Brief Answer:
Kindly read my detailed answer.

Detailed Answer:
Hello welcome to HCM.
I have read your question and understand your concerns.

Unfortunate that she has suffered from such problems from longtimes.

Deep venous thrombosis patients have always more chances of pulmonary embolism. So Longterm anticoagulation with warfarin or heparin is recommended.

Actually thrombophillia work up should be done after 3 weeks stoppage of warfarin otherwise reports can be modified. So kindly confirm about that thing.

Warfarin is still has better efficacy then some of the newer anticoagulants in prevention of pulmonary embolism in dvt patients. But the problem is that the protein C and protein S are also get affected by warfarin treatment. So in patients with protein C and S deficiency and resistance, warfarin treatment has controversial role.

Second thing to remember is all green leafy vegetables including spinach, carrot, cabbage should be avoided during warfarin treatment. Otherwise it will not be effective .

At present my advice is continue LMWH and confirm that reports are reliable or not. If reports are reliable then warfarin treatment has controversial role and better to continue with LMWH.

Ask your doctor about IVC filters, which can prevent pulmonary embolism in chronic DVT patients. Avoid prolonged air travel, avoid prolonged bed rest, prolonged standing.

Repeat lower limb venous doppler every 3 monthly.

In patients of protein C and S resistance or deficiency lifelong anticoagulation is recommended otherwise she will again have such problems. So kindly confirm about reliability of that reports, ask your doctor about IVC filters and follow my advice.

You are always welcome to HCM if any questions are still there.
Thank you.
Wish you a good health.

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Brief Answer:
I also has advised to stop warfarin

Detailed Answer:
Kindly read my detailed answer.
I have understand your confusion. Let it be more clear.

As I have told you warfarin has more bleeding tendency, difficult to maintain INR and controversial role in protein C AND S DEFICIENCY - warfarin should be replaced with low molecular weight heparin (LMWH). Once a day preparations like dalteparin are also available.

Inj. Fondaparinox is also a good option in prophylaxis of dvt but as such it is a newer molecule and has limited clinical data in resistant cases of dvt, most of the doctors still don't want to take chance and have continued their use to warfarin or acitrom. As such use of fondaparinox is also allowed if you ask me, but better will be enoxaparin. Proper technique of how to give that inj should be learnt to avoid skin reactions, if still she has skin allergy than inj. Fondaparinox can be used.

Secondly she has deep venous thrombosis provoked by taking tab marvelon definitely. So is she still Taking that tab.? Don't restart that tab even anytime in life even.

So, me and my other couligue has advised same regarding stop warfarin and switched to LMWH or fondaparinox. Newer oral anticoagulants like revaroxaban also have doubtful role in Longterm prophylaxis.
So, kindly continue with one of the 2 inj adviced(preferably inj. LMWH according to me)
And just we can wait for 3-6 months. Conditions will be definitely improved don't worry.

Any further questions are welcomed always by me.
Thank you.

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Brief Answer:
Alternative medicine will be inj. LMWH.

Detailed Answer:
Hello and welcome back.

As I have already told you that warfarin will not work properly in protein c and S deficiency, you can read my previous answers, she needs to take inj. LMWH (low molecular weight heparin). INR of 1 has no advantage in prevention of DVT.

Secondly in cases of pulmonary embolism, pulmonary hypertension is a common finding, gradually it will be decreased once the embolus load will be decreased gradually. So pulmonary hypertension only suggest that she has Long term pulmonary embolism. However other causes should be ruled out also.

When you have given your review to my answer, you have mentioned about ELIQUIS (Apixaban).
Apixaban is a good option particularly for patients like you but unfortunately it's a new drug and it's efficacy in Long term prophylaxis of pulmonary embolism is still not much established. So, in my patients I still favour inj. LMWH in comparison to Apixaban or warfarin.

Other newer anticoagulants have also similar problems. They are only recommended after hip or knee surgery in prophylaxis of dvt. Inj.Fondaparinox has also similar problems of less data in resistant cases of DVT. However it can be an alternative option if you have heparin sensitivity.


So, I hope I have given you satisfactory answer to your question. If you feel same then Kindly improve the rating.

Thank you.
Have a nice day.

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Brief Answer:
Mostly it's to treat the cause of it.

Detailed Answer:
Hello welcome back.

Pulmonary hypertension in 90% of cases is secondary to other reasons where treatment of cause only can reduce the pulmonary pressure.

In your case it's the embolism which has caused back pressure and increases the blood pressure in pulmonary artery.

You must have undergone 2d echo study. In which they have written mild /moderate /severe pulmonary hypertension..

Severe pulmonary hypertension usually at longer term will cause back pressure to right heart and causes liver congestion and swelling in feet due to further back pressure. Eventually it will lead to right heart failure, which is dangerous condition.

Mild to moderate hypertension has less deleterious effect.

So, in your case to continue anticoagulation (preferably inj. LMWH) is only option. We can add mild diuretic drug at the most to reduce back pressure on right heart. But it will reduce gradually by its own usually, just repeat echo every 3 monthly.

The drugs like sildenafile, tadalafil, bosentan, ambrisentan are specific drugs for pulmonary hypertension. But their use in your cases is questionable. They can be used mostly in primarily pulmonary hypertension where no cause has been found. Ask your doctor about this and get further information.

I have tried my best to make the answer understandable and to give satisfactory answer as I understand the importance of it in your problem.
Don't worry the problem will get better soon.

Kindly rate the answer. Thank you.
Have a nice day.

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