JOSR: Journal of Social Research

Desember 2022, 2 (1), 261-270

p-ISSN: 2827-9832 e-ISSN: 2828-335x

Available online at http:// https://ijsr.internationaljournallabs.com/index.php/ijsr

http://ijsr.internationaljournallabs.com/index.php/ijsr

VENOUS THROMBOEMBOLISM IN HOSPITALIZED

PATIENT WITH HEART FAILURE, DOES HEART FAILURE

INCREASE THE RISK OF DVT?

Yuri Savitri, Aragibinafika, Lisna Agiara, Nurhafizah Muzainy, Nanda Chairina,

Dwi Novlita Rozi

Faculty Of Malikussaleh, University Cut Meutia Regional General Hospital North Aceh

yuribelluci@gmail.com, aragibinafika99@gmail.com, lisna.agiara@gmail.com,

nurhafizahmuzainy29@gmail.com, nanda.chairina210@gmail.com,

dwinovlitarozi20@gmail.com

Abstrak (Indonesia)

Received:

Revised :

Accepted:

Desember 06,

2022

Desember 15,

2022

Desember 19,

2022

Latar Belakang: Trombosis vena dalam (DVT) sering

diamati pada pasien dengan gagal jantung kronis (CHF),

meningkatkan risiko emboli paru (PE). Evaluasi klinis pasien

CHF dengan dugaan PE akut menantang karena penyakit ini

berbagi beberapa gejala dan tanda seperti dispnea.

Tujuan: Tujuan dari penelitian ini adalah untuk

menganalisis apakah gagal jantung meningkatkan risiko

DVT.

Metode: Penelitian ini menggunakan pendekatan kualitatif

dengan model studi kasus yang menganalisis dan

mengidentifikasi tromboemboli vena pada pasien rumah

sakit dengan gagal jantung, apakah gagal jantung

meningkatkan risiko DVT?

Hasilnya: DVT (Deep Vein Thrombosis) adalah

pembentukan trombus atau gumpalan darah yang sering

menyerang vena dalam ekstremitas bawah (seperti betis,

vena femoralis dan poplitea) atau vena dalam di daerah

panggul, lebih sering pada DVT proksimal daripada distal.

Kondisi ini berpotensi berbahaya, menyebabkan morbiditas

dan mortalitas yang pada dasarnya dapat menyebabkan

penyakit. Ini terjadi di seluruh dunia. Secara umum diagnosis

ini digabungkan dalam VTE (Venous Thromboembolism).

Pada pasien dengan DVT tanpa PE, tingkat kematian jangka

pendek 2-5% dilaporkan. Risiko kekambuhan tinggi,

terutama dalam 6 bulan pertama.

Kesimpulan: Dari hasil yang diperoleh kita dapat

mengetahui bahwa Pasien simtomatik dengan DVT

proksimal dapat hadir dengan nyeri ekstremitas bawah, nyeri

betis, dan pembengkakan ekstremitas bawah (Kesieme et al.,

2011) Sama dengan kasus ini, Pasien dirawat di rumah sakit

Yuri Savitri, Aragibinafika, Lisna Agiara, Nurhafizah Muzainy, Nanda Chairina, Dwi Novlita Rozi

/ JOSR: Journal of Social Research, 2(1), 261-270

Venous Thromboembolism in Hospitalized Patient with Heart Failure, Does

Heart Failure Increase the Risk of Dvt?

262

dengan keluhan pembengkakan seluruh tubuh, terutama kaki

disertai rasa sakit, kemerahan, merasa hangat beberapa jam

sebelum pasien pergi ke rumah sakit.

Kata kunci: penyakit jantung, DVT, bahaya penyakit

jantung

Abstract (English)

Background: Deep vein thrombosis (DVT) is frequently

observed in patients with chronic heart failure (CHF),

increasing the risk of pulmonary embolism (PE). Clinical

evaluation of CHF patients with suspected acute PE is

challenging since these diseases share several symptoms

and signs such as dyspnea.

Objective: The aim of this study was to analyze whether

heart failure increases the risk of DVT.

Method: This study uses a qualitative approach with a case

study model that analyzes and identifies venous

thromboembolism in hospital patients with heart failure,

does heart failure increase the risk of DVT?

Result: DVT (Deep Vein Thrombosis) is the formation of a

thrombus or blood clot that often attacks the deep veins of

the lower extremities (such as the calf, femoral and

popliteal veins) or deep veins in the pelvic area, more

frequent in proximal than distal DVT. This condition is

potentially dangerous, leading to morbidity and mortality

that can essentially lead to disease. This happens all over

the world. In general these diagnoses are combined in VTE

(Venous Thromboembolism). In patients with DVT without

PE, short-term mortality rates of 2–5% were reported.

Recurrence risk is high, especially within first 6 months.

Conclusion: From the results obtained we can know that

Symptomatic patients with proximal DVT may present with

lower extremity pain, calf tenderness, and lower extremity

swelling (Kesieme et al., 2011) Same with this case, Patient

was admitted to the hospital with complaints swelling of the

whole body, especially the legs accompanied by pain,

redness, feel warmed a few hours before the patient going

to hospital.

Keywords: heart disease, DVT, danger of heart disease

*Correspondent Author: Lisna Agiara

Email: lisna.agiara@gmail.com

Yuri Savitri, Aragibinafika, Lisna Agiara, Nurhafizah Muzainy, Nanda Chairina, Dwi Novlita Rozi

/ JOSR: Journal of Social Research, 2(1), 261-270

Venous Thromboembolism in Hospitalized Patient with Heart Failure, Does

Heart Failure Increase the Risk of Dvt?

263

INTRODUCTION

Deep vein thrombosis (DVT) is frequently observed in patients with chronic heart

failure (CHF), increasing the risk of pulmonary embolism (PE). Clinical evaluation of CHF

patients with suspected acute PE is challenging since these diseases share several symptoms

and signs such as dyspnea. Thus, it is intuitive that a correct and fast diagnosis of PE in

these patients might be able to significantly change their clinical outcomes. In the present

report, we describe a rare case of a patient with CHF and PE due to a huge thrombosis of

deep veins and of the right atrium in whom echo evaluation permitted the correct diagnosis

and therapy (Mebazaa et al., 2014; Sugraliyev et al., 2020).

Deep venous thrombosis (DVT) is frequently observed in patients with chronic

heart failure (CHF), ranging from 1% to 59%. This variability might be due to the different

sensitivity of diagnostic criteria in reports: those hospitals, in which the screening for DVT

is more accurate, are likely to find more cases of DVT and pulmonary embolism (PE).

Myocardial infarction and heart failure increase the risk of PE. (Darze et al., 2007)

Conversely, patients with DVT have an increased risk of developing myocardial infarction

and stroke. Thus, a correct and fast diagnosis of PE in these patients plays a pivotal role to

change their clinical outcomes.

DVT accounts for 2/3 of cases of venous thromboembolism in which 80% of cases

of DVT are proximal DVT. The incidence of DVT has been reported to be 70-140/100,000

per year, whereas 25-50% of patients with first-episode DVT have no predisposing factors.

(Mazzolai et al., 2018) About two-thirds present with DVT of the limbs and one-third with

PE. Half of the people with PE have no signs and symptoms of DVT at first. 1-10% of

patients with venous thrombosis are fatal, especially in the elderly or patients with severe

diseases such as cancer. The incidence of this thrombosis increases exponentially with age.

In children the incidence is 1 per 100,000 per year, in young adults, the incidence is 1 per

10,000, in middle age it is 1 per 1000, in the elderly, it is 1%, and 10% in very old patients.

The recurrence of this thrombosis is 3 – 10% per year. (Bevis & Smith, 2016) DVT occurs

significantly and poses a challenge to healthcare professionals worldwide. The prevalence

of DVT is reported to be 100 per 100,000 people per year, although the incidence increases

with age. 4 The incidence of deep vein thrombosis (DVT) in the United States is more than

1 per 1000 and there are 200,000 new cases each year. Of the total incidence of deep vein

thrombosis, about 60% acquired pulmonary embolism with a risk of death of about 30%

within 30 days (Kakkos et al., n.d.; Stone et al., 2017).

Heart failure (HF) is an increasingly prevalent condition, with an estimated 6

million patients with HF in the United States(E. J. Benjamin et al., 2018) About one-half

of incident HF hospitalizations are characterized as HF with reduced ejection fraction

(HFrEF) and the other one-half as HF with preserved ejection fraction (HFpEF). HF is

characterized by a prothrombotic state, which not only increases the risk for cardioembolic

events and ischemic stroke but also increases the risk for deep venous thrombosis (DVT)

and pulmonary embolism (PE), which together constitute venous thromboembolism

(VTE). The lifetime risk for VTE is 8% (D. Benjamin, 2017).

About one-half of incident VTE events are considered “provoked” (Cushman et

al., 2004), with VTE incidence in patients with acute decompensated HF ranging from 4%

to 26% in retrospective analyses. Several clinical trials have demonstrated that the risk for

VTE in patients with HF hospitalization can be reduced with anticoagulation (Cohen et al.,

2006), which is supported by the American College of Chest Physicians (Kahn et al., 2012)

and the American Society of Hematology (Schünemann et al., 2018) guidelines advocating

prophylaxis in acutely ill patients with HF. However, prophylactic anticoagulation is

currently not recommended beyond hospital discharge.

Yuri Savitri, Aragibinafika, Lisna Agiara, Nurhafizah Muzainy, Nanda Chairina, Dwi Novlita Rozi

/ JOSR: Journal of Social Research, 2(1), 261-270

Venous Thromboembolism in Hospitalized Patient with Heart Failure, Does

Heart Failure Increase the Risk of Dvt?

264

RESEARCH METHOD

This study uses a qualitative approach with a case study model that analyzes and identifies

venous thromboembolism in hospital patients with heart failure, does heart failure increase

the risk of DVT?

RESULT AND DISCUSSION

A 56-year-old male patient, domiciled in Tambon Baru, North Aceh, the patient was

brought from PIM Hospital and admitted to the emergency department of Cut Meutia

hospital at 1.30 pm on April 16th, 2022. The patient was admitted to the hospitalwith

complaints swelling of the whole body, especially the legs accompanied by pain, redness,

feel warm. Patient complaints of dyspnea are felt suddenly when the patient duringactivities

dan working, The patient works as a truck driver and has a habit of sitting more than 12

hours a day. The patient also complains of getting tired easily when doing light physical

activities such as climbing 10 stairs, walk to the bathroom, and walking at a distance of

approximately 100 meters and the patient complains of dyspnea when sleeping at night.

The dyspnea decreases when the patient sleeps using 2/3 pillows. The patient also

complained of occasional cough, nausea, and throw up. The patient has a history of

Hyperlipidemia.

The patient belongs to the lower middle-class economy and the patient's diet is not

good because the patient does not regularly eat three times a day and patients like to

consume fatty foods and instant noodles.

Physicalexaminationbeforetreatmentwasobtainedthepatientlooked, weakness and

breathless, BP: 110/80 mmHg, HR: 92x/m, RR: 28x/m, T: 38,0

C, SpO2: 99%. For

generalist status get upper extremity : Oedema (-/-), cyanosis (-/-), lower extremity :

Oedema (+/+) erythema (+/+), cyanosis (-/-) homan sign(+/+).

The result of the laboratory on April, 16

2022, there were D-Dimer 5700, the

hemoglobin with 13.04g/dl, leucocyte with 9.07 ribs/uL, thrombocyte with 204 ribs/uL,

electrolyte with Na 133 mmol/L, K 3.6mmol/L, Cl 125 mmol/L, and Ca 0,32 mmol/L, and

then the result of the laboratory on April, 22rd 2022, there was haemoglobin with 8.64g/dl,

leucocyte with 13.90 ribs/uL, thrombocyte with 356 ribs/uL and blood glucose with 256

mg/dl.

Figure 1. ECG Findings

The electrocardiogram examination showed that sinus rhythm beats with rate 94 bpm,

AXIS: LAD, Poor R wave progression, Q pathologic lead II, III, avF and V1, V2, V3, and

V4, also T inversion in lead I, AVL, and v6.

Yuri Savitri, Aragibinafika, Lisna Agiara, Nurhafizah Muzainy, Nanda Chairina, Dwi Novlita Rozi

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Heart Failure Increase the Risk of Dvt?

265

Figure 2. X-Ray Findings

COR

- CTR >50%

- Aortic segment was normal

- Pulmonary was not prominent

- Flat heart waist

- The apex of the heart is shifted laterocaudally

- Normal vascular pattern

Result

- Cardiomegaly

Figure 3. Echocardiography Findings

Echocardiography examination showed EF 40%, LV dilatation, Tape 18, Efusi

pericardial (+), and Thrombus (+) in LV.

Yuri Savitri, Aragibinafika, Lisna Agiara, Nurhafizah Muzainy, Nanda Chairina, Dwi Novlita Rozi

/ JOSR: Journal of Social Research, 2(1), 261-270

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266

Figure 4. USG Doppler Findings

A. Femoralis Dextra & Sinistra: Triphasic wave, Plaque atherosclerosis (-)

V. Femoralis Dextra & Sinistra: Triphasic wave, Plaque atherosclerosis (-)

A. Poplitea Dextra & Sinistra: Triphasic wave, Plaque atherosclerosis (-)

V. Femoralis Dextra & Sinistra : Insufficiency valve (+), CUS (+), thrombus (+)

The patient was given treatment at Cut Meutia General Hospital. We administrate O2

2-4 LPM, three-way, injection of furosemide amp/8h, injection of Arixtra amp/24h, nylon

1 flash. Spironolacton 1x50 mg, CPG 1x75 mg, KSR 2x600 mg, and lansoprazole 1x30

mg.

DISCUSSION

DVT (Deep Vein Thrombosis) is the formation of a thrombus or blood clot that often

attacks the deep veins of the lower extremities (such as the calf, femoral and popliteal veins)

or deep veins in the pelvic area, more frequent in proximal than distal DVT. This condition

is potentially dangerous, leading to morbidity and mortality that can essentially lead to

disease. This happens all over the world. In general, these diagnoses are combined in VTE

(Venous Thromboembolism). In patients with DVT without PE, short-term mortality rates

of 2–5% were reported. Recurrence risk is high, especially within the first 6 months. The

Virchow triad of venous stasis, endothelial damage, and inflammation represent the main

underlying pathology for the development of VTE. The major risk factors for VTE include

recent hospitalization, surgery, malignancy, obesity, immobility, advanced age, hormone

use, and inherited thrombophilia (Cushman, 2007).

Patients with lower extremity DVT often do not present with erythema, pain, warmth,

swelling, or tenderness. Symptomatic patients with proximal DVT may present with lower

extremity pain, calf tenderness, and lower extremity swelling (Kesieme et al., 2011) Same

with this case, the Patient was admitted to the hospital with complaints of swelling of

the whole body, especially the legs accompanied by pain, redness, feel warmed a few

hours before the patient going to the hospital. Patient complaints of dyspnea are felt

suddenly when the patient during activities dan working. The patient works as a truck

driver and has a habit of sitting more than 12 hours a day.

The patient also complains of getting tired easily when doing light physical

activities such as climbing 10 stairs, walking to the bathroom, and walking at a

distance of approximately 100 meters and the patient complains of dyspnea when

sleeping at night. The dyspnea decreases when the patient sleeps using 2/3 pillows.

Yuri Savitri, Aragibinafika, Lisna Agiara, Nurhafizah Muzainy, Nanda Chairina, Dwi Novlita Rozi

/ JOSR: Journal of Social Research, 2(1), 261-270

Venous Thromboembolism in Hospitalized Patient with Heart Failure, Does

Heart Failure Increase the Risk of Dvt?

267

The patient also complained of an occasional cough, nausea, and throw up. The

patient has a history of Hyperlipidemia. On physical examination, before treatment

was obtained the patient looked, weak and breathless, BP: 110/80 mmHg, HR: 92

bpm, RR: 28x/m, T: 38,0ºC, SpO2: 99%.

The first step in diagnosing DVT is to assess the pretest probability using the Wells

Score. If the score is ≤ 1 (DVT unlikely) and ≥ 2 (DVT likely). (Mazzolai et al., 2018b)

For general status, the patient's lower extremities were found: Edema (+/+), erythema

(+/+), and Homan's sign (+/+). Using the Wells Score, local tenderness was found

along the distribution of the deep venous system (+1), swelling of the whole leg (+1),

and pitting edema limited to the symptomatic leg (+1). So the result Wells Score for

this patient is 3, which means the possibility of DVT.

In this case on laboratory examination in April, 16

2022, there were D-Dimer

5700 ng/L, which means that the D-Dimer level increased than the normal value. D-dimer

is a fibrin degeneration product that is useful for detecting abnormal blood clot formation

or the presence of thrombotic events (indirect) and for detecting clot lysis or fibrinolytic

processes (direct). The higher the D-dimer result, the stronger the suspicion of thrombus

formation and breakdown in the body. Normal D-dimer levels can be used to rule out the

differential diagnosis of a blood clotting disorder as the cause of the clinical symptoms

(Kakkos et al., n.d.).

The first electrocardiogram showed that sinus rhythm beats with rate 94 bpm,

AXIS: LAD, poor R wave progression, Q pathologic in II, III, avF and V1, V2, V3, V4

also T inversion in lead I, aVL, and V6. The conclusion is sinus rhythm

inferoanteroseptal old myocardial infarct with LV strain. Inferior old myocardial infarction

is associated with a decrease in blood supply to the inferior wall of the heart. The inferior

myocardium receives vascular supply via the right coronary artery (RCA) (Bansal et al.,

2021). While the anterior wall and septal are supplied by the branch of the left anterior

descending (LAD) artery.

X-ray examination showed the presence of cardiomegaly. The apex of the heart is

shifted later-caudally with a CTR of more than 50%. Cardiomegaly occurs when the heart

muscle pumps blood harder than usual, causing a thickening of the heart muscle, so the

heart becomes larger in size. Coronary artery disease including myocardial infarction and

ischemia is the most common causes of cardiomegaly. Also, the enlargement of the heart

both in the form of dilatation or hypertrophy leads to a spectrum of clinical heart failure

syndrome (Amin & Siddiqui, 2021).

An echocardiography examination showed that the result of fractional ejection

(EF) was 40% and there was an LV dilatation, which indicated this patient had

congestive heart failure (CHF). Heart failure to reduce ejection fraction occurs when the

left ventricular ejection fraction is 40% or less and is accompanied by progressive left

ventricular dilatation and adverse cardiac remodeling (Murphy et al., 2020). Pericardial

effusion that showed in the result occurs from the blood accumulation and excess fluid in

the pericardial cavity (located between the parietal and visceral pericardium). Pericardial

effusion can be attributed to several etiologies, the known cause from this report were

congestive heart failure (Albugami et al., 2020).

Doppler ultrasound examination showed insufficiency valve (+), CUS (+), and

thrombus (+) from femoral extra & Sinistra venous. Venous ultrasound is the standard

imaging test for patients suspected of having lower extremity deep venous thrombosis

(DVT). Ultrasound is appropriate for patients with a likely pretest probability of DVT, an

unlikely pretest probability of DVT with a positive D-dimer, and those in whom the pretest

probability was not assessed.

The patient was treated by giving an injection of Arixtra (fondaparinux) once

daily. The initial and standard pharmacological approach for in patients with DVT started

with parenteral anticoagulants and usually involves achieving a therapeutic dose of UFH

Yuri Savitri, Aragibinafika, Lisna Agiara, Nurhafizah Muzainy, Nanda Chairina, Dwi Novlita Rozi

/ JOSR: Journal of Social Research, 2(1), 261-270

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268

or LMWH, or with fondaparinux. Using direct oral anticoagulants (DOACs) was suggest

over vitamin K antagonists (VKAs) but this recommendation may not apply to certain

subgroups of patients, such as those with renal insufficiency (creatinine clearance <30

mL/min), moderate to severe liver disease, antiphospholipid syndrome. The therapeutic

management can be divided into 3 phases: 1) initial management, which occurs from the

time of diagnosis through the first 3 weeks of therapy (5-21days); 2) primary treatment,

which is a time-limited phase that typically runs for a minimum of 3 months; and 3)

secondary prevention, which begins after completion of the primary treatment phase and

extends for a prolonged, usually indefinite, period of time (Ortel et al., 2020). The goal of

therapy for DVT is to prevent the extension of thrombus, acute pulmonary embolism,

recurrence of thrombosis, and the development of late complications such as pulmonary

hypertension and post-thrombotic syndromes (Kesieme et al., 2011; Wang et al., 2016).

CONCLUSION

From the results obtained we can know that Symptomatic patients with proximal

DVT may present with lower extremity pain, calf tenderness, and lower extremity swelling

Same with this case, Patient was admitted to the hospital with complaints swelling of the

whole body, especially the legs accompanied by pain, redness, feel warmed a few hours

before the patient going to hospital.

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