The potential role of fondaparinux as venous thromboembolism prophylaxis after total hip or knee replacement or hip fracture surgery.
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Arthroplasty, Replacement, Hip↗
Biomedical subjects
John A Heit
Publications and source records attributed to John A Heit.
Relative impact of risk factors for deep vein thrombosis and pulmonary embolism: a population-based study.
OBJECTIVE: To assess the potential impact of controlling risk factors on the incidence of venous thromboembolism by estimating the population attributable risk (defined as the percentage of all cases of a disease in a population that can be "attributed" to a risk factor) for deep vein thrombosis and pulmonary embolism associated with venous thromboembolism risk factors. METHODS: Using data from a population-based, nested, case-control study of the 625 Olmsted County, Minnesota, residents with a definite first lifetime deep vein thrombosis or pulmonary embolism diagnosed during the 15-year period 1976 to 1990 and 625 unaffected Olmsted County residents matched for age and sex, we developed a conditional logistic regression model appropriate to the matched case-control study design and then estimated attributable risk for the risk factors individually and collectively. RESULTS: Fifty-nine percent of the cases of venous thromboembolism in the community could be attributed to institutionalization (current or recent hospitalization or nursing home residence). Hospitalization for surgery (24%) and for medical illness (22%) accounted for a similar proportion of the cases, while nursing home residence accounted for 13%. The individual attributable risk estimates for malignant neoplasm, trauma, congestive heart failure, central venous catheter or pacemaker placement, neurological disease with extremity paresis, and superficial vein thrombosis were 18%, 12%, 10%, 9%, 7%, and 5%, respectively. Together, the 8 risk factors accounted for 74% of disease occurrence. CONCLUSIONS: Factors associated with institutionalization independently account for more than 50% of all cases of venous thromboembolism in the community. Greater emphasis should be placed on prophylaxis for hospitalized medical patients. Other recognized risk factors account for about 25% of all cases of venous thromboembolism, while the remaining 25% of cases are idiopathic.
Adult↗
Venous thromboembolism epidemiology: implications for prevention and management.
Venous thromboembolism is a major health problem, with an incidence that exceeds 1 per 1000. Over 200,000 new cases occur in the United States annually. Of these, 30% of patients die within 30 days; one-fifth suffer sudden death due to pulmonary embolism. Despite improved prophylaxis, the incidence of venous thromboembolism has not changed significantly since 1980. Independent risk factors for venous thromboembolism include increasing age, male gender, surgery, trauma, hospital or nursing home confinement, malignancy, neurologic disease with extremity paresis, central venous catheter/ transvenous pacemaker, prior superficial vein thrombosis, and varicose veins; among women, the risk factors include pregnancy, oral contraceptives, and hormone replacement therapy. About 30% of surviving patients develop recurrent venous thromboembolism within 10 years. Independent predictors for recurrence include increasing age, obesity, malignant neoplasm, and extremity paresis. About 28% of patients develop venous stasis syndrome within 20 years. To reduce venous thromboembolism incidence, improve survival, and prevent recurrence and complications, patients with these characteristics should receive appropriate prophylaxis.
Age Factors↗
Mapping out the future in venous thromboembolism and acute coronary syndromes.
Identification of risk factors for incident venous thromboembolism and predictors of recurrent venous thromboembolism and appropriate antithrombotic prophylaxis and therapy are vital to improve survival after pulmonary embolism and prevent complications such as venous stasis syndrome after deep-vein thrombosis. Risk stratification is increasingly important; future prophylaxis and treatment strategies should be targeted to the patients who will derive the greatest benefit. For established antithrombotic agents, the most appropriate dose, dosing schedule, and duration of prophylaxis and therapy are being refined. In addition, new antithrombotic agents such as the oral direct thrombin inhibitors are being identified and developed. The management of acute arterial thrombosis (for example, acute coronary syndromes) is an important and relatively new indication for antithrombotic agents such as the low-molecular-weight heparins and the platelet glycoprotein IIb/IIIa antagonists.
Adult↗
Hypercoagulability: too many tests, too much conflicting data.
It is now possible to identify hereditary and acquired risk factors in a substantial percentage of patients presenting with a venous thrombotic event. The clinician is faced with an ever-growing number of laboratory tests that can be ordered in such patients, and there is considerable uncertainty as to how this information should be utilized in patient management. Some have argued that widespread testing of thrombosis patients for prothrombotic abnormalities such as the factor V Leiden and prothrombin G20210A mutations has been prematurely adopted into clinical practice as there are few data that their identification leads to improved clinical outcomes. Dr. Rosendaal provides an overview of the epidemiology of venous thrombosis with an emphasis on hereditary and acquired risk factors. The presentation will include information obtained from properly designed case-control studies as well as family studies. While some have suggested treatment strategies for managing patients with hereditary thrombophilia with prior thrombotic events or for managing patients undergoing procedures associated with increased thrombotic risk, clinical decision making is complicated by the need to assess the risk of recurrence and the likely benefit of prolonged anticoagulation versus the associated bleeding risk. Drs. Bauer, Heit, and Rosendaal discuss their approaches to patient management. Case presentations are used to illustrate the impact of laboratory test results on decisions.
Anticoagulants↗
Iliac arterial thrombosis after inguinal hernia repair.
Vascular complications after inguinal hernia repair have been well documented. To our knowledge, all previously reported cases have been due to direct injury or compression of the vessels during the repair. We present the first case of thrombosis of the left common iliac artery after inguinal herniorrhaphy that was not due to direct injury or compression of the artery. Special coagulation testing revealed that the patient was a heterozygous carrier of the factor V R506Q (Leiden) mutation. This mutation is the most common cause of familial thrombophilia (hypercoagulable disorder) and is a known risk factor for venous thromboembolism. However, the association of this mutation with arterial thrombosis is less certain. Patients with thrombosis of the iliofemoral artery or vein after inguinal herniorrhaphy should be considered for special coagulation testing because of potentially important differences in anticoagulant treatment of the affected patient and for genetic counseling of potentially affected family members.
Factor V↗
Outcomes after withholding anticoagulation from patients with suspected acute pulmonary embolism and negative computed tomographic findings: a cohort study.
OBJECTIVE: To determine the outcome of withholding anticoagulation from patients with suspected acute pulmonary embolism in whom computed tomographic (CT) findings are interpreted as negative for pulmonary embolism. PATIENTS AND METHODS: This retrospective cohort study included 1512 consecutive patients referred from August 7, 1997, to November 30, 1998, for CT because of clinically suspected acute pulmonary embolism. All patients were examined by electron beam CT, and scanning was performed in a cephalocaudad direction from the top of the aortic arch to the base of the heart with 3-mm collimation, 2-mm table incrementation, and an exposure time of 0.2 second (130 peak kV, 620 mA, and standard reconstruction algorithm). Contrast material was infused at a rate of 3 to 4 mL/s through an antecubital vein with an automated injector. Findings on CT were interpreted as either positive or negative. The main outcome measures were deep venous thrombosis, pulmonary embolism, and vital status within 3 months after the CT scan and the cause of death based on medical record review, mailed patient questionnaires, and telephone interviews. RESULTS: In 1010 patients (67%) CT scans were interpreted as negative for acute pulmonary embolism. Seventeen patients were excluded because they received anticoagulation. Of the remaining 993 patients, deep venous thrombosis or pulmonary embolism developed in 8; 118 patients died, 3 of pulmonary embolism. Nineteen patients were known to be alive, but additional clinical information could not be obtained. The 3-month cumulative incidence of overall deep venous thrombosis or pulmonary embolism was 0.5% (95% confidence interval, 0.1%-1.0%) and of fatal pulmonary embolism, 0.3% (95% confidence interval, 0.0%-0.7%). CONCLUSIONS: The incidence of (1) overall deep venous thrombosis or pulmonary embolism or (2) fatal pulmonary embolism among patients with suspected acute pulmonary embolism, negative CT results, and no other evidence of venous thromboembolism is low. Withholding anticoagulation in these patients appears to be safe.
Acute Disease↗
Clinical utility of factor V leiden (R506Q) testing for the diagnosis and management of thromboembolic disorders.
OBJECTIVE: To review the current state of the art regarding the role of the clinical laboratory in diagnostic testing for the factor V Leiden (FVL) thrombophilic mutation (and other protein C resistance disorders), and to generate, through literature reviews and opinions of recognized thought-leaders, expert consensus recommendations on methodology and diagnostic, prognostic, and management issues pertaining to clinical FVL testing. DATA SOURCES, EXTRACTION, AND SYNTHESIS: An initial thorough review of the medical literature and of current best clinical practices by a panel of 4 experts followed by a consensus conference review, editing, and ultimate approval by the majority of a panel of 28 additional coagulation laboratory experts. CONCLUSIONS: Consensus recommendations were generated for topics of direct clinical relevance, including (1) defining those patients (and family members) who should (and should not) be tested for FVL; (2) defining the preferred FVL laboratory testing methods; and (3) defining the therapeutic, prophylactic, and management ramifications of FVL testing in affected individuals and their family members. As FVL is currently the most common recognized familial thrombophilia, it is hoped that these recommendations will assist laboratorians and clinicians caring for patients (and families) with this common mutation.
Abortion, Habitual↗
Regional anesthesia in the anticoagulated patient: defining the risks (the second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation).
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Anesthesia, Conduction↗