of the leg, we recommend early initiation of VKA (eg, same day as parenteral therapy is started) over delayed initiation, and continuation of parenteral anticoagulation for a minimum of 5 days and until the international normalized ratio (INR) is 2.0 or above for at least 24 h (Grade 1B). In patients with acute DVT of the leg treated with LMWH, we suggest once- over twice-daily administration (Grade 2C) . Remarks: This recommendation only applies when the approved once-daily regimen uses the same daily dose as the twice-daily regimen (ie, the once-daily injection contains double the dose of each twice-daily injection). It also places value on avoiding an extra injection per day. 2.7. In patients with acute DVT of the leg and whose home circumstances are adequate, we recommend initial treatment at home over treatment in hospital (Grade 1B).

13 Lo que dicen las guías 2.14. In patients with acute DVT of the leg, we suggest early ambulation over initial bed rest (Grade 2C). Remarks: If edema and pain are severe, ambulation may need to be deferred. We suggest the use of compression therapy in these patients. In patients with a proximal DVT of the leg provoked by a nonsurgical transient risk factor, we recommend treatment with anticoagulation for 3 months over (i) treatment of a shorter period (Grade 1B) , (ii) treatment of a longer time- limited period (eg, 6 or 12 months) (Grade 1B) , and (iii) extended therapy if there is a high bleeding risk (Grade 1B) . We suggest treatment with anticoagulation for 3 months over extended therapy if there is a low or moderate bleeding risk (Grade 2B). In patients with an unprovoked DVT of the leg (isolated distal [see remark] or proximal), we recommend treatment with anticoagulation for at least 3 months over treatment of a shorter duration (Grade 1B) . After 3 months of treatment, patients with unprovoked DVT of the leg should be evaluated for the risk-benefit ratio of extended therapy. In patients with a first VTE that is an unprovoked proximal DVT of the leg and who have a low or moderate bleeding risk, we suggest extended anticoagulant therapy over 3 months of therapy (Grade 2B) .

14 Systematic review: case-fatality rates of recurrent VTE and major bleeding events among patients treated for VTE Carrier y col. Ann Intern Med 2010; 152: 578

15 Lo que dicen las guías 3.2. In patients with DVT of the leg who are treated with VKA, we recommend a therapeutic INR range of 2.0 to 3.0 (target INR of 2.5) over a lower (INR , 2) or higher (INR ) range for all treatment durations (Grade 1B). In patients with DVT of the leg and no cancer, we suggest VKA therapy over LMWH for long-term therapy (Grade 2C) . For patients with DVT and no cancer who are not treated with VKA therapy, we suggest LMWH over dabigatran or rivaroxaban for long-term therapy (Grade 2C). 4.1. In patients with acute symptomatic DVT of the leg, we suggest the use of compression stockings (Grade 2B). Remarks: Compression stockings should be worn for 2 years, and we suggest beyond that if patients have developed PTS and find the stockings helpful.

16 Caso 2 Mujer 24 años, Parto eutócico 15 días antes
Acude por dolor región gemelar MID Ligero edema MID y empastamiento muscular Dímero-D: 800ng/mL ECOdoppler: no se aprecia trombosis Tratamiento sintomático

17 Lo que dicen las guías 3.4. In patients with a high pretest probability of first lower extremity DVT, we recommend either (i) proximal CUS or (ii) whole-leg US over no testing (Grade 1B for all comparisons) or venography (Grade 1B for all comparisons). In patients with a negative proximal CUS, we recommend additional testing with a highly sensitive D-dimer or whole-leg US or repeat proximal CUS in 1 week over no further testing (Grade 1B for all comparisons) or venography (Grade 2B for all comparisons) . We recommend that patients with a single negative proximal CUS and positive D-dimer undergo whole-leg US or repeat proximal CUS in 1 week over no further testing (Grade 1B) or venography (Grade 2B) . In patients with negative serial proximal CUS, a negative single proximal CUS and negative highly sensitive D-dimer, or a negative whole-leg US, we recommend no further testing over venography or additional US (Grade 1B for negative serial proximal CUS and for negative single proximal CUS and highly sensitive D-dimer; Grade 2B for negative whole-leg US). We recommend that in patients with high pretest probability, moderately or highly sensitive D-dimer assays should not be used as standalone tests to rule out DVT (Grade 1B)

18 Caso 2 A las 24h acude, de nuevo, a urgencias por progresión del dolor en MID Dolor agudo a la palpación región gemelar ECodoppler: TVP gemelar MID Tratamiento: tinzaparina 170 UI/kg qd

19 Lo que dicen las guías In patients with acute isolated distal DVT of the leg and without severe symptoms or risk factors for extension, we suggest serial imaging of the deep veins for 2 weeks over initial anticoagulation (Grade 2C). In patients with acute isolated distal DVT of the leg and severe symptoms or risk factors for extension (see text), we suggest initial anticoagulation over serial imaging of the deep veins (Grade 2C). Remarks: Patients at high risk for bleeding are more likely to benefit from serial imaging. Patients who place a high value on avoiding the inconvenience of repeat imaging and a low value on the inconvenience of treatment and on the potential for bleeding are likely to choose initial anticoagulation over serial imaging. In patients with an isolated distal DVT of the leg provoked by surgery or by a nonsurgical transient risk factor (see remark), we suggest treatment with anticoagulation for 3 months over treatment of a shorter period (Grade 2C) and recommend treatment with anticoagulation for 3 months over treatment of a longer time-limited period (eg, 6 or 12 months) (Grade 1B) or extended therapy (Grade 1B regardless of bleeding risk).

20 Pregunta caso 2 En una puérpera lactante con un TEV, ¿cual crees que es la mejor estrategia anticoagulante? HBPM seguida de AVK HBPM Rivaroxaban 1 y 2 son correctas

21 Caso 3 Mujer de 38 años, fumadora, S. ansioso-depresivo, endometriosis. Anticonceptivos orales (inicio 6 meses antes) 2d antes dolor y aumento del perímetro infrapoplíteo MII Es atendida por episodio sincopal, vegetatismo, disnea de inicio súbito posterior. RS, TA: 100/60mmHg, FC:110 lpm, ECG: S1Q3T3, DD: ng/mL, Enoxaparina 1mg/kg y remisión a Hospital de referencia

22 Caso 3 En Hospital de referencia: TA 100/60 mmHg, FC 105 lpm
SaO2: 99%, FG>60mL/min Troponina I: 0.86ug/L (n:<0.2) AngioTC: TEP masivo bilateral, signos sobrecarga D, signos sugerentes TVP poplítea bilateral ECOcar TT: VD dilatado, ratio VD/VI: 1.2, disfunción TAPSE 10mm ECOdoppler: VFS-P: ocupación de luz sin no-compresibilidad bilateral TAPSE: tricuspid annular plane systolic excursión

23 Caso 3 Tratamiento Angiografía pulmonar> trombectomía (PAm33>32); no trombolisis HNF (bolo 80 U/kg >perfusión 18 U/kg/h>ajustada a TTPa ) A los 2 días tinzaparina 175 U/kg qd A los 5 días inicio warfarina A los 20 días stop tinzaparina (INR 2.02)

24 ¿Cuanto tiempo anticoagularías a este paciente?
Pregunta caso 3 ¿Cuanto tiempo anticoagularías a este paciente? 3 meses 6 meses 1 año Indefinido

25 Lo que qué dicen las guías
In patients with a high clinical suspicion of acute PE, we suggest treatment with parenteral anticoagulants compared with no treatment while awaiting the results of diagnostic tests (Grade 2C). In patients with acute PE, we suggest LMWH or fondaparinux over IV UFH (Grade 2C for LMWH; Grade 2B for fondaparinux) and over SC UFH (Grade 2B for LMWH; Grade 2C for fondaparinux) . Remarks: Local considerations such as cost, availability, and familiarity of use dictate the choice between fondaparinux and LMWH. LMWH and fondaparinux are retained in patients with renal impairment, whereas this is not a concern with UFH. In patients with PE where there is concern about the adequacy of SC absorption or in patients in whom thrombolytic therapy is being considered or planned, initial treatment with IV UFH is preferred to use of SC therapies. 5.5. In patients with low-risk PE and whose home circumstances are adequate, we suggest early discharge over standard discharge (eg, after first 5 days of treatment) (Grade 2B) .

26 Criterios de Wells. Probabilidad Clínica de TEP.
• Síntomas clínicos de TVP 3,0 • Otros diagnósticos menos probables 3,0 • Frecuencia cardiaca mayor de 100 l.p.m. 1,5 • Inmovilización o cirugía en las últimas 4 semanas 1,5 • Antecedentes de TVP o TEP 1,5 • Hemoptisis ,0 • Cáncer ,0 Probabilidad Clínica de TEP. • Baja < 2 • Intermedia 2-6 • Alta > 6 Wells PS y cols. Ann Intern Med 2001.

27 Escala de riesgo pronóstico: PESI simplificado
Edad > 80 años punto Historia de cáncer punto Historia de insuficiencia cardiaca o EPOC 1 punto Pulso > 110 lpm punto Presión arterial sistólica < 100 mmHg 1 punto Saturación de O2 < 90% 1 punto Recomendación: Bajo riesgo: 0 puntos Alta precoz / hospitalización domiciliaria Alto riesgo: >1 Ingreso hospitalario. Elevación de Troponina y/o disfunción de VD (ecocardiograma): valorar UCI Jimenez D et al. Chest 2007

28 Lo que dicen las guías In patients with acute PE associated with hypotension (eg, systolic BP , 90 mm Hg) who do not have a high bleeding risk, we suggest systemically administered thrombolytic therapy over no such therapy (Grade 2C). In most patients with acute PE not associated with hypotension, we recommend against systemically administered thrombolytic therapy (Grade 1C). In selected patients with acute PE not associated with hypotension and with a low bleeding risk whose initial clinical presentation, or clinical course after starting anticoagulant therapy, suggests a high risk of developing hypotension, we suggest administration of thrombolytic therapy (Grade 2C). 5.7. In patients with acute PE associated with hypotension and who have (i) contraindications to thrombolysis, (ii) failed thrombolysis, or (iii) shock that is likely to cause death before systemic thrombolysis can take effect (eg, within hours), if appropriate expertise and resources are available, we suggest catheter-assisted thrombus removal over no such intervention (Grade 2C). In patients with a first VTE that is an unprovoked PE and who have a low or moderate bleeding risk, we suggest extended anticoagulant therapy over 3 months of therapy (Grade 2B).

29 Caso 4 Varón de 45 años, HTA, fumador, sin antecedentes familiares de TEV Desde hace 4 semanas dolor centrotorácico sin vegetatismo y dísnea progresiva>actualmente de reposo Hipotenso, mal perfundido, FC:125 lpm. SpO2 95% (Mónagan), PAO2/FIO2 145 (n>300),DD 2152 ng/mL, troponina I 0.20 ug/L; ECG: S1Q3T3 ECOcar TT: dilatación + disfunción VD AngioTAC: TEP masivo bilateral, sobrecarga cav. D, área vidrio deslustrado base , posible TVP. ECOdoppler: TVP FP MII OD: TEP + Neumonía Fraction of inspired oxygen (FiO2) partial pressure of oxygen in arterial blood (PaO2) Oxygen Saturation (SpO2) indicator of hypoxemia per the American-European Consensus Conference on lung injury

30 Caso 4 Arteriografía>trombectomía + fibrinolisis local
Puente de la Constitución Día INR HBPM/HNF Warfarina (mg) HNF 3 Tinzaparina 175 UI/kg qd 17 1 5-5-5 20 2.75 23 6.5 29 3.37 2.5 30 6.3 34 4.4 0-2.5 alternos 41 3.29 1 diario Vacaciones de Navidad

31 Lo que dicen las guías In patients with acute PE, when a thrombolytic agent is used, we suggest short infusion times (eg, a 2-h infusion) over prolonged infusion times (eg, a 24-h infusion) (Grade 2C). In patients with acute PE when a thrombolytic agent is used, we suggest administration through a peripheral vein over a pulmonary artery catheter (Grade 2C) . In patients with acute PE who are treated with anticoagulants, we recommend against the use of an IVC filter (Grade 1B) .

32 Caso 5 Varón 84 años, HTA, DLP, DM-II, BNCO, Cardiopatía isquémica (IAM hace años), I. renal crónica (creat 140), dependiente, movilización muy limitada AAS, pravastatina, insulina, haloperidol, omeprazol, O2 domiciliario Historia de 4 días de febrícula, expectoración purulenta, dísnea TA: 130/60, FC: 81, Sat O2: 98, DD6500, Troponina T <0.03 μg/L (n<0.014) TAC con contraste: TEP ramas segmento ant. LSD, condensación LID ECOcar: FE 45% hipocinesia septal HBPM>acenocumarol

33 ¿Cuanto tiempo anticoagularías a este paciente?
Pregunta caso 5 ¿Cuanto tiempo anticoagularías a este paciente? 3 meses 6 meses 1 año Indefinido

34 Lo que dicen las guías In patients with a first VTE that is an unprovoked PE and who have a high bleeding risk, we recommend 3 months of anticoagulant therapy over extended therapy (Grade 1B) .

35 Factores de riesgo de hemorragia en el tratamiento del TEV con AVK
(9ª ed guía ACCP) Edad > 65 años Edad > 75 años Sangrado previo Cáncer Cáncer metastático Insuficiencia renal Insuficiencia hepática Trombocitopenia Ictus previo Diabetes Anemia Tratamiento antiagregante Mal control de la anticoagulación Comorbilidades y capacidad funcional reducida Cirugía reciente Caídas frecuentes Enolismo Puntuación Riesgo Nº factores de riesgo Bajo Moderado Elevado 1 > 2

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37 Caso 6 Mujer 74 años, HTA, DM, DLP, TVP MII post-histerectomía hace 20 años > acenocumarol 4 años, antecedentes en familiares 1er orden de TEV Dianben, Omeprazol Acude por dolor y aumento del perímetro de MII MII caliente, empastamiento gemelar, asimetría DD 1200 ECOdoppler: TVP IFP MII

38 Lo que dicen las guías In patients with a second unprovoked VTE, we recommend extended anticoagulant therapy over 3 months of therapy in those who have a low bleeding risk (Grade 1B), and we suggest extended anticoagulant therapy in those with a moderate bleeding risk (Grade 2B) . In patients with a second unprovoked VTE who have a high bleeding risk, we suggest 3 months of anticoagulant therapy over extended therapy (Grade 2B) .

39 Caso 7 Varón de 72 años Cáncer ductal infiltrante de mama, metástasis óseas, estadio IV (6/11) TEP bilateral incidental (7/11) durante tto tamoxifeno/zometa >tinzaparina 175 UI/kg qd 6 meses>AVK Progresión M1 óseas y progresión biológica > decapeptyl/letrozol/zometa

40 Lo que dicen las guías 6.4. In patients with PE and active cancer, if there is a low or moderate bleeding risk, we recommend extended anticoagulant therapy over 3 months of therapy (Grade 1B) , and if there is a high bleeding risk, we suggest extended anticoagulant therapy (Grade 2B) . Remarks: In all patients who receive extended anticoagulant therapy, the continuing use of treatment should be reassessed at periodic intervals (eg, annually). 6.7. In patients with PE and cancer, we suggest LMWH over VKA therapy (Grade 2B) . In patients with PE and cancer who are not treated with LMWH, we suggest VKA over dabigatran or rivaroxaban for long-term therapy (Grade 2C). 6.9. In patients who are incidentally found to have asymptomatic PE, we suggest the same initial and long-term anticoagulation as for comparable patients with symptomatic PE (Grade 2B).

41 El Montanyà, Seva 2013 X Curso de Formación Continuada Muchas gracias