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PubMed1999

Recurrent venous thromboembolism in a Spanish population: incidence, risk factors, and management in a hospital setting.

The major concern in the management of venous thromboembolism is the propagation of thrombus and rethrombosis. The incidence of recurrences and the duration of oral anticoagulant therapy in these patients are still controversial. The aim of this study was to determine the incidence, timing, and outcome of further thrombotic events after an initial episode of venous thromboembolism in a hospital setting. In addition, we evaluated potential risk factors for all these outcomes. This was designed as a retrospective analysis of all patients admitted to our Center with an episode of deep vein thrombosis and/or pulmonary embolism between 1986 and 1996. The patients included in the study had to be treated with unfractionated heparin or low molecular weight heparin, followed by at least 3 months of oral anticoagulants. Natural and acquired hemostasis inhibitors were assayed in patients aged less than 50 years. A total of 290 patients with a first episode of venous thromboembolism were included in the study. A total of 33 patients (11.9%, 95% confidence interval. 7.4-14.6) had recurrent episodes. The cumulative incidence of recurrent venous thromboembolism after 2, 5, and 10 years was 7.68, 10, and 12.4%, respectively. The incidence of rethrombosis was significantly higher in patients with idiopathic venous thromboembolism than in patients with secondary thrombosis. Abnormalities of hemostasis were found in 54.5% (95% confidence interval, 37.6-71.4) of the patients with recurrences and under the age of 50 years. Three of seven patients who stopped anticoagulant therapy after the second episode presented a third thrombotic event. In our study population, those patients with idiopathic venous thromboembolism seem to have an increased risk of recurrence. The second thrombotic episode occurs more frequently during the following 2 years after cessation of anticoagulation therapy. Our findings strongly support the use of long-term anticoagulant therapy in patients with recurrent venous thromboembolism.

Aged↗
PubMed2003

Fibrillatory wave amplitude as a marker of left atrial and left atrial appendage function, and a predictor of thromboembolic risk in patients with rheumatic mitral stenosis.

BACKGROUND: Patients with mitral stenosis, especially those with atrial fibrillation, are at increased risk for thromboembolic complications. Size of the left atrium, left atrial appendage dysfunction and severity of mitral stenosis are known risk factors for thromboembolism in patients with mitral stenosis. It has been postulated that F-wave amplitude on surface ECG is correlated with left atrial size, left atrial appendage function, and risk of thromboembolism in patients with nonrheumatic atrial fibrillation. The aims of this study were as follows: (1) to examine the relationship between surface ECG F-wave amplitude and left atrial appendage function, and (2) to assess the clinical significance of F-wave amplitude as it relates to risk of thromboembolism in a group of patients with rheumatic mitral stenosis. MATERIAL AND METHODS: One hundred patients with rheumatic mitral stenosis and permanent atrial fibrillation but without moderate to severe mitral insufficiency were investigated by transthoracic and transesophageal echocardiography. Two groups were formed according to the presence of a coarse (Group 1; n=60; F-wave in lead V1> or =1 mm) or fine (Group 2; n=40; F-wave in lead V1<1 mm) F-wave on surface ECG. RESULTS: Comparison showed that Group 1 had significantly smaller mitral valve area (1.44+/-0.6 versus 1.7+/-0.74 cm2, respectively; P<0.05), lower peak left atrial appendage flow velocity (18.8+/-2.1 versus 25.6+/-1.9 cm/s, respectively; P<0.005), higher-grade spontaneous echo contrast (2.05+/-1.44 versus 0.98+/-1.14, respectively; P<0.0001), and higher prevalence of thromboembolism (35% versus 12.5%, respectively; P<0.012). Multiple logistic regression analysis revealed that mitral valve area, left atrial appendage peak velocity, and coarse F-wave were independent clinical risk factors for thromboembolism in this patient group. CONCLUSION: The data suggest that presence of a coarse F-wave on surface ECG is associated with left atrial appendage dysfunction, and indicates higher thromboembolic risk in patients with predominant rheumatic mitral stenosis.

Adolescent↗
PubMed2000

Mild mitral regurgitation was associated with increased prevalence of thromboembolic events in patients with nonrheumatic atrial fibrillation.

Although several studies demonstrated that the presence of significant mitral regurgitation was associated with reduced occurrence of thromboembolism, little data is available concerning the effect of mild mitral regurgitation on the occurrence of thromboembolic events. To evaluate the association between mild mitral regurgitation and thromboembolic events, we reviewed 232 patients' records between January 1996 and September 1997 who had nonrheumatic atrial fibrillation. There were 59 patients (25%) with mitral regurgitation > or = grade 2, 69 patients (30%) with grade 1 mitral regurgitation, and 104 patients (45%) with no mitral regurgitation. Patients with grade 1 mitral regurgitation had significantly higher prevalence of thromboembolic events (28%) than those with mitral regurgitation > or = grade 2 (8%, P=0.006) or those with no mitral regurgitation (11%, P=0.007). A history of previous thromboembolic events were compared between 173 patients with grade 1 mitral regurgitation and those with no mitral regurgitation using the logistic regression analysis adjusted for age, sex, administration of warfarin, and presence of hypertension, diabetes mellitus, structural heart disease, enlarged left atrium (> or = 40 mm), chronic atrial fibrillation, and grade 1 mitral regurgitation. Grade 1 mitral regurgitation (odds ratio=2.689, 95% confidence interval=1.039-7.189, P=0.0434) and no warfarin administration (odds ratio=0.045, 95% confidence interval=0.002-0.242, P=0.0036) were significantly associated with the history of thromboembolic events. The presence of mild mitral regurgitation in nonrheumatic atrial fibrillation was associated with higher prevalence of thromboembolic events.

Aged↗
PubMed1997

Thromboembolism in chronic atrial flutter: is the risk underestimated?

OBJECTIVES: We sought to evaluate the risk of thromboembolic events in the presence of chronic atrial flutter and to determine the impact of anticoagulation therapy, if any, on this risk. BACKGROUND: Thromboembolic events are thought to be rare after cardioversion of atrial flutter. METHODS: This study was a retrospective analysis of 110 consecutive patients referred to the electrophysiology laboratory for cardioversion of chronic atrial flutter from 1986 to 1996. Atrial flutter was present for at least 6 months. Of the 110 patients reviewed, 100 had adequate information available regarding the effectiveness of anticoagulation (mean age 64 years, range 27 to 86; 75 men, 25 women; mean left ventricular ejection fraction 42%). RESULTS: Thirteen patients (13%) had a thromboembolic event. Of these, seven were attributable to causes other than atrial flutter. In the remaining six patients (6%), thromboembolic events occurred during a rhythm of atrial flutter or after cardioversion to sinus rhythm. Other causes of thromboembolism were excluded. Effective anticoagulation was associated with a decreased risk of thromboembolism (p = 0.026). CONCLUSIONS: Patients with chronic atrial flutter are at an increased risk of thromboembolic events. Effective anticoagulation may decrease this risk.

Adult↗
PubMed1998

Treatment of patients with venous thromboembolism and malignant disease: should vena cava filter placement be routine?

PURPOSE: It has been proposed that inferior vena cava filter placement should be the initial treatment of deep venous thrombosis (DVT) or pulmonary embolus (PE) in patients with coexisting malignant disease. We have chosen instead to selectively place filters only in patients with either a contraindication to anticoagulation therapy or a subsequent complication from anticoagulation therapy. The treatment efficacy and mortality rates in patients with concomitant malignant disease and venous thromboembolism using this approach was determined. METHODS: We retrospectively reviewed all patients at our institution with malignant disease in whom venous thromboembolism developed between August 1991 through August 1996 and identified 166 patients with PE (n = 8), DVT (n = 147), and DVT/PE (n = 11). Of these patients, 138 (83.1%) were initially treated with anticoagulation therapy, and 28 (16.9%) had primary filter placement because of contraindications to anticoagulation therapy (10 for intracranial tumors, 11 for recent or upcoming operations, 6 for recent hemorrhage, and 1 for a malignant bloody pericardial effusion). RESULTS: Thirty-two (23%) of the 138 patients who initially underwent anticoagulation therapy subsequently required a filter for the following reasons: bleeding (n = 15, 10.9%); recurrent thromboembolism (n = 6, 4.3%); heparin-induced thrombocytopenia (n = 1, 0.7%); and perceived high risk for bleeding with continued anticoagulation therapy (n = 11, 8%). Both bleeding and recurrent thromboembolism developed in 1 patient. Sixty patients (36%) received filters. No major technical complications occurred from filter placement. Major recurrent thromboembolic complications developed in 10 patients: DVT (n = 6, 10%), PE (n = 2, 3.3%), inferior vena cava thrombosis and phlegmasia cerulea dolens (n = 1, 1.7%), superior vena cava thrombosis (n = 1, 1.7%). Venous gangrene developed in 1 patient with DVT. The 1-year actuarial survival rates for patients treated with filter and anticoagulation therapy were 35% and 38%, respectively (P = NS). CONCLUSION: In summary, our experience suggests that 64% of patients with malignant disease and venous thromboembolism are effectively treated with anticoagulation alone; 17% require primary filter placement for standard indications, and an additional 19% require subsequent filter placement because of complications (primarily bleeding) or failure of anticoagulation therapy. Although technical complications of filter placement are low, serious life-threatening or limb-threatening thromboembolic complications developed in 17% of patients. Survival was poor in all patients, regardless of treatment. These data support a conservative approach of routine anticoagulation therapy with selective filter placement.

Adolescent↗
PubMed2005

Oral contraceptives and the risk of venous thromboembolism.

BACKGROUND: Oral contraceptives were introduced in the late 1950s, and their use has altered society and has led to radical changes. Combined oral contraceptives are considered the most acceptable, effective, and most easily reversible method of contraception. In the early 1960s, an association between venous thrombosis and pulmonary emboli and oral contraceptive use was identified. In response, the amount of estrogen used in these contraceptives was decreased. Later, the concept that reducing the dose of estrogen would eliminate the risk of venous thrombosis was strongly challenged. OBJECTIVE: The available epidemiologic data and the mechanisms that underly the risk of venous thromboembolism as a side effect of oral contraceptive use will be described. Clinical implications based on both the relative and absolute risks in the general population and in women with a known tendency for venous thromboembolism will be discussed. METHODS: A literature search of MEDLINE was conducted for the years 1995 through 2005, using search word combinations including oral contraceptive, estrogen, progestin, venous thrombosis, venous thromboembolism, pulmonary emboli, and pulmonary embolism. Relevant articles relating to the topic of oral contraceptives and the risk of venous thromboembolism were studied and summarized for inclusion in this review article. RESULTS: Certain third-generation progestins in low-estrogen preparations were found to increase the risk of venous thrombosis and pulmonary embolism. Also, the realization that genetic factors play a role in the degree of thrombosis risk led to insights into the hemostatic changes that occur during oral contraceptive use and that predispose women to thrombosis. Known risk factors for venous thromboembolism-inherited thrombophilia, a personal history of venous thromboembolism, and obesity-pose varying degrees of concern for both women and their physicians regarding the safety of oral contraceptives. CONCLUSION: In order to prevent venous thromboembolism, prudence is required when prescribing oral contraceptives to women who have an increased risk of that condition. Furthermore, having a risk factor may not be an absolute contraindication to the use of oral contraceptives, but it offers the opportunity for women to make informed decisions about their use. In the future, researchers should focus on developing effective oral contraceptives that are even safer than those that are available today.

Cardiovascular Diseases↗
PubMed2000

Prognosis of cancers associated with venous thromboembolism.

BACKGROUND: Little is known about the prognosis of cancer discovered during or after an episode of venous thromboembolism. METHODS: We linked the Danish National Registry of Patients, the Danish Cancer Registry, and the Danish Mortality Files to obtain data on the survival of patients who received a diagnosis of cancer at the same time as or after an episode of venous thromboembolism. Their survival was compared with that of patients with cancer who did not have venous thromboembolism (control patients), who were matched in terms of type of cancer, age, sex, and year of diagnosis. RESULTS: Of 668 patients who had cancer at the time of an episode of deep venous thromboembolism, 44.0 percent of those with data on the spread of disease (563 patients) had distant metastasis, as compared with 35.1 percent of 5371 control patients with data on spread (prevalence ratio, 1.26; 95 percent confidence interval, 1.13 to 1.40). In the group with cancer at the time of venous thromboembolism, the one-year survival rate was 12 percent, as compared with 36 percent in the control group (P<0.001), and the mortality ratio for the entire follow-up period was 2.20 (95 percent confidence interval, 2.05 to 2.40). Patients in whom cancer was diagnosed within one year after an episode of venous thromboembolism had a slightly increased risk of distant metastasis at the time of the diagnosis (prevalence ratio, 1.23 [95 percent confidence interval, 1.08 to 1.40]) and a relatively low rate of survival at one year (38 percent, vs. 47 percent in the control group; P<0.001). CONCLUSIONS: Cancer diagnosed at the same time as or within one year after an episode of venous thromboembolism is associated with an advanced stage of cancer and a poor prognosis.

Case-Control Studies↗
PubMed2003

Long-term, low-intensity warfarin therapy for the prevention of recurrent venous thromboembolism.

BACKGROUND: Standard therapy to prevent recurrent venous thromboembolism includes 3 to 12 months of treatment with full-dose warfarin with a target international normalized ratio (INR) between 2.0 and 3.0. However, for long-term management, no therapeutic agent has shown an acceptable benefit-to-risk ratio. METHODS: Patients with idiopathic venous thromboembolism who had received full-dose anticoagulation therapy for a median of 6.5 months were randomly assigned to placebo or low-intensity warfarin (target INR, 1.5 to 2.0). Participants were followed for recurrent venous thromboembolism, major hemorrhage, and death. RESULTS: The trial was terminated early after 508 patients had undergone randomization and had been followed for up to 4.3 years (mean, 2.1). Of 253 patients assigned to placebo, 37 had recurrent venous thromboembolism (7.2 per 100 person-years), as compared with 14 of 255 patients assigned to low-intensity warfarin (2.6 per 100 person-years), a risk reduction of 64 percent (hazard ratio, 0.36 [95 percent confidence interval, 0.19 to 0.67]; P<0.001). Risk reductions were similar for all subgroups, including those with and those without inherited thrombophilia. Major hemorrhage occurred in two patients assigned to placebo and five assigned to low-intensity warfarin (P=0.25). Eight patients in the placebo group and four in the group assigned to low-intensity warfarin died (P=0.26). Low-intensity warfarin was thus associated with a 48 percent reduction in the composite end point of recurrent venous thromboembolism, major hemorrhage, or death. According to per-protocol and as-treated analyses, the reduction in the risk of recurrent venous thromboembolism was between 76 and 81 percent. CONCLUSIONS: Long-term, low-intensity warfarin therapy is a highly effective method of preventing recurrent venous thromboembolism.

Aged↗
PubMedDate not supplied

Regulation of microvascular thromboembolism in vivo.

Atherothrombosis and embolization are main causes of morbidity and mortality in the Western world. To optimize treatment, better understanding of the factors involved in thromboembolism in vivo is needed. The course and outcome of a thromboembolic process are determined by the local balance between anti and prothrombotic factors. In healthy vessels, endothelial antithrombotic properties prevent blood platelets from interacting with the vessel wall. Upon vessel wall damage or endothelial activation, however, prothrombotic factors temporarily overrule the antithrombotic factors, leading to thrombus formation and embolization. According to this concept, thromboembolism ends when the balance is restored. Animal models on microvascular thromboembolism have provided evidence that the endothelium is eminently involved in the regulation of thromboembolism, and that shear forces are an important determinant of endothelial function. Therefore, in this review focus is on the endothelial regulation of platelet-vessel wall interactions during thromboembolism in vivo. Anti- and prothrombotic properties of vascular endothelium will be discussed, paying special attention to the endothelium-derived platelet inhibiting substances nitiric oxide (NO) and prostacyclin (PGl(2)) and to differences between arteriolar and venular endothelium. In addition, the involvement of shear forces in microvascular thromboembolic processes in vivo will be described

Animals↗
PubMed2004

Thromboembolism following removal of femoral venous apheresis catheters in patients with breast cancer.

BACKGROUND: Apheresis catheters have simplified collection of peripheral blood stem cells (PBSC), but may be associated with thrombosis of the instrumented vessels. We performed a retrospective analysis to study the prevalence of thromboembolism associated with the use of femoral apheresis catheters in patients with breast cancer. PATIENTS AND METHODS: Patients were participants in clinical trials of high-dose chemotherapy with autologous PBSC rescue. They underwent mobilization with either high-dose cyclophosphamide (n = 21) or cyclophosphamide/paclitaxel (n = 64), followed by filgrastim. Double lumen catheters (12 or 13 Fr) were placed in the femoral vein and removed within 12 h of the last apheresis procedure. Apheresis was performed using a continuous flow cell separator and ACD-A anticoagulant. Thromboembolism was diagnosed by either venous ultrasonography or ventilation-perfusion scan. RESULTS: Nine of 85 patients (10.6%) undergoing large volume apheresis with use of a femoral catheter developed thromboembolic complications. Pulmonary embolus (PE) was diagnosed in five and femoral vein thrombosis in four patients. Four of the five patients who developed PE were symptomatic; one asymptomatic patient had a pleural-based, wedge-shaped lesion detected on a staging computed tomography scan. The mean number of apheresis procedures was 2.4 (range one to four) and the mean interval between removal of the apheresis catheter and diagnosis of thrombosis was 17.6 days. In contrast, none of 18 patients undergoing apheresis using jugular venous access and none of 54 healthy allogeneic donors undergoing concurrent filgrastim-mobilized PBSC donation (mean 1.7 procedures/donor) using femoral access experienced thromboembolic complications. CONCLUSIONS: Thromboembolism following femoral venous catheter placement for PBSC collection in patients with breast cancer may be more common than previously recognized. Healthy PBSC donors are not at the same risk. Onset of symptoms related to thrombosis tended to occur several weeks after catheter removal. This suggests that the physicians not only need to be vigilant during the period of apheresis, but also need to observe patients for thromboembolic complications after the catheter is removed. The long interval between the removal of apheresis catheter and the development of thromboembolism may have a potential impact on prophylactic strategies developed in future, such as the duration of prophylactic anticoagulation. Avoidance of the femoral site in breast cancer patients, and close prospective monitoring after catheter removal, are indicated.

Adolescent↗
PubMed2004

Contralateral breast cancer and thromboembolic events in African American women treated with tamoxifen.

BACKGROUND: Information about breast cancer treatment and prevention in African American women is scant, and recommendations for therapy from clinical trials for breast cancer are based primarily on data obtained from white women. METHODS: We compared the effects of tamoxifen on risk of contralateral breast cancer and thromboembolic events in African American women and white women with a history of primary breast cancer. Data from 13 National Surgical Adjuvant Breast and Bowel Project clinical trials were pooled for analyses of time to contralateral breast cancer as a first event (eight trials and 10,619 patients) and of time to any thromboembolic phenomenon as a first event (all 13 trials and 20,878 patients). Risk factors for contralateral breast cancer and thromboembolic events among all women were determined using univariate proportional hazards models. (For each racial group, the rate of events associated with tamoxifen use was calculated as the ratio of the incidence rate with tamoxifen to that without tamoxifen.) Proportional hazards regression models were used to calculate 95% confidence intervals (CIs) and risk ratios. All statistical tests were two-sided. RESULTS: Risk factors for contralateral breast cancer were body mass index (BMI) and lymph node positivity; those for thromboembolic events were BMI and age. In women of both ethnicities with estrogen receptor-positive breast cancer, those who took tamoxifen experienced a similar reduction in contralateral breast cancer (risk ratio for African American women = 0.74, 95% CI = 0.46 to 1.17, n = 690; risk ratio for white women = 0.76, 95% CI = 0.59 to 0.98, n = 9929; P = .92). Tamoxifen was also associated with an increase in thromboembolic events. The relative risk for thromboembolic events was higher in both African American and white women treated with tamoxifen and chemotherapy than in those who were treated with tamoxifen alone (risk ratio for African American women = 10.70, 95% CI = 5.94 to 19.28 versus 2.16, 95% CI = 1.26 to 3.71; n = 1842; risk ratio for white women = 15.49, 95% CI = 9.53 to 25.17 versus 3.13, 95% CI = 2.04 to 4.79, n = 19,036), and this effect was similar between the races (P = .10). CONCLUSIONS: African American and white women appear to have the same risks of contralateral breast cancer and thromboembolic events in response to tamoxifen treatment.

Adult↗
PubMed2004

Venous thromboembolism after trauma.

PURPOSE OF REVIEW: The trauma population is at increased risk of venous thromboembolic disease, a potentially preventable cause of mortality and morbidity. Although the association between trauma and venous thromboembolism has been recognized for more than a century, there is still great variability in the clinical practices with respect to prophylaxis. This thorough review of recent literature aims to clarify the incidence and risk factors for deep venous thrombosis and pulmonary embolism after trauma, review options and recommendations for detection of deep venous thrombosis and pulmonary embolism, and give evidence-based recommendations for prophylaxis. Special attention is paid to patients with spinal cord injury, patients with head injury, and pediatric trauma patients. RECENT FINDINGS: Highlights in this field during the past year include stratification of venous thromboembolism risk factors after trauma using a large national database, the expanded use of venous duplex ultrasound surveillance in the ICU and during rehabilitation, and investigations into the safety of low molecular weight heparins in patients with solid organ and traumatic brain injuries. Additionally, two new classes of anticoagulant drugs have been introduced for venous thromboembolism prophylaxis, and there are some preliminary studies on a temporary vena cava filter for the prevention of pulmonary embolism. SUMMARY: Venous thromboembolism remains an area of active clinical research focusing on evolving diagnostic techniques, newer methods of chemical and mechanical prophylaxis, and improved understanding of the etiologic factors of posttraumatic venous thromboembolism. These efforts will undoubtedly decrease the posttraumatic morbidity and mortality associated with venous thromboembolism.

Algorithms↗
PubMed2003

Venous thromboembolism in travellers: can we identify those at risk?

To assess the prevalence of clinical and laboratory risk factors in patients who develop venous thromboembolism following travel. The design was a case series of 58 consecutive patients presenting with venous thromboembolism within 30 days of travel. The setting was a major metropolitan teaching hospital and an affiliated private practice. The main outcome measures were prevalence of clinical and laboratory risk factors for venous thromboembolism, time to presentation, mode and duration of travel. Forty-eight [83%; 95% confidence interval (CI), 71-91%] of 58 patients developed venous thromboembolism following air travel. Thirty-four (59%; 95% CI, 45-71%) patients had travelled for more than 8 h and most patients were diagnosed with venous thromboembolism within 1 week of completing their journey. Pulmonary embolism occurred in 24 patients (41%; 95% CI, 29-55%), proximal deep vein thrombosis in 23 patients (40%; 95% CI, 27-53%), calf vein thrombosis in four patients (7%; 95% CI, 2-17%), and superficial thrombophlebitis in seven patients (12%; 95% CI, 5-23%). At least one clinical or laboratory risk factor (other than travel) was found in 49 patients (84%; 95% CI, 73-93%) and two or more risk factors were found in 30 patients (52%; 95% CI, 38-65%). The most common risk factors were oestrogens (24%; 95% CI, 14-37%), a past history of thrombosis (24%: 95% CI, 14-37%), and factor V Leiden (24%: 95% CI, 14-37%). These retrospective uncontrolled data suggest that at least one clinical or laboratory risk factor is present prior to travel in more than 80% of patients who develop venous thromboembolism within 30 days of travel. In most cases these risk factors can be identified by the clinical history alone, without recourse to laboratory testing. Whether patients with known risk factors for venous thromboembolism prior to travel should be targeted with specific thromboprophylaxis requires randomized evaluation.

Adolescent↗
PubMed2005

Thromboembolism in heart transplantation: role of prothrombin G20210A and factor V Leiden.

BACKGROUND: Thromboembolism has been reported as a frequent complication after cardiac transplantation. Many risk factors for thrombosis may explain this, such as metabolic alterations and the use of cyclosporine. In the general population, two single nucleotide polymorphisms (SNPs), factor V Leiden and prothrombin G20210A (PT G20210A), have been associated with a significant increase in the risk of thrombosis. However, these mutations have not been analyzed in cardiac transplant patients. We describe the protracted history of recurrent thromboembolism in a rare case of homozygosity for the PT G20210A variant. This prompted us to analyze the entire cardiac transplant cohort for the incidence of thromboembolic events and their association with these genetic polymorphisms. METHODS: We report the study of 84 cardiac transplant recipients. We retrospectively analyzed the frequency of thromboembolic episodes. The genotypes for FVL and PT G20210A were determined and correlated with those episodes. RESULTS: Our results confirm a very high incidence of thromboembolism in this population. We also found a significant increase in the likelihood of thromboembolism in subjects with the PTB G20210A variant (odds ratio 3.08; 95% confidence interval: 1.7-5.5). CONCLUSIONS: The incidence of thromboembolic complications after heart transplantation is increased and may be related in part to genetic predisposition.

Adult↗
PubMed1968

Puerperal thromboembolism in relation to the inhibition of lactation by oestrogen therapy.

An analysis was made of 111 consecutive cases of puerperal thromboembolism by the age, parity, mode of delivery, and lactation habit of the women concerned, and the findings were compared with those from control groups.The statistics show that inhibition of lactation by means of ethinyloestradiol is associated with a threefold increase in thromboembolism, although the effect is seen mainly in women who have an operative delivery and who are aged more than 25 years. Among women aged more than 35 years who have an assisted delivery, inhibition of lactation is accompanied by a tenfold increase in the incidence of puerperal thromboembolism.Advancing age and operative intervention (especially caesarean section) are in themselves predisposing causes of deep venous thrombosis and embolism. They can also constitute indications for inhibiting lactation. This makes it difficult to assess whether the relation of thromboembolism to inhibition of lactation or to the administration of oestrogen is real or apparent. Doubts on the interpretation of the findings are raised by the fact that the number of fatal cases of puerperal thromboembolism in England and Wales, and of non-fatal cases in the hospitals under review, has not increased in recent years despite a progressive decrease in breast-feeding. Nevertheless, the evidence suggests that although the administration of ethinyloestradiol is not by itself enough to cause puerperal thromboembolism, it may be a factor which can tip the scales in women who are already predisposed to suffer this condition.Any thromboembolic hazard associated with administration of oestrogens for inhibiting lactation is probably acceptable except in women known to be at special risk by reason of age, operative delivery, obesity, and a past history of thromboembolic episodes.

Adult↗
PubMed1999

Arterial thromboembolism in patients with sick sinus syndrome: prediction from pacing mode, atrial fibrillation, and echocardiographic findings.

OBJECTIVE: To evaluate whether thromboembolism in sick sinus syndrome can be predicted by pacing mode, atrial fibrillation, or echocardiographic findings. METHODS: Patients were randomised to single chamber atrial (n = 110) or ventricular (n = 115) pacing. They were divided into subgroups with and without brady-tachy syndrome at time of randomisation. The occurrence of atrial fibrillation and thromboembolism during follow up were investigated and compared with echocardiographic findings. RESULTS: The annual risk of thromboembolism was 5.8% in patients with brady-tachy syndrome randomised to ventricular pacing, 3.2% in patients without brady-tachy syndrome randomised to ventricular pacing, 3% in patients with brady-tachy syndrome randomised to atrial pacing, and 1.5% in patients without brady-tachy syndrome randomised to atrial pacing. In atrial paced patients without brady-tachy syndrome at randomisation and without atrial fibrillation during follow up, the annual risk of thromboembolism was 1.4%. Left atrial size measured by M mode echocardiography was of no value in predicting thromboembolism. CONCLUSIONS: Arterial thromboembolism in patients with sick sinus syndrome is very common and is associated primarily with brady-tachy syndrome at randomisation and with ventricular pacing. The risk of thromboembolism is small in atrial paced patients in whom atrial fibrillation has never been documented.

Aged↗
PubMed2003

Reduction of venous thromboembolism following prolonged prophylaxis with the low molecular weight heparin Certoparin after endoprothetic joint replacement or osteosynthesis of the lower limb in elderly patients.

The peri- and postsurgical thromboembolic prophylaxis with low molecular weight heparins is a well established therapy regimen, but the optimum duration of prophylaxis after surgery still remains uncertain. A few studies have pointed to the fact that the thromboembolic risk of high-risk patients persists longer than the in-hospital period correlating with respective hypercoagulatory conditions. The aim of the present study was to test if a prolongation of thromboprophylaxis with the low molecular weight heparin Certoparin further reduces the rate of thromboembolism in high-risk patients after orthopedic surgery. The "Long-term Thromboprophylaxis"-Study was a multicenter, randomized, double-blind, placebo-controlled trial. 360 patients who underwent endoprothetic joint replacement or osteosynthesis of the lower limb were initially enrolled, all of them received prophylactically 3000 U anti-Xa of Certoparin once daily for 14 days followed by randomization to prolonged Certoparin application or to placebo up to day 42. Patients were screened for deep vein thrombosis by sonography every week. Coagulation markers (fibrin monomers and D-dimers) were determined during the course of the study. Venous thromboembolism during the prolongation period was observed in 18 patients receiving placebo versus 8 patients of the prolonged Certoparin group (12.1% versus 5.0%, intention-to-treat sample). The analysis revealed a statistically significant difference in favor of Certoparin (p=0.020), which was confirmed by per-protocol analysis (14.2% versus 5.5%, p=0.012). The differences remained significant, if analyses considered only clinically symptomatic thromboembolic events (p=0.040). Patients who developed a thrombosis showed a strong increase of coagulation markers as compared to patients without subsequent thrombosis. The respective differentiation started around 18 days before diagnosis of thrombosis. Only one minor bleeding complication was observed during prolonged Certoparin prophylaxis. The present study shows that patients after joint replacement or osteosynthesis of the lower extremities have a persisting risk to develop thromboembolic complications beyond the routine duration of thromboprophylaxis. Extended prophylaxis with Certoparin resulted in a significantly lower rate of thromboembolism and should be strongly recommended.

Aged↗
PubMed2004

Increased fasting total homocysteine plasma levels as a risk factor for thromboembolism in children.

Elevated total homocysteine (tHcy) concentrations are an independent risk factor for thromboembolic events in adults. In children with moderate hyperhomocysteinemia data are sparse. Therefore, between 1995 and 2002 we consecutively recruited 163 white pediatric patients with a first symptomatic thromboembolic event and 255 healthy controls (mean age: 6.4 years in patients vs. 6.6 years in controls, range: 3 months to 18 years) and measured fasting tHcy levels. Median tHcy levels in patients were significantly higher (6.6 micromol/l, range 2.9-20.4 micromol/l) than in controls (5.7 micromol/l, 2.0-14.0 micromol/l, p<0.0001). 48 of the 163 patients with thromboembolism (29.5%) versus 26 of the 255 controls (10.2%) had tHcy levels above the age-specific normal 90th percentile (OR 2.9, 95%CI: 1.7-4.8). The odds ratio for children in the highest quintile compared to children with levels in the lowest quintile was 4.3 (1.6-8.1; highest quintile: median tHcy level 9.6 micromol, range 8.0-20.4), showing a significantly increased risk for thromboembolic disease with even mild hyperhomocysteinemia. We conclude that hyperhomocysteinemia above the age-specific cut-off values is a risk factor for thromboembolic events in children. Therefore, screening for elevated fasting tHcy levels of patients with thromboembolism is recommended to stratify the risk of thromboembolism.

Adolescent↗