What is the most appropriate management for an 86-year-old woman with worsening left leg pain, redness, and firmness, but no swelling, after a recent cross-country flight, with a history of varicose veins, heart failure, and chronic recurrent urinary tract infections, and taking furosemide (Lasix) and valsartan (Diovan)?

Management of Superficial Thrombophlebitis in an Elderly Patient

Initiation of anticoagulant therapy is the most appropriate management for this 86-year-old woman with superficial thrombophlebitis following a cross-country flight. 1

Clinical Assessment and Diagnosis

• The patient presents with classic signs of superficial thrombophlebitis: worsening pain, redness, and firmness in the left leg with a palpable 6 cm cord of the saphenous vein 1
• The recent cross-country flight (10 days ago) represents a transient risk factor for venous thromboembolism (VTE) 1
• Her history of varicose veins is an additional risk factor that increases her susceptibility to superficial thrombophlebitis 2
• The absence of swelling does not rule out the need for anticoagulation, as the palpable cord indicates thrombosis of the saphenous vein 1

Rationale for Anticoagulation

• Superficial thrombophlebitis, particularly when involving the saphenous vein, carries a risk of progression to deep vein thrombosis (DVT) and pulmonary embolism (PE) 1
• The patient's advanced age (86 years) places her at increased risk for thromboembolic complications 1
• Her history of heart failure represents an additional risk factor for VTE complications 1
• The presence of a palpable cord indicates a significant thrombus burden that warrants anticoagulation rather than observation alone 1

Anticoagulation Approach

• Initial treatment should include low molecular weight heparin (LMWH) or unfractionated heparin (UFH) followed by transition to an oral anticoagulant 1
• For a first episode of DVT attributed to a transient immobilization (airplane ride), a duration of 3 months of anticoagulation is recommended (Grade 1A) 1
• Target INR should be 2.5 (range 2.0-3.0) if using vitamin K antagonists 1
• Direct oral anticoagulants may be considered as alternatives to traditional vitamin K antagonists, though the guidelines give a weak recommendation in favor of VKA and LMWH therapy 1

Important Considerations for This Patient

• Monitor for potential drug interactions between anticoagulants and her current medications (furosemide and valsartan) 3
• Assess renal function before initiating anticoagulation, as both furosemide and valsartan can affect kidney function 4, 5
• Consider the patient's bleeding risk given her advanced age, though this does not contraindicate anticoagulation when properly indicated 1
• Compression stockings should be recommended in addition to anticoagulation to help prevent post-thrombotic syndrome (Grade 1A) 1

Why Other Options Are Not Appropriate

• Ambulation with monitoring alone is insufficient given the extent of thrombophlebitis (6 cm cord) and her risk factors 1
• Hematology consult may be helpful but is not the most immediate step; anticoagulation should be initiated promptly 1
• Vascular surgery consultation is not indicated as first-line management for uncomplicated superficial thrombophlebitis 1
• Antibiotics are not indicated as there are no signs of infection; the redness and firmness are due to thrombophlebitis rather than cellulitis 1

Follow-up Recommendations

• Regular monitoring of anticoagulation therapy (INR if using warfarin) 1
• Reassessment of symptoms to ensure resolution of thrombophlebitis 1
• Education about signs and symptoms of potential progression to DVT or PE that would warrant immediate medical attention 6
• Consider reassessment of the need for continued anticoagulation at the end of the 3-month treatment period 1