Cardiovascular
Please answer question 1 and 2 refer to the chest guideline please
VP is a 72 year old man with a history of hypertension, hyperlipidemia, mild depression and coronary artery disease s/p CABG 6 years ago. He has been managed on simvastatin, aspirin, metoprolol, valsartan and amlodipine since his coronary artery intervention and has been doing well. He sees a cardiologist twice annually and keeps up with any surveillance ordered.
In addition to his vascular issues, Mr P has had a good amount of knee pain over the last 1-2 years. His L knee required arthroscopy to address a full lateral meniscal tear 2 years ago – at that time it was evident that he had extensive DJD of both knees, R worse than L. 3 months ago, he had to proceed with R total knee replacement because of daily limiting pain.
After his replacement he had a short stint with inpatient rehabilitation and then was sent home to continue. Ten days after discharge he reported pain and swelling distal to his knee and also felt somewhat winded walking up the steps and also on even ground. He was sent to the emergency room and found to have a room air pulse ox of 94% that fell to 90% with walking, sinus rhythm at 92, a clear chest x ray but a CT angiogram with segmental perfusion defects in the RML and LLL. The patient was admitted and anti coagulated for post operative DVT and PE – he was placed on apixiban 10 mg twice daily. Serum Cr was 1.4, and has been in the range of 1.3 to 1.5 for the last 2-3 years on review of his outpatient chart. He had improvement of pain, again was assessed for his mobility and was discharged home.
On getting home and going to the pharmacy to get his medications, it was explained that apixiban was not on his formulary and would cost him 85$ for the month. He wasnt able to afford this and called his internist. The office ascertained that rivaroxaban was covered with a copay of 35$, which was acceptable to the patient. He was started on 20 mg daily as an extension of the 3 days of apixiban he received as an inpatient.
The patient did well for 5 weeks but then reported some swelling and stiffness around the replaced R knee. This was painful with walking, as any extension or flexion seemed restricted and resulted in a quick jolt of pain. On visits with his orthopedist, arthrocentesis resulted in a bloody return. Sonogram guidance showed some loculations of the effusion. His hemarthrosis required 6-8 more weeks to reabsorb. In that time, dopplers of his calf revealed organisation of clot but no fresh clot. Rivaroxabam was held for 3-4 weeks, while the patient was given aspirin. When his effusion was nicely improved, his anticoagulation was resumed but changed back to apixiban at the request of the orthopedist.
Learning Objectives to be Prepared :
1. What is the current guideline recommendation re: peri hip and knee replacement anticoagulation for short term DVT prophylaxis? Please refer to the CHEST guideline on prevention of VTE in orthopaedic surgery patients included.
2. Lets deal with duration first – whats the optimal duration of anticoagulation for a provoked DVT? What if it was an unprovoked DVT? Please refer to the CHEST guideline on antithrombotic therapy of VTE disease, also included
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