ASL PROVINCIA DI BERGAMO
Corso di aggiornamento
La gestione del paziente in Terapia Anticoagulante Orale (TAO)
TVP
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Although none of the symptoms or signs of
DVT is diagnostic in isolation, it has been well
established that a clinical prediction rule that
takes into account signs, symptoms and risk
factors can be accurately applied to
categorize patients as having low, moderate
or high probability of DVT
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Recommendation 1:
Low-molecular-weight heparin (LMWH) rather
than unfractionated heparin should be used
whenever possible for the initial inpatient
treatment of deep venous thrombosis (DVT).
Either unfractionated eparin or LMWH is
appropriate for the initial treatment of
pulmonary embolism.
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Recommendation 2:
Outpatient treatment of DVT, and possibly
pulmonary embolism, with LMWH is safe and
cost effective for carefully selected patients
and should be considered if the required
support services are in place.
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Recommendation 3:
Compression stockings should be used
routinely to prevent post thrombotic
syndrome, beginning within 1 month of
diagnosis of proximal DVT and continuing for
a minimum of 1 year after diagnosis.
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Recommendation 5:
Anticoagulation should be maintained for 3
to 6 months for VTE secondary to transient
risk factors and for more than 12 months for
recurrent VTE.
While the appropriate duration of
anticoagulation for idiopathic or recurrent
VTE is not definitively known, there is
evidence of substantial benefit for extendedduration therapy.
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Recommendation 6:
LMWH is safe and efficacious for the longterm treatment of VTE in selected patients
(and may be preferable for patients with
cancer).
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For patients with DVT or PE secondary to a transient (reversible) risk
factor, we recommend treatment with a VKA for 3 months over
treatment for shorter periods (Grade 1A).
For patients with unprovoked DVT or PE, we recommend treatment with
a VKA for at least 3 months (Grade 1A), and that all patients are then
evaluated for the risks to benefits of indefinite therapy (Grade 1C). We
recommend indefinite anticoagulant therapy for patients with a first
unprovoked proximal DVT or PE and a low risk of bleeding when this is
consistent with the patient’s preference (Grade 1A), and for most
patients with a second unprovoked DVT (Grade 1A).
We recommend that the dose of VKA be adjusted to maintain a target
INR of 2.5 (INR range, 2.0 to 3.0) for all treatment durations (Grade 1A).
We recommend at least 3 months of treatment with LMWH for patients
with VTE and cancer (Grade 1A), followed by treatment with LMWH or
VKA as long as the cancer is active (Grade 1C).
For prevention of postthrombotic syndrome (PTS) after proximal DVT, we
recommend use of an elastic compression stocking (Grade 1A).
For DVT of the upper extremity, we recommend similar treatment as for
DVT of the leg (Grade 1C).
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età giovanile di comparsa dell’evento trombotico,
arterioso o venoso (< 45 anni)
TEV idiopatica
TEV dopo stimoli di entità trascurabile
TEV ricorrente
trombosi venose in sedi non usuali
storia familiare positiva per tromboembolie
venose
associazione di trombosi con perdita fetale
necrosi cutanea indotta da anticoagulanti orali
porpora fulminante neonatale
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TEMPO DI PROTROMBINA (come indice di funzionalità
epatica)
aPTT
FIBRINOGENO
ANTITROMBINA III
PROTEINA C
PROTEINA S
RESISTENZA ALLA PROTEINA C ATTIVATA (se alterata
ricerca della mutazione Fattore V Leiden)
MUTAZIONE G20210A DEL GENE DELLA PROTROMBINA
RICERCA DEL LUPUS ANTICOAGULANT (LAC)
ANTICORPI ANTICARDIOLIPINA (e anticorpi antibeta2
Glicoproteina I)
OMOCISTEINA (di base e dopo carico con metionina)
È necessario tener presente che, a differenza dei test
genetici, i test funzionali per alterazioni trombofiliche
risultano spesso alterati in modo aspecifico nelle seguenti
condizioni:
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durante la fase acuta di un evento trombotico, sia venoso
che arterioso
durante la terapia anticoagulante (eparina, anticoagulanti
orali)
durante malattie intercorrenti acute che possono
influenzare i risultati
durante trattamento estro-progestinico
durante la gravidanza
in caso di presenza di epatopatie con presumibile
alterazione secondaria dei test coagulativi
1.
MMG: sospetto diagnostico e valutazione della
probabilità clinica di TVP
2. MMG: invio alla struttura ospedaliera idonea
secondo modalità concordate; in caso di invio non
immediato valutazione dell’opportunità di iniziare
terapia con EBPM a domicilio
3. OSPEDALE: accoglimento del paziente e suo
inserimento nel percorso diagnostico di base
predefinito
4. OSPEDALE: diagnosi di TVP o, in caso d’incertezza,
predisposizione delle misure diagnostiche,
predefinite, successive all’iter di base già eseguito
5. OSPEDALE: eventuale terapia per il tempo necessario
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Indefinite anticoagulation is commonly
reserved for patients with permanent risk
factors for thrombosis
patients with unprovoked DVT generally
receive 6 months of anticoagulation
those with DVT associated with transient risk
factors receive treatment for 3 months
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Overall, 46 (17.2%) of 268 patients allocated to
fixedduration anticoagulation and 32 (11.9%) of
270 patients allocated to flexible-duration
anticoagulation developed recurrent VTE (adjusted
hazard ratio [HR], 0.64 [95% CI, 0.39 to 0.99]).
For patients with unprovoked DVT, the adjusted HR
was 0.61 (CI, 0.36 to 1.02) and 0.81 (CI, 0.32 to
2.06) for those with secondary DVT.
Major bleeding occurred in 2 (0.7%) patients in the
fixed-duration group and 4 (1.5%) patients in the
flexible-duration group (P 0.67).
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In patients who have completed at least 3
months of anticoagulation for a first episode of
unprovoked VTE and after approximately 2
years of follow-up, a negative D-dimer result
was associated with a 3.5% annual risk for
recurrent disease, whereas a positive D-dimer
result was associated with an 8.9% annual risk
for recurrence. These rates should inform
decisions about the balance of risks and
benefits of prolonging anticoagulation.