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Unnecessary hospitalizations for DVT in the era of NOACs

      Venous thromboembolism (VTE) includes deep vein thrombosis (DVT) and pulmonary embolism (PE), two closely connected conditions that involve similar pathophysiology, often co-exist at a different degree in some patients, while their treatment is quite similar, requiring anticoagulation as the mainstay of treatment in both cases. However, their prognosis is quite different, with DVT and PE having a 30-day mortality rate of 3% and 31% respectively [
      • Søgaard K.K.
      • Schmidt M.
      • Pedersen L.
      • Horváth-Puhó E.
      • Sørensen H.T.
      30-year mortality after venous thromboembolism: a population-based cohort study.
      ]. It has been previously suggested in the literature that most patients with DVT can be safely discharged and treated as outpatients [
      • Wells P.S.
      Outpatient treatment of patients with deep-vein thrombosis or pulmonary embolism.
      ]. However, there is quite significant hesitance to discharge the patients with DVT [
      • Cei M.
      • Cei F.
      • Mumoli N.
      Deep vein thrombosis: who still needs to be admitted?.
      ], with significant implications in cost, since the annual cumulative cost in USA for DVT ranges from $4.9 billion to $7.5 billion [
      • Mahan C.E.
      • Borrego M.E.
      • Woersching A.L.
      • Federici R.
      • Downey R.
      • Tiongson J.
      • et al.
      Venous thromboembolism: annualised United States models for total, hospital-acquired and preventable costs utilising long-term attack rates.
      ]. Evidence suggests that admission rates for DVT vary greatly depending on the geographic region, with a rate of about 19% for North America and up to 82% at Eastern Europe [
      • van Bellen B.
      • Bamber L.
      • Correa de Carvalho F.
      • Prins M.
      • Wang M.
      • Lensing A.W.
      Reduction in the length of stay with rivaroxaban as a single-drug regimen for the treatment of deep vein thrombosis and pulmonary embolism.
      ]. In practice, home treatment of DVT is not frequently chosen due to lack of previous solid evidence in the literature, legal concerns and difficulty of arranging follow-up. However, one might consider admitting a patient with DVT especially if the DVT is massive, which is the case in 5% of symptomatic patients with lower limb DVT, when swelling of the entire limb, acrocyanosis, or venous limb ischemia occur and treatment with unfractionated heparin and possibly surgical treatment or catheter directed thrombolysis can be considered [
      • Casey E.T.
      • Murad M.H.
      • Zumaeta-Garcia M.
      • Elamin M.B.
      • Shi Q.
      • Erwin P.J.
      • et al.
      Treatment of acute iliofemoral deep vein thrombosis.
      ]. Furthermore, in patients with bilateral lower limb DVT a possibility of inferior vena cava thrombosis exists, and in these cases inpatient management is mandated, as is in patients with concomitant symptomatic PE [
      • Douketis J.D.
      Treatment of deep vein thrombosis: what factors determine appropriate treatment?.
      ]. Finally, if there is an active bleeding or high risk of bleeding (5–10% of patients), like in cases with a recent surgery or lumber puncture or if there is a recent history of gastrointestinal or intracranial bleeding, inpatient management can help diagnose complications of bleeding promptly, or offer alternative methods of PE prevention, like placement of an IVC filter.

      Abbreviations:

      DVT (deep vein thrombosis), NOACs (novel oral anticoagulants), VTE (venous thromboembolism), PE (pulmonary embolism)
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