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A 50 year old man presents with a 1-day history of recurrent swelling and pain of the left leg. He was discharged from the hospital 1 week ago after being treated for deep vein thrombophlebitis of the same leg. Since discharge he has been taking warfarin, 2.5 mg daily. His INR is 1.2. A venogram documents recurrent thrombosis extending to the inferior vena cava. Which therapy would you now recommend for this patient?
A-Increase the warfarin dose to bring the INR into therapeutic range
B-Switch to dicumarol
C-Interrupt the inferior vena cava with a filter
D-Discontinue warfarin and begin heparin at a therapeutic dose
E-Discontinue warfarin and begin thrombolytic therapy
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d,
ideally the answer shud be discontinue warfarin+heparin bolus+start warfarin dose once the therapeutic aPTT is reached and continue that therapeutic dose to maintain INR at 2 to 3. warfarin dose shud be increased ultimately...but the thrombus shud be taken care of first..
i really doubt if thrombolysis is required here!!
please put some light....
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filter is placed only when thr is some contraindication for thrombolytic or anticoagulant therapy....whats the CI here?
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The recurrent thrombosis was with an under rage IRN , so you can t say that this was a treatment failure.
In this case you have to switch back to heparin to achive a "safe zone" and after soso 48 hrs more less , re start warfarine
I go for D
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Acute Thrombosis,,,,,answer is ..DD
This 50 year old man has suffered a recurrent venous thrombosis, most likely from suboptimal prophylactic anticoagulation. The target INR for warfarin anticoagulation to prevent recurrent thromboembolism is 2.0-3.0. When a new thrombosis is diagnosed, therapeutic doses of heparin must be initiated. Simply increasing the warfarin dose to bring the INR into therapeutic range is inadequate, because warfarin is used for prophylaxis only, rather than for the treatment of acute thrombosis. For the same reason, switching to a different anticoagulant like dicumarol would be ineffective. After starting up heparin he should be restarted at a higher dose of warfarin.
Interruption of the inferior vena cava with a filter is primarily indicated only for patients in whom anticoagulation is contraindicated or in whom thrombosis has recurred despite adequate prophylactic anticoagulation. Neither of these considerations applies to this patient.
Thrombolytic therapy is not necessary in most case of DVT of the leg. This mode of therapy can be considered in patients with extensive venous thrombosis, particularly involving extension into the inferior vena cava, in order to prevent long-term postphlebetic complications.
Of note, Low Molecular Weight Heparins (LMWH) will be of major therapoutic thrust soon. Recent studies have shown the LMWH to be of possible benefit in the treatment of D.V.T.'s (4,5,7,8 ) and in documented pulmonary embolism (6).
