**12. DVT and PE in the elderly – Two sides of the same coin VTE**

The continuum of DVT and PE in the elderly is quite similar to that of the younger patient. Constant consideration of the diagnosis and application of standard diagnostic and therapeutic strategies will be a benefit for the patients and also enhance the mental equanimity and professional satisfaction of physicians caring for the elderly.

#### **12.1 Deep vein thrombosis**

The incidence of deep vein thrombosis increases with age.

#### **12.1.1 Etiology**

Immobilization, prolonged sitting (as it may occur during long drives or air travel), or even a relatively sedentary existence can lead to venous stasis and predisposes to thrombosis, because the emptying of veins in the extremities depends entirely on skeletal muscles that pump blood and on one-way venous valves that inhibit retrograde flow. Since incompetent venous valves lead to deep vein thrombosis, which damages the valves, deep vein thrombosis tends to recur.

Deep vein thrombosis occurs in 20 to 25% of patients > 40 after routine surgery and in almost 50% after hip surgery when no prophylaxis is given.

#### **12.1.2 Symptoms and signs**

54 Pulmonary Embolism

Mechanical and pharmacologic measures often succeed in preventing this complication. Patients who have undergone total hip replacement, total knee replacement, or cancer surgery will benefit from extended pharmacologic prophylaxis for a total of 4 to 6 weeks, especially with LMWH or UFH about 2 in 3 cases (Bottaro et al., 2008; Reynolds et al., 2009). Thromboembolic complications are prevalent in the perioperative period. It has been estimated that between 20% and 30% of patients undergoing general surgery develop deep venous thrombosis, and the incidence is as high as 40% in hip and knee surgery, gynecological cancer operations, open prostatectomies, and major neurosurgical procedures. Although fatal pulmonary embolism occurs in 1% to 5% of all surgical patients, it accounts for a larger proportion of operative deaths in middle-aged and older individuals. Because venous thrombosis and pulmonary emboli can be difficult to diagnose and treat,

Patients at high risk can receive a combination of mechanical and pharmacologic modalities. Graduated compression stockings and pneumatic compression devices may complement mini-dose unfractionated heparin (5000 units subcutaneously twice or preferably three times

Overall the literature suggests that any association of age with risk of bleeding on heparin or warfarin is weak, and contrasts with the strong, consistent finding of an exponential increase in thrombembolic risk with age (Kanaan et al., 2007; Kakkar et al., 2010). However, geriatritians should consider several practical considerations when prescribing oral

1. Sensitivity to the anticoagulant effect of a given dose increases with age (e.g. decrease of

2. Polypharmacy (including self-medication) increases the risk of drug interactions which alter oral anticoagulant effect, or which increase the risk of bleeding (e.g. aspirin and

3. Increased prevalence of concurrent or intercurrent illness also increases the risk of bleeding (e.g. severe anemia, renal failure, gastrointestinal bleeding, hemorrhagic

4. Decreased compliance or decreased access to monitoring – whether performed by the general practitioner or hospital anticoagulant clinic – also increases risk of bleeding.

The continuum of DVT and PE in the elderly is quite similar to that of the younger patient. Constant consideration of the diagnosis and application of standard diagnostic and therapeutic strategies will be a benefit for the patients and also enhance the mental

Immobilization, prolonged sitting (as it may occur during long drives or air travel), or even a relatively sedentary existence can lead to venous stasis and predisposes to thrombosis, because the emptying of veins in the extremities depends entirely on skeletal muscles that pump blood and on one-way venous valves that inhibit retrograde flow. Since incompetent

**12. DVT and PE in the elderly – Two sides of the same coin VTE** 

equanimity and professional satisfaction of physicians caring for the elderly.

The incidence of deep vein thrombosis increases with age.

daily), low-molecular-weight heparin, a pentasaccharide or warfarin administration.

considerable effort has been focused on prophylaxis.

daily dose of warfarin)

stroke, bleeding disorder)

**12.1 Deep vein thrombosis** 

**12.1.1 Etiology** 

other NSAD)

anticoagulants to the elderly (Beers et al., 2006; Cassel et al., 2003).

DVT usually occurs in the leg, regardless of the cause. The hallmark symptom is rapid onset of unilateral leg swelling with dependent edema – in advanced age predominantly asymptomatic. Generally, patients first note swelling when they awaken. In ambulatory patients, swelling is maximal at the ankle and lower leg, usually developing over 1 or 2 days.

Calf vein thrombosis may produce no symptoms or mild tenderness and mild edema. Calf vein thrombosis without swelling is common only among sedentary or bedridden patients.

Complications of DVT include venous thromboembolism, particularly pulmonary embolism (which can lead to death within 30 minutes of onset).

#### **12.1.3 Diagnosis**

Risk factors (eg, dehydration, estrogen use (LaCrox et al., 2011; Sare et al., 2008), heart failure, hip fracture, hypercoagulable states, immobilization or decreased physical activity, malignancy, obesity (Barba et al., 2008), polycythemia, thrombocytosis, trauma, venous damage) should be sought unless the cause is clear.

#### **12.1.4 Prophylaxis**

**Orthopedic procedures:** DVT is common among the elderly because they commonly undergo high-risk orthopedic procedures, particularly semi-elective or urgent procedures (eg, after a traumatic fracture). If the procedure involves the extremities, the value of lowdose heparin is limited; full-dose heparin or warfarin is effective, but each has a significant risk of bleeding.

After elective total hip replacement, the incidence of proximal deep vein thrombosis (without prophylaxis after surgery) approaches 25%, and the incidence of fatal pulmonary embolism is 3 to 4%. Prophylaxis reduces the occurrence of venous thromboembolism by 30 to 50%.

Low-dose heparin or low-molecular-weight heparin reduces the occurrence of deep vein thrombosis by at least 50%.

#### **12.1.5 Treatment**

The objective is to prevent pulmonary embolism and chronic venous insufficiency. Patients > 70 (especially women) receiving warfarin therapy are at high risk of hemorrhage. Since many elderly persons with arthritic or neurologic disorders fall frequently, warfarin is often contraindicated in patients > 80 and frail patients > 70.

#### **12.2 Pulmonary embolism**

Since the symptoms and signs are nonspecific, pulmonary embolism may be overdiagnosed or underdiagnosed, especially in the elderly. Patients with cardiac and respiratory disorders are especially at risk of misdiagnosis.

The first step in making the diagnosis is a careful physical examination to evaluate alternative diagnoses, for example, congestive heart failure, coronary artery disease,

Pulmonary Embolism in the Elderly – Significance and Particularities 57

About 33% of elderly patients with pulmonary embolism have pleural effusions, which are usually unilateral. About 67% of these effusions are bloody. Bloody pleural effusions generally have a pulmonary infiltrate on chest x-ray that suggests hemorrhagic consolidation of the lung parenchyma. The infiltrate usually resolves over several days. About 10% of patients with pulmonary emboli, especially those with severe heart failure,

Syncope, a systolic blood pressure < 100 mm Hg, or a markedly decreased systolic blood pressure in a hypertensive patient suggests the possibility of a massive pulmonary embolism or, in a patient with marginal cardiopulmonary function, a significant

A patient who is hypotensive because of pulmonary embolism has elevated right atrial and ventricular pressures (as measured by a pulmonary arterial catheter). Thus, a normal right atrial or ventricular pressure in a patient with hypotension argues against pulmonary

The most important consideration for determining the extent of testing is the clinical assessment of pretest probability (Bertoletti et al., 2011). The clinical probability (Wells or Geneva score) of pulmonary embolism pretest places patients into low-, moderate- , or high-probability groups. This grouping is combined with the results of ventilationperfusion scans or of spiral chest CT scans to determine whether further testing is

Very useful and easy for diagnosis of PE in daily clinical practice in elderly patients seems to be the combination of clinical pretest probability (PTP) and D-dimer result (Pasha et al., 2010). In VIDAS study the combination of a negative D-dimer result and non-high PTP effectively and safely excludes PE in an important proportion of outpatients with suspected

A chest x-ray, an ECG, and arterial blood gas values should be obtained. If pulmonary embolism is still considered to be likely, the next step is usually to obtain a ventilationperfusion lung scan. If the lung scan is likely to be indeterminate (because of underlying lung disease), spiral chest CT scans may be useful. Finding deep vein thrombosis with ultrasonography indicates the need for anticoagulation and usually eliminates the need for further testing for pulmonary emboli. The gold standard for diagnosing pulmonary

**Chest x-rays:** Results of chest x-rays may be normal or may show nonspecific abnormalities,

**ECG:** ECG findings are usually nonspecific; 33% of patients with pulmonary embolism have

BNP (brain natriuretic peptid) and echocardiography may be also useful determinants of the

**d-Dimer:** Levels of d-dimer, a fibrin-specific product, are increased in patients with acute thrombosis (Douma et al., 2010; Kabrhel et al. 2010). About 60% of patients < 50 who are suspected of having a pulmonary embolus have an abnormal d-dimer result. In contrast, 92% of patients > 70 have abnormal d-dimer levels, probably due to comorbid conditions (Douketis

eg, atelectasis, an elevated hemidiaphragm, pleural effusion, or an infiltrate.

short-term outcome for patiens with PE (Sanchez et al., 2010).

develop pulmonary infarction.

embolism as the cause.

PE (Carrier et al., 2009).

a normal ECG.

**12.2.4 Laboratory findings** 

embolism is pulmonary angiography.

**12.2.3 Diagnosis** 

embolus.

needed.

malignancy, and infections that are all frequent in the elderly and may on occasion be confused with pulmonary embolism.

The most common and serious major error is one of omissions, when the diagnosis simply is not considered clinically and is confirmed only at autopsy. Pleural changes and possibly some local asymmetric changes in vascularity may be detected if the film is keenly studied; however, the most common finding is that of an essentially normal chest roentgenogram in a very sick patient.

#### **12.2.1 Etiology**

Bed rest and inactivity pose the greatest risk for developing of deep vein thrombosis. Certain medical conditions common among the elderly (eg, trauma to leg vessels, obesity (Barba et al., 2008), heart failure, malignancy, hip fracture, myeloproliferative disorders) predispose them to venous thrombosis, as do smoking, estrogen usage (LaCroix et al., 2011; Sare et al., 2008), tamoxifen therapy, the presence of a femoral venous catheter, and surgery (Barba et al., 2008). Risk factors for venous thrombosis are vessel wall injury, stasis, and conditions that increase the tendency of the blood to clot, including rare deficiencies of antithrombin III, protein C, and protein S as well as disseminated intravascular coagulation, polycythemia vera, or the presence of a lupus anticoagulant or antiphospholipid antibodies. Ageing is also associated with increased coagulation and products of fibrinolysis, resulting in an overall prethrombotic state.

About 90% of blood clots that cause pulmonary embolism originate in the legs. The risk that a clot will embolize and lodge in the lungs is greater if the clot is in the popliteal or iliofemoral vein (about 50%) than if it is confined to the calf veins (< 5%). Less common sites of thrombosis that may lead to pulmonary embolism are the right atrium, the right ventricle, and the pelvic, renal, hepatic, subclavian, and jugular veins.

#### **12.2.2 Symptoms and signs**

In elderly patients, the most common symptoms are tachypnea (respiratory rate > 16 breaths/minute), shortness of breath, chest pain that may be pleuritic, anxiety, leg pain or swelling, hemoptysis, and syncope. Patients who have small thromboemboli may be asymptomatic or have atypical symptoms. Nonspecific symptoms suggestive of pulmonary emboli in the elderly include persistent low-grade fever, change in mental status, or a clinical picture that mimics airway infection.

Patients with pulmonary embolism (West, 2007) usually present with one of the following symptom patterns: (1) diagnostically confusing syndromes (confusion, unexplained fever, wheezing, resistant heart failure, unexplained arrhythmias); (2) transient shortness of breath and tachypnea; (3) pulmonary infarction (pleuritic pain, cough, hemoptysis, pleural effusion, pulmonary infiltrate); (4) right-sided heart failure along with shortness of breath and tachypnea secondary to pulmonary embolism; or (5) cardiovascular collapse with hypotension and syncope. Fewer than 20% of elderly patients have the classic triad of dyspnea, chest pain, and hemoptysis. If tachypnea is absent, pulmonary embolism is unlikely to occur.

The most common physical findings are tachypnea, tachycardia, fever, leg edema or tenderness, cyanosis, and a pleural friction rub. Although most elderly patients with pulmonary embolism have deep vein thrombosis as the initial source of the embolus, only 33% have clinical signs of leg thrombosis.

About 33% of elderly patients with pulmonary embolism have pleural effusions, which are usually unilateral. About 67% of these effusions are bloody. Bloody pleural effusions generally have a pulmonary infiltrate on chest x-ray that suggests hemorrhagic consolidation of the lung parenchyma. The infiltrate usually resolves over several days. About 10% of patients with pulmonary emboli, especially those with severe heart failure, develop pulmonary infarction.

Syncope, a systolic blood pressure < 100 mm Hg, or a markedly decreased systolic blood pressure in a hypertensive patient suggests the possibility of a massive pulmonary embolism or, in a patient with marginal cardiopulmonary function, a significant embolus.

A patient who is hypotensive because of pulmonary embolism has elevated right atrial and ventricular pressures (as measured by a pulmonary arterial catheter). Thus, a normal right atrial or ventricular pressure in a patient with hypotension argues against pulmonary embolism as the cause.
