Thrombosis&nbsp;&nbsp;&nbsp;

For patients with newly diagnosed VTE on IV heparin planned for transition to DOAC, would you start at the loading or maintenance DOAC dose?

If they have been on IV heparin for 3 days, for example, would you subtract those days from the recommended loading dose time?

How would you manage superficial vein thrombosis that persists on imaging after treatment with full dose anticoagulation?

Thrombosis of the greater saphenous vein extending from SFJ to mid-calf, unchanged on follow-up Doppler imaging after 3 months of full dose rivaroxaba...

How would you manage distal DVT in first trimester of pregnancy?

Cardiolipin was mildly positive and persistent after 12 weeks (29->28 MPL). No other significant provoking factors. The patient started on LMWH. W...

What genetic testing would you consider for recurrent arterial events (cryptogenic strokes, MI) in patients with limited risk factors?

Family history is notable for CVA and early onset MI in nonsmokers, but no personal or family history of VTE. APLS testing is negative. Previously fou...

Would you evaluate for thrombophilia in patients with incidental splenic infarcts in the setting of known cirrhosis, portal hypertension, and splenomegaly?

How would you approach anticoagulation in this situation? Does the presence of thrombocytopenia or hemorrhagic splenic infarcts change your manag...

How would you manage symptomatic, bilateral subsegmental PE developed after long air travel?

The patient takes frequent flights for their job, with no prior history of VTE, and has already been taking measures for prevention including frequent...

Can anti-cardiolipin or anti-beta-2 glycoprotein antibodies cause prolonged PTT in the absence of a lupus anticoagulant?

Labs with normal PT, but prolonged PTT (47 sec, ULN 40 sec) that does not correct on immediate mix. Lupus anticoagulant negative (DRVVT and hexagonal ...

Is there any benefit of using aspirin to mitigate VTE risk in testosterone-induced polycythemia?

Would you start anticoagulation in a patient with RCC and related (tumor) thrombus with extension to renal vein and further?

How long would you anticoagulate for PE developed after air travel in a woman on an estrogen-containing vaginal ring for contraception?

Would you anticoagulate for a fixed or indefinite duration? Would you recommend changing her contraception method?

How would you manage superficial thrombophlebitis of the great saphenous vein involving the knee and calf?

Would you label this as intermediate or high risk and treat with prophylactic or full dose AC? What duration would you treat for?

What is your approach to symptomatic superficial thrombosis of the pelvic veins occurring in the immediate postpartum period?

No prior hx of DVT/SVT. Negative LE doppler. Would you consider anticoagulating and at what dose, or favor close observation?

What would you recommend for long term management of extensive dural venous sinus thrombosis (CVST) in young females when the only provoking risk factor is combined OCP?

Thrombophilia testing, including JAK2 is negative. When would you stop anticoagulation?

In extremely obese patients with spontaneous DVT/PE who have been anticoagulated for > 6 months, do you feel comfortable reducing the DOAC to prophylactic dose or do you prefer continuing full dose indefinite anticoagulation?

BMI>40

What is your approach to DVT prophylaxis in patients who require IVIG but are at increased risk for thrombotic events?

E.g., a patient with newly diagnosed CIDP who is wheelchair-bound.

How do you start and manage therapeutic SC heparin for acute thrombosis in pregnancy as the patient approaches delivery?

Assume patient requires anticoagulation in the setting of acute thrombosis, with no need for IVC filter, but is approaching the end of her third trime...

How would you manage a patient with morbid obesity who presents with new symptomatic pulmonary embolism a few days after he was started on DOAC for DVT?

What is your preferred anticoagulation in patients with BMI >50?

5 Answers available

How is your experience with point-of-care INR systems for home monitoring of vitamin K antagonists?

Are the INRs reliable? In what scenarios would you not recommend POC INR use for warfarin monitoring? Are these typically covered by insurance? Are t...

Does your evaluation of a young person with spontaneous upper extremity DVT vary as compared to lower extremity DVT?

Do you do additional workup for venous obstruction or any other different testing/evaluation?

How would you counsel a female to male transgender patient regarding VTE risk with testosterone therapy, who has additional mild-moderate risk factors for thrombosis?

Additional risk factors could be family history of VTE or thrombophilia, such as antithrombin deficiency.

When do you use clinical decision tools, like HERDOO2 or DASH, to determine duration of anticoagulation in venous thromboembolism?

How do you manage a patient with no history of miscarriage but who is unable to conceive, who has a positive lupus anticoagulant without diagnosis of antiphospholipid syndrome?

How do you manage concurrent nonlife-threatening hemoptysis and acute pulmonary embolism?

Estimating blood loss from hemoptysis is not always reliable. The bleeding may be due to the PE itself. Is anticoagulation with any degree of hemoptys...

Does PT/PTT elevation due to severe vitamin K deficiency protect against thrombosis?

In the setting of requiring anticoagulation for atrial fibrillation and bioprosthetic valve, but also having severe vitamin K deficiency, would you st...

How would you manage a provoked blood clot for a patient who had been placed on low dose DOAC for history of unprovoked blood clot?

Are SCDs contraindicated in patients with acute DVTs?

Is it different than early mobility that we always encourage?

For a patient with May-Thurner syndrome and DVT, would you recommend anticoagulation for 3-6 months or indefinitely?

4 Answers available

How would you manage a patient with SLE that has a remote history of positive anti-phospholipid antibodies with a current DVT and now completely negative APLs?

Would you still plan for lifelong anticoagulation in this scenario?

Would you recommend indefinite anticoagulation in any scenario of a provoked clot?

E.g. young male, morbid obesity, with BMI >50

Would you extend the duration of anticoagulation in patients with a provoked DVT, but evidence of residual clot at 3 months?

While follow up ultrasound is not usually recommended in provoked DVT, it often is done either for other reasons or by other physicians. Would this in...

How do you approach anticoagulation in the setting of HIT and thrombocytopenia?

I.e. platelet count <30. Would your management change if HIT were only suspected rather than confirmed?

How long do you anticoagulate for cirrhosis patients who have portal vein thrombosis extending to the mesenteric veins?

How long post operatively do you wait before transitioning from parenteral anticoagulation to oral anticoagulants after pulmonary thromboendarterectomy for CTEPH?

How do you dose apixaban in patients with CrCl <30 mL/minute?

What are the factors that you would consider for the use of ESA in patients with anemia of CKD with a history of stroke or TIA?

Would you anticoagulate a patient with splenic infarctions in the setting of CMV viremia?

If so, for how long?

What are the indications for anticoagulation in splenic infarctions?

What is the work up and what is the duration of anticoagulation if used?

What is the ideal period to wait until curative surgery for patients with acute pulmonary embolism and solid malignancy?

Specifically, asymptomatic subsegmental PE diagnosed within a month from planned bilateral mastectomy for breast cancer.

How do you manage a DOAC if interested in testing for lupus anticoagulant?

Significant history of autoimmune diseases and DVT in family, recent PE/DVT for a month

4 Answers available

How do you manage me anticoagulation in a patient with May Thurner Syndrome, who does not have history of thrombosis, and becomes pregnant?

Can you use apixaban or rivaroxaban in case of dabigatran failure?

Would you give transdermal hormone replacement therapy to a woman with remote history of provoked pulmonary embolism?

Is patch or gel HRT with ASA prophylaxis a reasonable option after counseling? Or do you add a prophylactic DOAC?

How do you treat a patient with warfarin failure, with therapeutic INR 2-3 at the time of DVT, and no underlying malignancy or hypercoagulable state?

Is lifelong LMWH the anticoagulant of choice? Would DOACs be an option?

What is your practice for work up and treatment of incidental splenic infarcts with or without splenomegaly in patients without sickle cell disease?

For patients with incidental findings of venous thromboembolism during workup of a treatable malignancy, how do you approach discontinuation after the treatment is complete?

Would you consider low dose indefinite anticoagulation in any scenario? Any difference in approach between hematological malignancy and solid tum...

In a young female with severe osteoporosis due to congenital estrogen deficiency, can estrogen be prescribed if genetic testing for congenital disorders reveals a heterozygous Factor V Leiden mutation?

No prior thrombosis; no family history of thrombosis. As per endocrine, the only useful therapy for the osteoporosis is estrogen.

Would you anticoagulate a patient with an asymptomatic gonadal vein thrombosis on CT scan, found on surveillance imaging for colorectal cancer?

Do you repeat images in patients with venous thrombosis to inform decision about duration of anticoagulation?

E.g. pulmonary embolism, portal vein thrombosis, cerebral venous sinus thrombosis

Would you consider using DOACs in a young patient with SLE and Libman-Sacks endocarditis, who is negative for APS?

Do you send an antiphospholipid antibody panel routinely for all patients with an unprovoked thrombus?

Would you discontinue anticoagulation in patients with antiphospholipid antibody syndrome, who have a remote history of thrombotic events and are now negative for pathogenic antiphospholipid antibodies?

Would the answer differ if the index event was arterial vs venous?

Is there any role in continuing apixaban in a patient with occlusion of the right internal jugular vein with chronic postthrombotic change to prevent a recurrent DVT?

Previous provoking factors resolved (CVC, malignancy, etc)

Would you consider thrombophilia testing in a pregnant patient with VTE?

If work-up is sent and the patient is found to have a persistently positive antiphospholipid antibody, particularly lupus anticoagulant, would you con...

How would you approach a young patient with a history of APLS and VTE, desiring hormone replacement therapy after oophorectomy?

Currently on nonwarfarin therapeutic anticoagulation

How would you manage IVF using ovarian stimulation in a woman with a prior estrogen related thrombotic event?

Do you recommend long term anticoagulation for all patients with first time unprovoked VTE?

What recommendations do you have for a transgender female patient with history of prothrombin gene mutation who is interested in starting gender affirming hormone therapy?

The patient has no personal history of VTE, but has positive family history of VTE. Any prophylactic anticoagulation options? How would manage...

In a patient identified as having APLS because of recurrent pregnancy loss without history of thrombosis, but now has a new DVT/PE during pregnancy despite use of enoxaparin—for how long would you recommend anticoagulation?

Is it time limited since it may have been triggered by the pregnancy or is it indefinite since it is APLS associated?

In patients who develop a VTE, what conditions do you consider as persistent, provoking risk factors, and at what point are they controlled enough to stop anticoagulation?

I.e., what constitutes well-controlled cancer, IBD, nephrotic syndrome, etc. What other diseases do you put in this category (obesity, autoimmune dise...

Do you consider travel as a risk factor for DVTs in the absence of any other underlying predisposing factors?

i.e. long car rides or plane rides

How would you manage an incidental catheter-related thrombosis in a functioning dialysis catheter?

- Dialysis catheter used for hemodialysis- RIJ thrombus in dialysis catheter was incidentally found- Patient asymptomatic with no prior history of VTE...

Do you always initiate hypercoagulable work up in a patient with recurrent stroke?

If so, what would you consider ordering?

How do you counsel patients with elevated factor VIII levels for their thrombosis risk?

Should we stop checking factor VIII levels as part of thrombosis workup?

How do you determine duration of anticoagulation for an ovarian vein thrombosis following a provoking event?

Should a pregnant woman who is heterozygous for factor V Leiden who has never had a thrombotic event receive prophylactic anticoagulation?

Are there any situations you would recommend prophylactic anticoagulation for a patient with Factor V heterozygosity?

FVL heterozygotes are often treated similarly to the general population. Aside from avoiding other VTE risk factors, are there situations where prophy...

Should we recommend the COVID-19 booster vaccine to patients who had a DVT or any other complications such as hemolytic anemia or thrombocytopenia from prior vaccine doses?

In a patient with a heterozygous prothrombin gene mutation who has COVID with minimal symptoms, do you recommend prophylactic and/or therapeutic anticoagulation?

What is your preferred anticoagulant for acute portal vein thrombosis?

How does cirrhosis and/or underlying thrombophilia affect your decision?

Does testing for elevated serum homocysteine have any relevance in thrombophilia management?

What should be done with a high level?

Are you comfortable using DOACs in obese patients with VTE?

Do you approach the diagnosis and treatment of HIT patients differently in the outpatient setting or in a resource-limited community setting?

For example, for outpatients or resource-limited settings with a moderate probability 4-T score (but low clinical suspicion), would you ever consider ...

How do you manage HIT in a patient with high bleeding risk?

e.g. in the setting of using prophylactic heparin in the past but now requiring therapeutic anticoagulation

How do you manage a patient with superficial venous thrombosis with close proximity (<3 cm) to deep veins and an inherited thrombophilia ?

Would you offer indefinite anticoagulation if the event is unprovoked and the patient has low bleeding risk?

Are there any circumstances where you consider repeating CT Angiogram Chest after 3-6 months of anticoagulation for pulmonary embolism?

Is prophylactic anticoagulation indicated in patients with frequent ulcerative colitis flares?

If so, what agent(s) do you prefer?

What is your standard workup and treatment for an incidentally-noted splanchnic vein thrombosis?

What is your duration of anticoagulation?

Do you utilize D-dimer to inform anticoagulation duration in the treatment of VTE?

Provoked or unprovoked VTE: Do you use D-Dimer (or even repeat imaging to reassess residual clot) in any capacity to guide anticoagulation duration? E...

Would you use aspirin 81 mg for VTE prophylaxis in patients on adjuvant tamoxifen/SERMs?

Is there data that it actually helps?

What is the anticoagulation recommendation for a chronic DVT?

How soon after a VTE would you feel comfortable with a patient undergoing an elective surgery?

While there are many factors involving:- type (DVT vs PE, unprovoked vs provoked) and severity of venous thromboembolism (VTE) size- duration of antic...

How do you advise a patient with VTE on indefinite anticoagulants regarding the Ad26.COV2.S Johnson & Johnson/Janssen COVID vaccine?

How do you approach evaluation of pulmonary vein thrombosis?

Is there any difference between anticoagulants in this clinical context (e.g. anti-Xa inhibitors vs warfarin vs LMWH)?

What is your approach to platelet transfusion in heparin induced thrombocytopenia?

Does having a concurrent consumptive process e.g. DIC change your management?

How do you approach the use of low-dose aspirin for primary prevention in non-pregnant patients with SLE and positive aPL antibodies, without clinical criteria for APS?

Do you follow the 2019 EULAR Guidelines that SLE patients with asymptomatic, positive aPL should be on low-dose ASA?

Should patients receive thrombophilia testing in the setting of a provoked VTE secondary to hormonal therapy/OCPs?

While thrombophilia testing is not routinely recommended prior to starting OCPs, how about after the development of a VTE?

Do you generally reduce DOAC dosing for extended anticoagulation in patients with first unprovoked VTE?

Ref: EINSTEIN-CHOICE and AMPLIFY-EXT Would you approach this differently in patients with inherited thrombophilias?

Should venous thrombosis in a patient with Behcet syndrome be treated with both immunosuppression and anticoagulation?

Would you place an IVC filter in a patient with an acute PE and an absolute contraindication for anticoagulation, but negative imaging for proximal DVT?

How do you manage VTE in the setting of persistent severe thrombocytopenia?

Is there a preferred strategy of transfusional support versus reduced-dose anticoagulation during the duration of thrombocytopenia?

Would you recommend anticoagulation for patients with partial false lumen thrombosis in type B aortic dissection?

Would you offer this routinely or only if specific complications arise, such as distal emboli?

Do you use bevacizumab in patients with history of VTE (DVT/PE) who are stable on anticoagulation?

Would it make a difference if the VTE diagnosis occurs during bevacizumab therapy or whether it preceded the cancer diagnosis?

Would you recommend anticoagulation prophylaxis for a pediatric patient admitted with COVID-19?