Table of Contents  
REVIEW ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 1  |  Page : 11-18

Clinical practice patterns in the identification, diagnosis, and management of venous thromboembolism: An observational, physician-based survey in India with the expert panel opinion


1 Department of Peripheral Vascular and Endovascular Surgery, Institute of Vascular and Endovascular Sciences, Sir Ganga Ram Hospital, New Delhi, India
2 Department of Cardiology, Janakpuri Super Speciality Hospital, New Delhi, India
3 Consultant Physician, Mukund Hospital, Mukund Nagar Co Operative Housing Society, Mumbai, Maharashtra, India

Date of Submission19-Oct-2020
Date of Acceptance23-Oct-2020
Date of Web Publication20-Feb-2021

Correspondence Address:
V S Bedi
Department of Peripheral Vascular and Endovascular Surgery, Institute of Vascular and Endovascular Sciences, Sir Ganga Ram Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_141_20

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  Abstract 


Background: We conducted a physician-based survey to understand the management and clinical practicing patterns of venous thromboembolism (VTE) by physicians in India. Methods: This was an observational, physician-based clinical survey. A set of 22 questions on diagnosis, prophylaxis, duration of treatment, and risk factors of VTE was formulated along with nine patient case-studies. Seventy-six consulting physicians across India responded to the survey questionnaire. An expert panel comprising vascular surgeon, cardiac surgeon, and senior physicians provided recommendations on the recorded survey responses. Results: About 63.16% of physicians considered clinical examination of VTE based on signs and symptoms, whereas 23.68% used deep-vein thrombosis (DVT) scores (Wells score) to assess patients' risk. Recent surgery was considered a risk factor for developing DVT or pulmonary embolism by 86.84% of physicians; 82.89% preferred performing duplex ultrasonography test, and on positive results, treated patients for DVT. Dabigatran was the preferred choice of treatment by the participants. VTE prophylaxis with oral anticoagulants was considered by 80.3% of physicians during major orthopedic surgery. Direct oral anticoagulant (DOAC) with bridging therapy was preferred by 44.74% of physicians and 77.63% felt that DOACs will lead to a better quality of life for VTE patients. For patients with permanent risk factors of DVT, 76.32% of physicians preferred the indefinite duration of anticoagulation therapy. Conclusions: VTE remains a growing area of concern that needs to be managed in line with the clinical guidelines. These insights may aid in developing strategies for diagnostic accuracy and treatment of DVT.

Keywords: Anticoagulants, D-dimer, deep vein thrombosis, direct oral anticoagulants


How to cite this article:
Bedi V S, Dhall A, Dargad R. Clinical practice patterns in the identification, diagnosis, and management of venous thromboembolism: An observational, physician-based survey in India with the expert panel opinion. Indian J Vasc Endovasc Surg 2021;8:11-8

How to cite this URL:
Bedi V S, Dhall A, Dargad R. Clinical practice patterns in the identification, diagnosis, and management of venous thromboembolism: An observational, physician-based survey in India with the expert panel opinion. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2021 Apr 18];8:11-8. Available from: https://www.indjvascsurg.org/text.asp?2021/8/1/11/309699




  Introduction Top


Venous thromboembolism (VTE) is a global health problem that describes the diagnosis of deep-vein thrombosis (DVT) or pulmonary embolism (PE).[1] VTE associated with hospitalization has been the leading cause of disability-adjusted life-years lost in low-income and middle-income countries?.[2] The global disease burden associated with VTE, therefore, remains high (100 cases/100,000 patient-years).[3]

The overall incidence of VTE has been reported as 1–2/1000 person-years in the general population, rising up to 8/1000 person-years in people >85 years old.[4],[5] There remains, however, a discordant view on the incidence of VTE in Asia[6] due to the silent nature of the disease. Interestingly, studies from mainland China, Hong Kong, Taiwan, Korea, Japan, and Singapore have reported significant VTE rates in the respective Asian populations, thereby disproving the perception surrounding the low incidence of VTE in Asia.[7],[8],[9],[10],[11] In India, too, the rate of VTE is expected to mimic that observed in the Asian countries, i.e., increasing.[12] Annually, over 2.5 lakh patients are identified as having an acute VTE event in India. Morbidity and mortality from VTE have been shown to be a significant challenge in India.[13] VTE prophylaxis will assist in bringing down the mortality rate in India; however, regular prophylaxis is not administered routinely among the Asian population.[14]

A group of consulting physicians and a panel of clinical experts in Vascular Surgery, Cardiology, and General Medicine from across India were brought together and a physician survey was conducted to understand the clinical practicing patterns in identification, diagnosis, and anti-coagulation management of VTE by physicians in India. The knowledge so obtained would be crucial in understanding the therapy and providing guidance in an area where strong scientific evidence is lacking.


  Methods Top


During a 1-day meeting held at Delhi, India, on May 18, 2019, the consulting physicians and the clinical experts in managing VTE participated in a physician-based clinical survey based on their experience of managing specific VTE-related clinical scenarios, and this was followed by a panel discussion on the management of VTE in India.

Survey design

This was a noninterventional, observational, physician-based, one-time clinical survey where 76 consulting physicians (including hematologists and vascular surgeons) experienced in the management of DVT and PE-related clinical scenarios across India were asked to complete a detailed questionnaire to gather information on their routine clinical practice patterns in identification, diagnosis and anticoagulation management of VTE. The expert panel comprising three specialists, i.e., vascular surgeon, cardiac surgeon, and the senior physician, then provided their recommendations on the collated physician response. Physicians with relevant experience in the therapy area (thromboembolism), and those willing to participate in the survey by providing their signed consent and feedback on the questionnaire were included in the study.

The set of 22 questions and 9 patient case studies were provided to the physicians [Supplementary File]. The survey was designed to elucidate key elements of the current practicing patterns of the clinicians with respect to diagnosis, disease management, risk factors, anticoagulant prophylaxis, and adverse effects of VTE followed by the expert panel recommendations. Responses to the survey questionnaire were provided in the live survey and were expressed as a percentage.

The survey was conducted in accordance with the principles of the Declaration of Helsinki, International Conference on Harmonization, Good Clinical Practice guidelines, Indian Council of Medical Research, and Indian Good Clinical Practice guidelines. Prior approval of the protocol by the Independent Ethics Committee or Institutional Review Board, submission of any protocol amendments, and all study-related documents were mandatory in compliance with local regulatory requirements.

Data quality

No patient information or data was collected, and the questionnaire was forwarded for evaluation to Abbott, Mumbai, India. The survey questionnaire was reviewed, and a quality check was performed to ensure that the participating physicians complied with the protocol.


  Results Top


The expert panel reached consensus on several aspects of clinical practice among physicians for patients with VTE and provided recommendations for better practice patterns, diagnosis, management, and treatment in patients with VTE [Table 1]. The key aspects of the clinical practice survey response by the physicians are provided below.
Table 1: Expert panel statement on venous thromboembolism risk factors, diagnosis, anticoagulant use, and duration of treatment

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Risk factors

All experts completed the questionnaire without missing values. In their clinical practice, 82.89% of the physicians attended to 1–7 patients with a risk factor for VTE requiring prophylaxis, and 14.47% attended to 8–15 patients [Figure 1]a. Regarding a risk factor for VTE requiring prophylactic anticoagulation therapy, 68.42% of physicians considered >4 days of hospitalization and 21.05% considered >7 days of hospitalization as a risk factor [Figure 1]b. Recent surgery was considered as a risk factor for developing DVT or PE by 86.84% of the physicians, while 5.26% considered obesity as the risk factor [Figure 1]c. As per their daily clinical practice, 47.37% of the physicians felt that women are at greater risk to develop PE, while 35.53% felt that this risk is similar for both men and women [Figure 1]d.
Figure 1: Risk factors for venous thromboembolism – deep vein thrombosis or pulmonary embolism (a) How many patients do you see with a risk factor for venous thromboembolism requiring prophylaxis or treatment? (weekly); (b) How many days of hospitalization was considered as a risk factor for venous thromboembolism requiring prophylactic anticoagulation? (c) Which factors you consider for being at-risk for developing deep vein thrombosis or pulmonary embolism? (d) Who do you think is at greater risk for PE as per your clinical experience?

Click here to view


The expert panel opinion on the risk factors for VTE, DVT, or PE is provided in [Table 1]A.

Diagnosis

More than half (63.16%) of the physicians performed a clinical examination for VTE only based on signs and symptoms, while 23.68% of physicians used DVT scores such as Wells score to assess the patients' risk of DVT [Figure 2]a. If a patient scored ≥2 on the Wells score, 82.89% of the physicians preferred to perform duplex ultrasonography (USG) test and if the results were positive, then they would treat the patients for DVT. Only 6.58% of physicians responded to performing the D-dimer test before treating patients for DVT in case of a positive outcome [Figure 2]b. A majority (63.16%) of the physicians used the Cockcroft-Gault formula for estimating creatinine clearance (CrCL) to assess the renal function of a patient before initiating direct anticoagulants (DOACs), followed by 22.37% of physicians who used CrCL based on the Chronic Kidney Disease Epidemiology Collaboration equation [Figure 2]c. A majority (68.42%) of the physician's advised hemoglobin, renal function test, and liver function tests before initiating patients on DOACs for DVT, followed by 7.89% of physicians who advised hemoglobin, renal function test and liver function test, stool for occult blood, and urine routine for hematuria before initiating patients on DOACs.
Figure 2: Diagnostic modalities (a) How do you initially in a patient assess the risk of deep vein thrombosis; (b) What should the next course of action be if a patient scores ≥2 on the Wells score?; (c) How do you assess the renal function of a patient before initiating direct oral anticoagulants

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The expert panel opinion on the diagnosis for VTE is provided in [Table 1]A.

Use of anticoagulants

The non-Vitamin K antagonist oral anticoagulant (NOAC), dabigatran, was considered the preferred choice of treatment when affordability was not thought as an issue in elderly patients (>65 years), young adults (18–35 years), women, middle-aged (35–65 years), frequent travelers, in contact sports, with a risk of high bleeding but requiring oral anticoagulants (OAC), with the previous stroke, in need for once-daily dosing, and for those of doubtful compliance [Figure 3]a. VTE prophylaxis would be considered with OAC by 80.26% of the physicians during major orthopedic surgery and by 6.58% for the treatment of atrial fibrillation with thrombosis [Figure 3]b. Among the choice of anticoagulant therapy during the hospital stay, 84.21% of physicians preferred low molecular weight heparin (LMWH)/Fondaparinux (considering normal estimated glomerular filtration rate [eGFR]) and 7.89% preferred DOACs [Figure 3]c. Almost half (44.74%) of the physicians preferred DOAC with bridging therapy, and 36.84% preferred LMWH/Fondaparinux (considering normal eGFR) as the preferred first-line treatment for infra-inguinal DVT [Figure 3]d. In patients with active cancer, 44.74% of physicians preferred DOACs and 22.37% each preferred LMWH with Vitamin K antagonist (VKA) treatment and LMWH as the treatment for DVT.
Figure 3: Use of anticoagulants (a) In the following patient profiles, considering affordability to be not an issue, what was your choice of the molecule? (b) What were the conditions/indications where you considered venous thromboembolism prophylaxis with oral anticoagulants? (c) In the case scenario of hospitalization, what is your preferred anticoagulant during the hospital stay? (d) What is your preferred first-line treatment for Infra-inguinal deep vein thrombosis?

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The expert panel opinion on the use of anticoagulants is provided in [Table 1]B.

Duration of treatment

In patients with recurrent DVT, 68.42% of physicians considered lifelong therapy, 26.32% considered 1 year, and 3.95% considered <1 year of anticoagulation therapy. With respect to anticoagulation therapy for patients with permanent risk factors of DVT, 76.32% of the physicians preferred indefinite duration of therapy and 14.47% preferred therapy for 6 months' duration [Figure 4]a. For patients with isolated calf vein thrombosis, 44.74% of physicians suggested 12 weeks of anticoagulant therapy, 27.63% suggested 6 months, and 22.37% suggested 6 weeks of anticoagulant therapy. For patients with superficial venous thrombosis, 85.53% of physicians considered 6 weeks of anticoagulant therapy and 7.89% considered 12 weeks of therapy.
Figure 4: Duration of anticoagulant treatment (a) How long your patients with permanent risk factors for deep vein thrombosis are put on anticoagulation? (b) How long your patients with provoked proximal deep vein thrombosis or pulmonary embolism are put on anti-coagulation?

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Regarding anticoagulation therapy for patients with provoked proximal DVT or PE, 52.63% of the physicians preferred 6 months of treatment, followed by 31.58% who preferred a 3-month treatment duration [Figure 4]b. Of 52.63% of physicians who responded with 6 months treatment duration, 55.0% preferred dabigatran, and 15.0% preferred rivaroxaban as a NOAC. Furthermore, 51.32% of the physicians considered that the occurrence of provoked DVT is higher among the Indian population, while 23.68% felt that the occurrence of both provoked and unprovoked DVT is similar [Figure 5].
Figure 5: Rate of occurrence of provoked and unprovoked deep vein thrombosis

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The expert panel opinion on the duration of treatment is provided in [Table 1]C.

Disease management and quality of life (from a patient's perspective)

From the patient's perspective, 56.58% of physicians felt monitoring, and 10.53% felt affordability as the most important challenge in anticoagulant management [Supplementary Figure 1]. Similarly, 77.63% of the physicians reported that treatment with DOACs will lead to a better quality of life for VTE patients [Supplementary Figure 2]. The expert panel opinion is provided in [Table 1]D.



What is the rate of occurrence of provoked and unprovoked DVT?

Expert panel statements

Considering the survey response, a panel of experts provided their view on physician responses related to current clinical practices for the identification, diagnosis, and anti-coagulant management of patients with VTE. These are provided in [Table 1].


  Case Presentations Top


Case 1

A 44-year-old man was evaluated during a follow-up of an unprovoked left proximal leg DVT episode 3 months ago. In this case, 48.68% of the physicians would extend anticoagulation therapy, while 25.0% would discontinue VKA and perform thrombophilia testing as the most appropriate management. However, experts, in this case, recommended discontinuing VKA in another 3 months. Interestingly, 80.26% of the physicians responded that thrombophilia profile testing results will modify the anticoagulation management in this patient, in line with the expert opinion, while 17.11% opined that it will not modify the anticoagulant management.

Case 2

A senior pilot with a commercial airline developed a mild swelling over his left ankle while flying as the second commander for a long-haul transcontinental flight. The majority (60.53%) of the physicians preferred LMWH and 25.0% preferred DOACs as an anticoagulant. However, the expert panel recommended DOAC in this scenario.

Case 3

A 24-year-old professional Kathak dancer was admitted with acute onset of heaviness, pain and functional impairment of her right (dominant) arm, 64.47% of physicians considered catheter-directed thrombolysis as the most appropriate management, aligned with the expert panel opinion.

Case 4

A 30-year-old woman was presented to ambulatory care with pain and swelling of her left leg for a duration of 2 days, 32.89% of physicians considered catheter-directed thrombolysis as the correct treatment, followed by 26.32% who suggested anticoagulation for 3 months and left below-knee? thromboembolism deterrent (TED) stocking as the correct treatment. Experts, in this case, recommended anticoagulation therapy for 6 months with left below-knee TED stocking. In elderly patients (>65 years) with low body weight and moderate risk of PE with moderate renal impairment, 39.47% of physicians responded that their choice was parenteral anticoagulation followed by DOACs and for 32.89% the choice was parenteral anticoagulation followed by VKA. Experts recommended parenteral anticoagulation followed by DOACs. The remaining cases along with expert opinion are presented in the Supplementary File.


  Discussion Top


This observational study was an attempt to understand the clinical practice patterns of the physicians with respect to identification, diagnosis, and anticoagulant management of VTE (DVT and PE) in India. Our survey findings indicate a gap between current practicing patterns of physicians versus expert panel recommendations for managing patients with VTE in the Indian population.

Risk factors and diagnosis

In our survey, it was commonly observed that 63% of physicians generally performed clinical examination based only on signs and symptoms to assess the patient's risk of DVT, while only about 24% preferred using DVT risk assessment tool for the diagnosis of the condition. Whereas, the experts recommended the risk assessment to be done both by clinical examination and DVT risk assessment scores such as Wells score to determine the probability of having DVT. The Wells scoring system is the most widely used pretest probability scoring system stratifying patients with suspected DVT or PE.[15],[16] Recommendations from the inter-disciplinary group of Indian experts in the management of VTE suggest a combination of signs, symptoms, and clinical prediction rules to be able to categorize patients with risk of DVT,[17],[18] including using the Wells score for clinical prediction of DVT. The Asian VTE guidelines and recommendations suggest using risk assessment tools such as Caprini risk score and an individual risk assessment model that may be useful for further stratification of the risk to recommend appropriate prophylaxis.[6] Experts in our survey recommended treatment initiation for DVT only when the Well's score was ≥2 for a patient and after a positive duplex USG test. Modified Wells score >2 is suggestive of likely DVT.[19],[20],[21] Duplex USG test is a noninvasive technique and is becoming more readily available and accepted as a diagnostic modality in India.[12],[13] In line with our study findings, guidelines on the management of DVT in India suggest that D-dimer test does not necessarily help in the diagnosis of VTE but rather in ruling out thrombotic conditions.[18]

Hospitalization of patients is considered as a risk of VTE in the Indian/Asian population.[12] Almost 68% of the physicians, along with the experts in our survey, opined that patients hospitalized for >4 days should be considered as a risk factor for VTE requiring prophylactic anticoagulant therapy. The subset of ENDORSE study showed that in India, 53.6% of hospitalized patients (surgical [61.3%], medical [44.7%]) were at risk for VTE.[22] In a retrospective study on Indian patients with VTE (ARRIVE), >3 days of immobilization was considered as a risk factor for VTE.[23] Recent surgery, per 87% of the physicians, along with the expert opinion, was also considered as the risk factor for developing DVT or PE in our survey, aligned with findings in the Indian and the Asian populations.[6],[12],[23],[24] Regarding gender, according to experts in our survey, the risk for developing PE was similar for men and women. Interestingly, 47% of the physicians were of the opinion that women are at greater risk as per their daily clinical practice. Heit et al. have listed the male gender as a major risk factor for developing VTE.[25] Three population-wide studies in Asia reported on gender and VTE risks; in Korea, women were less likely to be diagnosed for VTE (relative risk [RR]: 0.96) or DVT alone (RR: 0.87) but more likely to be diagnosed for PE (RR: 1.11).[26] In Taiwan, 54% of patients with VTE were female,[27] while the study in China reported no significant difference.[28]

Use of anticoagulants

Appropriate treatment of VTE is critical to minimizing long-term morbidity and mortality. The NOAC, dabigatran was the treatment of choice in our survey findings. In India, dabigatran was approved for the treatment and secondary prevention of DVT and PE in patients who have been treated with a parenteral anticoagulant (unfractionated heparin [UFH] or LMWH/fondaparinux) for 5–10 days.[18] Efficacy and safety evidence of NOACs exist from large phase III clinical trials for the treatment of acute VTE.[18] The Asia-Pacific Thrombosis Advisory Board suggests that the use of NOACs may simplify patient management in Asia primarily due to no regular coagulation monitoring requirement since they demonstrate no interactions with nonsteroidal anti-inflammatory drugs and should be used in patients with major orthopedic surgery.[29] Our survey findings showed that in patients who underwent major orthopedic surgery, 80.26% of physicians would consider VTE prophylaxis with OAC. Lee et al. showed that 98% of the Indian patients with VTE were managed by anticoagulation alone, consisting of both UFH as well as LMWH.[13] In line with the Indian guidelines for the management of VTE,[18] and a retrospective registry of Indian patients with VTE (ARRIVE),[23] experts as well as 84% of the physicians in our survey preferred LMWH/Fondaparinux (considering normal eGFR) for anticoagulant therapy during the hospital stay of patients with VTE. The Asian guidelines suggest use of LMWH in patients with higher thrombotic risk, either due to predisposing risk or concomitant surgery.[6] The emergence of DOACs has provided clinicians with expanded therapeutic options for patients with VTE. The American College of Chest Physicians favors DOACs over traditional anticoagulants.[30] DOACs are recommended by major guidelines as first-choice agents for both stroke prevention in nonvalvular atrial fibrillation and treatment/prevention of VTE in noncancer patients.[31] In this survey, experts recommended DOACs or DOACs with bridging therapy as the preferred first-line treatment for infra-inguinal DVT. DOACs present no monitoring requirement and could be useful as a therapeutic option in the Indian setting, especially when our survey showed that 57% of the physicians along with the expert panel felt the need for monitoring as the most important challenge in the management of anticoagulant therapy; 78% of the physicians along with the experts also felt that DOAC therapy will lead to a better quality of life for the patients.

Duration of treatment

The duration of anticoagulant therapy is defined as acute (0–7 days), long-term (≥3 months of therapy), and extended therapy (>3 months).[32] With respect to the use and duration of anticoagulants, 53% of physicians, along with the expert panel, recommended 6 months of anticoagulant therapy for provoked proximal DVT or PE. While 68% of physicians recommended lifelong anticoagulation therapy, about 1 year of anticoagulant therapy was recommended by experts for patients with recurrent DVT. Long-term anticoagulation duration has been recommended for 6 months in the ARRIVE study.[23] For patients with permanent risk factors of DVT, experts recommended anticoagulant therapy for an indefinite period, aligned with 76% of the physician's observations. The 6th American College of Chest Physicians Consensus Conference on Antithrombotic Therapy has made the following recommendations for duration of anticoagulation: Patients with reversible or temporary risk factors for VTE may be treated for 3–6 months, while patients with irreversible risk factors such as thrombophilic states and malignancy are to be treated indefinitely.[33]

Strengths and limitations

Like any survey-based study, controlling for bias and confounders was difficult as there was no randomization and blinding. However, this was one of its kind surveys conducted among physicians across India to get their opinion on current practicing patterns on VTE in India. However, the findings cannot be generalized to other populations and any indirect comparison should take into account the differences with respect to study design, populations, methodology, clinical setting, and approach.


  Conclusions Top


Physician survey and the expert opinion reflecting day-to-day clinical practice patterns in India showed that though there is an increased disease awareness on VTE (DVT and PE), it remains a growing area of concern that needs to be managed in line with the clinical guidelines. We believe our survey findings and the expert opinion will provide capable insights that could serve as an opportunity to increase awareness regarding practicing patterns in India in line with the clinical guidelines. The need gaps and insights captured by this survey may aid in developing strategies on patient education and physician programs to improve accurate diagnosis and treatment of DVT, to prevent progression or recurrence of thromboembolic disease and to safely use anticoagulants to reduce the likelihood of patients' harm and complications of anticoagulation therapy.

Disclosure

The survey was done in association with Abbott Healthcare Pvt. Ltd. The views expressed and discussed in the meeting and stated in this article are the views of the authors and not of Abbott Healthcare Pvt. Ltd.

Acknowledgment

The authors would like to thank CBCC Global Research for assisting in manuscript development. The authors also thank all the physicians for their participation in this study.

Financial support and sponsorship

Nil.

Conflicts of interest

This survey was supported by Abbott Healthcare Pvt. Ltd.


  Survey Questionnaire Top


1. In your practice, how many patients do you see with a risk factor for VTE requiring prophylaxis or treatment? (weekly)

  1. 1-7
  2. 8-15
  3. >15


2. How do you initially in a patient assess the risk of DVT?

  1. Clinical examination only based on signs & symptoms
  2. DVT scores like Wells score etc
  3. D-Dimer only
  4. Duplex USG


3. What should the next course of action be if a patient score greater or equal to 2 on the Wells score?

  1. Do D-dimer, if positive, treat as DVT.
  2. Do Duplex USG, if positive, treat for as DVT.
  3. Do Duplex USG, if negative, DVT ruled out.
  4. If Wells score >2, treat as DVT.


4. What were the conditions/indications where you considered VTE prophylaxis with oral anticoagulants?

  1. Major orthopedic surgery
  2. Cardiac surgery
  3. Myocardial Infarction
  4. Acute heart failure
  5. Others __________________________


5. In the above patients, how many days of hospitalization was considered as a risk factor for VTE requiring prophylactic anticoagulation?

  1. >4 days
  2. >7 days
  3. >14 days
  4. >1month


6. In the above case scenario of hospitalization, what is your preferred anti-coagulant during the hospital stay?

  1. Low molecular weight heparin/Fondaparinux (considering normal eGFR)
  2. NOACs
  3. Aspirin
  4. Unfractioned heparin
  5. Vit K Anatagonists


7. Which factors you consider for being at-risk for developing deep vein thrombosis or pulmonary embolism:

  1. Obesity
  2. Recent surgery
  3. Smoking
  4. Any of the above


8. Who do you think is at greater risk for pulmonary embolism as per your clinical experience?

  1. Men
  2. Women
  3. Young women
  4. The risk is the same for men and women


9. What is your preferred first line treatment for DVT ?

  1. Low molecular weight heparin/Fondaparinux (considering normal eGFR)
  2. NOACs
  3. Aspirin
  4. Unfractioned heparin
  5. Vit K antagonists


10. What is your preferred treatment of DVT in patients that suffer from active cancer by you?

  1. Low molecular weight heparin with VKA
  2. Low molecular weight heparin
  3. Unfractioned heparin
  4. NOACs
  5. Vit K antagonists


11. How long your patients with provoked proximal DVT or PE are put on anti-coagulation?

  1. 2 months
  2. 3 months
  3. 6 months
  4. 4 months
  5. 1 month


12. How long your patients with recurrent DVT are put on anti-coagulation?

  1. 5 years
  2. 1 year
  3. 10 months
  4. 3 years
  5. Permanent


13. How long your patients with permanent risk factors for DVT are put on anti-coagulation?

  1. 3 months
  2. 12 months
  3. 6 months
  4. 4 months
  5. 8 month


14. How long would you anti-coagulate patients with isolated calf vein thrombosis?

  1. 2 weeks
  2. 10 weeks
  3. 6 weeks
  4. 1 month


15. Which of them has a higher occurrence in Indian population?

  1. Provoked DVT
  2. Unprovoked DVT
  3. Same
  4. Can't say


CASE-BASED Discussions

15. A 54 year old male smoker was admitted with gradually worsening breathlessness over the last 10 days. He reported a cough but no obvious fever or discoloured sputum. Her past medical history included a DVT 5 years previously. She was not taking any regular medication. There were no findings on review of systems and nothing abnormal on clinical examination apart from breathlessness.

Her blood results and chest X-ray were normal. A subsequent CT pulmonary angiogram was performed and showed bilateral proximal pulmonary emboli with no evidence of right heart strain. She was started on low molecular weight heparin and VKA.

What further investigations should she have?

  1. CT of abdomen and pelvis
  2. Ultrasound of abdomen and pelvis
  3. CT of abdomen and pelvis + thrombophilia screen
  4. CT of chest, abdomen and pelvis
  5. CT of abdomen and pelvis + mammogram


16. A 30 year old woman, who was 20 weeksf pregnant, presented to Ambulatory Care with pleuritic chest pain and breathlessness, which had been present for 2 days. She had no past medical history, was a non--smoker and was not taking any regular medication apart from an antacid for reflux. On examination there was nothing abnormal to find. She had no symptoms or signs of deep vein thrombosis.

Her creatinine, electrolytes, liver tests and baseline clotting results were normal. A chest X---ray was performed which was also normal.

What is the most appropriate next investigation in this case?

  1. CT pulmonary angiogram
  2. Doppler ultrasound of both legs
  3. MR pulmonary angiogram
  4. Perfusion scan of the lungs
  5. Ventilation---perfusion scan of the lungs


17. A 44-year-old man is evaluated in follow-up for an episode of unprovoked left proximal leg deep venous thrombosis 3 months ago. Following initial anticoagulation with low-molecular-weight heparin, he began treatment with a VKA (Vit K antagonist). INR testing done every 3 to 4 weeks has shown a stable therapeutic INR. He has mild left leg discomfort after a long day of standing, but it does not limit his activity level. He tolerates treatment well. Family history is unremarkable, and he takes no other medications. No other apparent risk factors present.

17.a.Which of the following is the most appropriate management as per you?

  1. Extend anticoagulation
  2. Discontinue Vit K antagonist in another 3 months
  3. Discontinue Vit K antagonist now
  4. Discontinue Vit K antagonist and perform thrombophilia testing


17.b. In your opinion does thrombophilia profile testing result modify the anticoagulation management

  1. Yes
  2. No
  3. Can't say


18. A 45 year old man presents with mild-moderate calf pain and swelling for 5 days since he was kicked playing football in his colony. Ultrasound shows DVT in the posterior tibeal vein.

In your opinion whats the appropriate management?

  1. Start anti-coagulation
  2. No need for anti-coagulation
  3. Monitor by serial imaging x 2 weeks
  4. Systemic thrombolysis


19. A senior pilot with a commercial airline with over 12,000 hours of flying to his credit developed a mild swelling over his left ankle while flying as second commander for a long-haul trans continental flight. Over the next 6 hours the swelling gradually increased from the ankles to involve the entire left leg, accompanied by a nagging pain. On arrival he reported to the airline physician and was diagnosed as a case of DVT and admitted to a hospital. On admission, all routine blood and biochemical parameters including LFT were within normal limits. Ultrasound Doppler examination of the left lower limb showed extensive deep vein thrombosis extending from the left femoral vein down to the proximal calf vein. On ultrasound the left iliac vein and IVC were patent. All coagulopathy tests were normal.

What is the preferred anti-coagulant in a case?

  1. LMWH
  2. VKA
  3. NOACs
  4. Anyone


20. A 24 year old professional kathak dancer was admitted with acute onset of heaviness, pain and functional impairment of her right (dominant) arm. The arm was cyanotic and swollen. For the past few weeks, she reported transient paraesthesia of her right arm during overhead activities.

She had no past medical history, was taking no medication and had no personal or family history of thrombosis. On examination, her right arm was significantly swollen and cyanotic.

An urgent Doppler USS of the right arm showed axillary and subclavian vein thrombosis.

What is the most appropriate management in this case?

  1. Anticoagulation for 3 months
  2. Anticoagulation for 6 months
  3. Anticoagulation for 6 months and referral to lymphoedema clinic
  4. Catheter---directed thrombolysis
  5. Intravenous thrombolysis


21. A 30 year old woman presented to Ambulatory Care with pain and swelling of her left leg, which had been present for 2 days. She had no past medical history and was not taking any regular medication apart from the combined oral contraceptive pill. On examination there was obvious swelling of her left leg compared with the right.

Her blood results were normal and a pregnancy test was negative. An urgent Doppler ultrasound scan confirmed a proximal deep vein thrombosis.

What is the correct treatment in this case?

  1. Anticoagulation for 3 months + left below knee TED stocking
  2. Anticoagulation for 6 months + left below knee TED stocking
  3. Anticoagulation for 6 months + bilateral below knee TED stockings
  4. Anticoagulation for life + left below knee TED stocking E Catheter directed thrombolysis


22. A 50-year-old woman presents to you following GP referral. She complains of pain in her left calf, which has been present for a week. Three weeks ago she had acute appendicitis with hospital admission. For the last day her left thigh has been painful. Her medical records do not indicate that she received VTE prophylaxis while in hospital. She has no significant past medical history. On examination her entire left leg is swollen. Left calf 38 cm, right calf 34 cm, left thigh 56 cm, right thigh 52 cm. Her heart rate is 70 beats per minute, respiratory rate 14 breaths per minute, blood pressure 120/80 mmHg, temperature 98.6 Farenheit and SpO2 99% in air.

The proximal leg vein ultrasound scan identifies an occlusive clot in the common femoral vein.

In the above case?

  1. May consider catheter-directed thrombolysis
  2. Should consider catheter-directed thrombolysis
  3. Should not consider catheter-directed thrombolysis
  4. Can't say


22.b. In the above case

  1. May consider IVC filter
  2. Should consider IVC filter
  3. Should not consider IVC filter
  4. Can't say


23. aIn elderly patients (>65 years), with low body weight and moderate risk of PE (pulmonary embolism) with moderate renal impairment, what was your antithrombotic management of choice?

  1. Parenteral anticoagulation followed by VKA
  2. Parenteral anticoagulation followed by NOACs
  3. NOACs directly without parenteral anticoagulation
  4. Others ___________________


23.b. If you ticked the option c in question 11, Which NOAC did you prefer? ____________

24. How do you assess renal function of a patient before initiating NOACs? (multiple choices may be ticked)

  1. CrCL based on Cockcroft Gault formula
  2. CrCL based on CKD-EPI formula
  3. 24 hr urine creatinine clearance


25. What tests you advise before initiating your patients on NOACs for DVT? (multiple choices may be ticked)

  1. Hemoglobin, RFT and LFT
  2. RFT and LFT
  3. Stool for occult blood
  4. Urine routine for hematuria
  5. Others __________________


26. In the following patient profiles, considering affordability to be not an issue, what was your choice of molecule? Please tick only one option per scenario



27. What do you feel is the most important challenge in anticoagulation management from the patient's perspective? (according to you)

  1. Affordability
  2. Limitations to lifestyle
  3. Need for monitoring
  4. Disease and therapy very complicated for patients to understand and align to
  5. Complications (bleeding episodes, hematuria)


28. From the patient's perspective, on which of the therapy do you feel patients will have better Quality of Life? (multiple choices may be ticked)

  1. VKA
  2. NOACs
  3. LMWH/Fondaparinux
  4. UFH




 
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