A 40 years old female patient attends the OG department with swelling of legs for past one day. There is no history of fever. 2 years back she had a metastatic breast adenocarcinoma which was treated with paclitaxel and radiotherapy. Blood pressure 120/76 mmHg, Pulse rate 84/min, temperature 37.6 C, Respiratory rate 16/ min. Saturation was 99% in room air. There was warmth and tenderness over the left leg and left thigh. Auscultation of lungs revealed clear fields. Urine pregnancy test was negative. CT chest was normal. USG of left leg revealed thrombus in the superficial femoral vein. The most appropriate treatment is
Answer: c) Enoxaparin and warfarin therapy with a goal to maintain INR of 2-3 (HARRISON 19TH ED, P-1635)DEEP VEIN THROMBOSISMost common site of DVT - calf veinsRisk of pulmonary embolism is much higher with proximal DVT (40% to 50%) than with clots confined to the distal calf vessels (5% to 10%)Pain and swelling are the major complaints from patients with DVTA large number of patients are asymptomatic, particularly if the DVT is restricted to the calfPain with dorsiflexion of the foot (Homan's sign) may be present, but the low sensitivity and the low specificity limit the usefulness of this sign in the diagnosis of lower-extremity DVTDiagnosis of DVTD-dimer elevation is a highly sensitive indicator of DVT (but not specific)Duplex ultrasonography has greater sensitivity in detecting proximal DVT than distal DVT of the lower extremities.Contrast venography is the "gold standard" test, but it is invasive and technically difficultTreatmentImmediate Anticoagulation:Unfractionated heparin, bolus and continuous infusion, to achieve aPTT 2-3 times the normal, or Enoxaparin or Dalteparin or Fondaparinux.Continue parenteral anticoagulation for a minimum of 5 daysUnfractionated heparin, low-molecular-weight heparin, and fondaparinux are the usual immediately effective "bridging agents" used when initiating warfarinWarfarin Anticoagulation: Usual start dose is 5 mg; Titrate to INR, target 2.0-3.0
Dalteparin and enoxaparin together
Warfarin therapy with a goal to maintain INR of 2-3
Enoxaparin and warfarin therapy with a goal to maintain INR of 2-3
Aspirin and warfarin therapy with a goal to maintain INR of 2-3
Blood