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PubMed1981

Platelets, thromboembolism and mitral valve prolapse.

Cerebral and retinal ischemic events have been described in mitral valve prolapse. To determine whether platelets play a part in the pathogenesis of thromboembolism we studied 29 patients with mitral valve prolapse, including nine (group I) with thromboembolism (cerebral, retinal and deep venous), eight (group II) with transient visual obscurations and 12 (group III) with neither thromboembolism nor visual complaints, compared with 18 control patients and 38 normal subjects. Patients in groups I and II had increased platelet coagulant activities concerned with the initiation and early stages of intrinsic coagulation, and group I patients had an increased proportion of circulating platelet aggregates and platelets relatively insensitive top epinephrine in aggregation and secretion. The incidence of platelet coagulation hyperactivity in patients with mitral valve prolapse was 76% (100% in group I, 75% in group II, 58% in group III), compared with 6% in control patients. These results suggest that platelets play a role in the purported association of thromboembolism and mitral valve prolapse.

Adult↗
PubMed1985

Warfarin versus dipyridamole-aspirin and pentoxifylline-aspirin for the prevention of prosthetic heart valve thromboembolism: a prospective randomized clinical trial.

In a prospective, randomized, parallel study, two regimens of platelet-suppressant therapy (PST)--dipyridamole-aspirin and pentoxifylline-aspirin--were compared with standard oral anticoagulation with warfarin in the prevention of prosthetic heart valve thromboembolism. In the entire group of 254 patients followed for 395.6 patient-years, the thromboembolic rate was significantly less in the warfarin group (warfarin vs dipyridamole-aspirin, p less than .005; warfarin vs pentoxifylline-aspirin, p less than .05). Subgroup analysis disclosed that, in patients with isolated mitral valve replacement, warfarin was superior to both of the PSTs with respect to the prevention of thromboembolism (warfarin vs dipyridamole-aspirin, p = .005; warfarin vs pentoxifylline-aspirin, p less than .05). Furthermore, a significant number of our patients could not tolerate the antiplatelet agents. However, in the rare situation in which repeated significant bleeding occurs despite careful adjustment of the dosage of warfarin, PST may be an acceptable alternate method of thromboembolism prophylaxis.

Adult↗
PubMed2003

Recurrent thromboembolism in infants and children suffering from symptomatic neonatal arterial stroke: a prospective follow-up study.

BACKGROUND AND PURPOSE: The present study was performed to evaluate the rate of recurrent symptomatic thromboembolism with respect to prothrombotic risk factors and underlying clinical conditions. METHODS: In a series of 215 consecutively enrolled neonates with arterial ischemic stroke (AIS), the factor V G1691A mutation, factor II G20210A variant, methylenetetrahydrofolate reductase (MTHFR) T677T genotype, lipoprotein (Lp) (a), antithrombin, protein C, protein S, and anticardiolipin antibodies (ACA) were investigated. Patient median follow-up was 3.5 years (range, 1 to 8 years). RESULTS: During follow-up, 7 infants and children (3.3%) showed recurrent symptomatic thromboembolism (AIS, n=4; venous sinus thrombosis, n=2; deep vein thrombosis of the leg, n=1). The factor V mutation, factor II variant, elevated Lp(a) >30 mg/dL, protein C deficiency, and protein S or antithrombin deficiency were associated with first stroke onset. In 5 of 7 cases (71.4%), prothrombotic risk factors [MTHFR T677T, elevated Lp(a), hyperhomocysteinemia, protein C deficiency] were involved at the time of recurrence. Furthermore, a second thromboembolic event was triggered additionally by underlying diseases (71%), eg, cardiac malformation and immobilization, diarrhea, mastoiditis, and moyamoya syndrome. CONCLUSIONS: Data shown here give evidence that symptomatic recurrent thromboembolism is not common in children with neonatal AIS. The risk of a second event, however, is increased when underlying diseases occur and prothrombotic risk factors are involved.

Child↗
PubMed1990

Thromboembolic complications in atrial fibrillation.

I review the present understanding of thromboembolic complications and their prevention in patients with nonrheumatic atrial fibrillation. Chronic atrial fibrillation carries an annual 3-6% risk of thromboembolic complications, which is 5-7 times greater than that of controls with sinus rhythm. Paroxysmal atrial fibrillation is associated with a lower risk of thromboembolic complications than chronic atrial fibrillation. Heart failure and systemic hypertension seem to be significant clinical risk factors for stroke in patients with atrial fibrillation, but disagreement persists, and, with few exceptions, subgroups at particular risk have not been convincingly identified. The risk of stroke in persons with thyrotoxic atrial fibrillation seems to be lower than believed previously. Clinical studies have shown that left atrial dilatation is a consequence of the duration of atrial fibrillation rather than a cause, but the relation of left atrial enlargement to stroke is uncertain. Cerebral blood flow may be reduced during atrial fibrillation but seems to increase after cardioversion to sinus rhythm. A high prevalence of silent cerebral infarction has been detected in patients with chronic atrial fibrillation, but there seems to be a low risk of silent cerebral infarction in persons with paroxysmal atrial fibrillation. The one prospective study published to date on stroke prevention in patients with nonrheumatic chronic atrial fibrillation showed that anticoagulation with warfarin significantly reduced the incidence of thromboembolic complications.

Aged↗
PubMed2002

High plasma brain natriuretic polypeptide level as a marker of risk for thromboembolism in patients with nonvalvular atrial fibrillation.

BACKGROUND AND PURPOSE: Assessment of left atrial appendage (LAA) function with transesophageal echocardiography is useful for detecting patients at high risk for thromboembolism as a result of atrial fibrillation (AF). A recent study reported that the atrium is the main source of brain natriuretic polypeptide (BNP) in AF patients without overt heart failure. The purpose of this study was to assess a possible relationship between LAA function and plasma BNP levels in nonvalvular AF. METHODS: Thirty-four consecutive patients with chronic nonvalvular AF (age, 69+/-9 years) underwent transesophageal echocardiography and plasma BNP measurement. Thirteen patients with a history of thromboembolism or echocardiographic evidence of thrombus (E + group) were compared with 21 AF patients without complications (E- group). RESULTS: The E+ group patients demonstrated greater impairment of LAA velocity and higher plasma BNP levels than the E- group patients (LAA velocity: 12+/-6 versus 31+/-17 cm/s, P<0.05; plasma BNP: 126+/-53 versus 86+/-45 ng/L, P<0.05). Overall analysis of the continuous variables with multiple logistic regression analysis revealed that BNP was a significant predictor of thromboembolism. There was a weak but significant negative correlation between plasma BNP levels and LAA flow velocity (r=0.38, P<0.05). No intergroup difference in plasma atrial natriuretic polypeptide levels was found. CONCLUSIONS: The present data suggest the usefulness of measuring plasma BNP levels, which may reflect augmented atrial secretion of BNP from the impaired atrial myocardium, in detecting patients at high risk for thromboembolic complications in nonvalvular AF.

Adult↗
PubMed2002

Recurrent venous thromboembolism and bleeding complications during anticoagulant treatment in patients with cancer and venous thrombosis.

A small proportion of patients with deep vein thrombosis develop recurrent venous thromboembolic complications or bleeding during anticoagulant treatment. These complications may occur more frequently if these patients have concomitant cancer. This prospective follow-up study sought to determine whether in thrombosis patients those with cancer have a higher risk for recurrent venous thromboembolism or bleeding during anticoagulant treatment than those without cancer. Of the 842 included patients, 181 had known cancer at entry. The 12-month cumulative incidence of recurrent thromboembolism in cancer patients was 20.7% (95% CI, 15.6%-25.8%) versus 6.8% (95% CI, 3.9%- 9.7%) in patients without cancer, for a hazard ratio of 3.2 (95% CI, 1.9-5.4) The 12-month cumulative incidence of major bleeding was 12.4% (95% CI, 6.5%-18.2%) in patients with cancer and 4.9% (95% CI, 2.5%-7.4%) in patients without cancer, for a hazard ratio of 2.2 (95% CI, 1.2-4.1). Recurrence and bleeding were both related to cancer severity and occurred predominantly during the first month of anticoagulant therapy but could not be explained by sub- or overanticoagulation. Cancer patients with venous thrombosis are more likely to develop recurrent thromboembolic complications and major bleeding during anticoagulant treatment than those without malignancy. These risks correlate with the extent of cancer. Possibilities for improvement using the current paradigms of anticoagulation seem limited and new treatment strategies should be developed.

Adult↗
PubMed2005

Randomized comparison of low molecular weight heparin and coumarin derivatives on the survival of patients with cancer and venous thromboembolism.

PURPOSE: Experimental studies and indirect clinical evidence suggest that low molecular weight heparins may have antineoplastic effects. We investigated the influence of a low molecular weight heparin dalteparin on the survival of patients with active cancer and acute venous thromboembolism. PATIENTS AND METHODS: Survival data were examined in a posthoc analysis in patients with solid tumors and venous thromboembolism who were randomly assigned to dalteparin or a coumarin derivative for 6 months in a multicenter, open-label, randomized, controlled trial. All-cause mortality at 12 months was compared between treatment groups in patients with and without metastatic malignancy. The effect of dalteparin on survival was compared between the two patient subgroups. RESULTS: During the 12-month follow-up period, 356 of 602 patients with solid tumors and acute venous thromboembolism died. Among patients without metastatic disease, the probability of death at 12 months was 20% in the dalteparin group, as compared with 36% in the oral anticoagulant group (hazard ratio, 0.50; 95% CI, 0.27 to 0.95; P = .03). In patients with metastatic cancer, no difference in mortality between the treatment groups was observed (72% and 69%, respectively; hazard ratio, 1.1; 95% CI, 0.87 to 1.4; P = .46). The observed effects of dalteparin on survival were statistically significantly different between patients with and without metastatic disease (P = .02). CONCLUSION: The use of dalteparin relative to coumarin derivatives was associated with improved survival in patients with solid tumors who did not have metastatic disease at the time of an acute venous thromboembolic event. Additional studies are warranted to investigate these findings.

Acute Disease↗
PubMed2005

Venous thromboembolism associated with hip and knee replacement over a ten-year period: a population-based study.

This population-based study investigated the incidence and trends in venous thromboembolic disease after total hip and knee arthroplasty over a ten-year period. Death or readmission for venous thromboembolic disease up to two years after surgery for all patients in Scotland was the primary outcome. The incidence of venous thromboembolic disease, including fatal pulmonary embolism, three months after surgery was 2.27% for primary hip arthroplasty and 1.79% for total knee arthroplasty. The incidence of fatal pulmonary embolism within three months was 0.22% for total hip arthroplasty and 0.15% for total knee arthroplasty. The majority of events occurred after hospital discharge, with no apparent trend over the period. The data support current advice that prophylaxis should be continued for at least six weeks following surgery. Despite the increased use of policies for prophylaxis and earlier mobilisation, there has been no change in the incidence of venous thromboembolic disease.

Aged↗
PubMed2000

Short activated partial thromboplastin times are related to increased thrombin generation and an increased risk for thromboembolism.

This prospective study was designed to investigate whether patients with short activated partial thromboplastin times (aPTTs) have increased thrombin generation and are at increased risk for thromboembolism. During a 4-month period, routine coagulation specimens were screened for the presence of a short or normal aPTT, and, accordingly, 250 specimens were collected. Prothrombin fragment F1 + 2 (F1 + 2) was measured to evaluate thrombin activation, and a second aPTT was performed with a different reagent. Diagnoses were obtained from medical records after conclusion of sample collection. Five to 9 months later, patients were questioned on thromboembolic events during the previous 18 months by questionnaire and telephone interview. F1 + 2 and the incidence of venous thromboses were elevated significantly in the short aPTT group. Unexpectedly, patients with acute bleeding had short aPTTs, but 36% of these also had thromboembolic events during the 18 months proximal to blood collection. These findings were confirmed with the second aPTT reagent. Patients with short aPTTs have increased thrombin generation and are at increased risk for thromboembolism, mainly venous thromboses, despite the fact that a short aPTT can occur in the acute setting of bleeding.

Female↗
PubMed2006

Warfarin exposure and the risk of thromboembolic and major bleeding events among medicaid patients with atrial fibrillation.

BACKGROUND: Outcomes of anticoagulation have been assessed in commercially insured populations, but similar data do not exist for Medicaid populations. OBJECTIVE: To assess the association between warfarin exposure and rates of thromboembolic and bleeding events among patients with nonvalvular atrial fibrillation (NVAF) enrolled in California Medicaid. METHODS: Using a retrospective cohort design based on administrative claims data, we selected Medicaid enrollees aged 50 years and older based on their first claim with a diagnosis of AF between January 1, 1998, and March 31, 2002. Patients were excluded if they had selected contraindications to warfarin, claims for valve replacement procedures, or evidence that AF resulted from transient or reversible causes. Pharmacy claims and prothrombin time tests were used to define subsequent periods of warfarin use (exposure) and nonuse (nonexposure) by all patients. The relative rates of hospitalization for thromboembolic and bleeding events associated with periods of warfarin exposure versus nonexposure were estimated. RESULTS: The 4355 study patients had a mean age of 74 years, and 65% were female. Fifty-nine percent filled any prescriptions for warfarin following AF diagnosis. Across all patients, warfarin exposure occurred during 37% of days after diagnosis. Thromboembolic events were 27% less frequent during periods of warfarin exposure relative to periods of non-exposure (p < 0.01). Major bleeding events were not significantly more common during periods of warfarin exposure (p = 0.55). CONCLUSIONS: In this Medicaid population with NVAF, warfarin use was low and was associated with a relatively modest reduction in thromboembolic events, with no increase in major bleeding risk.

Aged↗
PubMed2002

Fondaparinux versus enoxaparin for the prevention of venous thromboembolism.

Venous thromboembolism is a frequent, life-threatening, postoperative complication of hip-fracture and total-knee-replacement surgery. Fondaparinux is a synthetic polysaccharide that selectively binds to antithrombin, the primary endogenous regulator of blood coagulation. Low molecular weight heparins, such as enoxaparin, are less specific inhibitors of coagulation. In patients undergoing hip-fracture surgery, fondaparinux is more effective than once-daily enoxaparin as prophylaxis for venous thromboembolism. Fondaparinux (25 mg/day sc.) was also more effective than enoxaparin (30 mg sc. b.i.d.) as prophylaxis for venous thromboembolism in elective knee surgery. These differences may be explained by the fact that there is less prophylaxis cover with enoxaparin, as it has a much shorter duration of action than fondaparinux. Thus, with the present dosing regimens, fondaparinux is probably preferable to enoxaparin for the prevention of venous thromboembolism.

Arthroplasty, Replacement, Hip↗
PubMed2003

Selective factor Xa inhibition improves efficacy of venous thromboembolism prophylaxis in orthopedic surgery.

Venous thromboembolism is a serious, frequent, and potentially fatal complication of major orthopedic surgery. Currently available pharmacologic agents for the prevention of venous thromboembolism in this high-risk population consist of the oral anticoagulants and the heparin family of antithrombotic agents (unfractionated heparin, low-molecular-weight heparin, heparinoids). These classes of agents interfere with the activity of both thrombin and factor Xa (or their respective zymogens) to varying degrees. Newer antithrombotic agents in various stages of development exert their antithrombotic effect through a more targeted mechanism of action. Direct factor Xa inhibitors and the newest class of antithrombotic agents, the indirect factor Xa inhibitors, the prototype of which is the synthetic pentasaccharide fondaparinux sodium, limit fibrin formation through their exclusive inactivation of factor Xa. Clinical data from venous thromboembolism prophylaxis trials in hip and knee replacement and hip fracture surgeries, including the recently completed fondaparinux phase II and phase III trials, indicate that selective antifactor Xa activity may improve the efficacy:safety ratio of antithrombotic therapies for the prevention of venous thromboembolism in high-risk major orthopedic surgery.

Factor Xa Inhibitors↗
PubMed1994

RD heparin compared with warfarin for prevention of venous thromboembolic disease following total hip or knee arthroplasty. RD Heparin Arthroplasty Group.

The efficacy and safety of RD heparin, a low-molecular-weight heparin, for the prevention of venous thromboembolic disease among patients managed with an elective total hip or total knee arthroplasty were compared with the efficacy and safety of warfarin in an open-label prospective, multicenter trial. Patients were randomized to receive either a fixed dose of fifty anti-factor-Xa units of RD heparin per kilogram of body weight, administered subcutaneously twice daily, beginning postoperatively; a fixed dose of ninety anti-factor-Xa units of RD heparin per kilogram of body weight, administered subcutaneously once daily, beginning postoperatively; or five milligrams of warfarin, administered orally preoperatively, followed by a daily adjusted dose of warfarin to prolong the prothrombin time ratio to 1.2 to 1.5. The primary measure of efficacy was contrast venography of the treated limb, performed by local radiologists blinded to the type of treatment that had been assigned. Nine hundred and sixty-nine patients had a complete assessment for the presence of deep-vein thrombosis. The over-all rates of venous thromboembolic disease were 16 percent (95 pecent confidence interval, 13 to 21 percent) (fifty-three) for the 328 patients who received RD heparin twice daily, 21 percent (95 percent confidence interval, 17 to 26 percent) (sixty-eight) for the 320 patients who received RD heparin once daily, and 27 percent (95 percent confidence interval, 22 to 32 percent) (eighty-seven) for the 321 patients who received warfarin (p < 0.001 for RD heparin administered twice daily compared with warfarin; p = 0.13 for RD heparin administered once daily compared with warfarin). Compared with warfarin, RD heparin administered twice daily and RD heparin administered once daily reduced the risk of venous thromboembolic disease by 41 percent (95 percent confidence interval, 20 to 56 percent) and 18 percent (95 percent confidence interval, -6 to 37 percent), respectively. The rates of venous thromboembolic disease after 523 total hip arthroplasties were 8, 14, and 14 percent for the patients who received RD heparin twice daily, those who received it once daily, and those who received warfarin (p = 0.07 for RD heparin administered twice daily compared with warfarin; p = 0.82 for RD heparin administered once daily compared with warfarin).(ABSTRACT TRUNCATED AT 400 WORDS)

Adult↗
PubMed1999

Thromboembolic prophylaxis with use of aspirin, exercise, and graded elastic stockings or intermittent compression devices in patients managed with total hip arthroplasty.

BACKGROUND: Prophylaxis against pulmonary embolism as a complication of total hip arthroplasty remains controversial. Our experience suggests that an inexpensive protocol of prophylaxis that includes aspirin and exercise is effective. METHODS: We investigated the effectiveness of aspirin, a program of intraoperative and postoperative exercises, and graded elastic stockings or intermittent compression devices as prophylaxis against thromboembolic disease in a series of 1267 patients who had had 1492 total hip arthroplasties. All of the operations were done through a posterior approach. For the purpose of this review, the duration of follow-up was limited to a minimum of three months. No patient was lost to follow-up. Any thromboembolic complications that may have occurred after the third postoperative month were not considered to be related to the operation and were not recorded. RESULTS: A fatal pulmonary embolism occurred after two arthroplasties (0.13 percent), a nonfatal pulmonary embolism was diagnosed after fourteen (0.94 percent), and deep venous thrombosis developed after fifteen (1.01 percent). Regional (epidural) anesthesia was used for 1099 arthroplasties (73.7 percent), and general anesthesia was used for 393 procedures (26.3 percent). A fatal pulmonary embolism occurred after two (0.18 percent) of the 1099 arthroplasties that had been performed with regional anesthesia and after none that had been performed with general anesthesia (chi square = 0.22; p > 0.05). A nonfatal pulmonary embolism occurred after two procedures (0.18 percent) that had been done with regional anesthesia and after twelve (3.05 percent) that had been done with general anesthesia (chi square = 25.3; p < 0.001). Deep venous thrombosis was diagnosed after seven procedures (0.64 percent) that had been performed with regional anesthesia and after eight (2.04 percent) that had been performed with general anesthesia (chi square = 5.45; p < 0.025). We detected a significant difference between men and women with respect to the rate of nonfatal pulmonary embolism (chi square = 4.36; p < 0.05). With the numbers available, we found no significant differences between the 774 arthroplasties (51.9 percent) in patients who had worn graded elastic stockings and the 718 arthroplasties (48.1 percent) in patients who had used intermittent compression devices, between the 774 arthroplasties (51.9 percent) that had been performed in Florida and the 718 (48.1 percent) that had been done in California, or between the 1313 primary arthroplasties (88 percent) and the 179 revision arthroplasties (12 percent), with regard to the prevalence of fatal pulmonary embolism, nonfatal pulmonary embolism, or deep venous thrombosis (p > 0.05 for all comparisons). In summary, we found that the type of compression (graded elastic stockings or intermittent compression devices), the geographic location (California or Florida), and the type of operation (primary or revision) had no significant effect, with the numbers available, on the rate of thromboembolic complications. Compared with general anesthesia, the use of regional anesthesia was associated with a significantly lower rate of nonfatal pulmonary embolism (p < 0.001) and deep venous thrombosis (p < 0.025). Both patients who had a fatal pulmonary embolism had had regional anesthesia (p > 0.05). CONCLUSIONS: This inexpensive method of prophylaxis against thromboembolic disease after total hip arthroplasty, which was based primarily on the use of aspirin as the pharmacological agent and the performance of intraoperative and postoperative exercises, produced good clinical results.

Arthroplasty, Replacement, Hip↗
PubMed1996

Prevention and treatment of venous thromboembolism.

All patients at moderate to high risk for the development of venous thromboembolism should receive prophylaxis. The approaches of proven value include low dose heparin, low molecular weight heparin, oral anticoagulants and intermittent pneumatic compression. The use of one of the cited heparin nomograms will ensure that all patients are rapidly brought within the therapeutic range. Because of the varying sensitivities of thromboplastins, each laboratory should establish a therapeutic range using the activated partial thromboplastin time (APTT) which will correspond to 0.2 to 0.4 U/ml of heparin. Constant vigilance and a high level of suspicion are necessary to establish the clinical diagnosis of heparin-induced thrombocytopenia, and to institute appropriate therapy. Physicians should be aware of the sensitivity of the thromboplastin being used in the performance of the International Normalised Ratio (INR). Care must be taken to ensure that patients are maintained within the target therapeutic range for INR (in most cases 2 to 3) by frequent determination of the INR and appropriate adjustments of warfarin dosage. Low molecular weight heparin is the recommended approach to the initial management of venous thromboembolism where these agents are available. Patients with an acute episode of venous thromboembolism should receive warfarin therapy for at least 3 months. At the present time it is reasonable to treat the first recurrence with oral anticoagulants for a period of 12 months and indefinitely for more than 1 recurrence. For selected patients with acute massive pulmonary embolism, thrombolytic therapy with one of the available agents is recommended. However, the role of thrombolytic therapy in patients with proximal venous thrombosis remains unclear. In selected patients with acute venous thromboembolism who have contraindications to anticoagulant therapy or who-have objectively documented recurrent disease while on adequate therapy, the insertion of an inferior vena cava filter is recommended.

Anticoagulants↗
PubMed2004

Tinzaparin sodium: a review of its pharmacology and clinical use in the prophylaxis and treatment of thromboembolic disease.

Tinzaparin sodium (tinzaparin; innohep) is a low molecular weight heparin (LMWH) formed by the enzymatic degradation of porcine unfractionated heparin (UFH). In clinical trials, once-daily subcutaneous (SC) tinzaparin was effective and generally well tolerated in the prophylaxis and treatment of thromboembolic disease. SC tinzaparin 75 anti-Xa IU/kg/day showed similar thromboprophylactic efficacy to adjusted-dosage oral warfarin in patients undergoing total hip arthroplasty; in patients undergoing knee replacement, the incidence of deep vein thrombosis (DVT) was significantly lower with tinzaparin. The drug had similar efficacy to equivalent-dosage SC enoxaparin sodium in orthopaedic surgery. In patients undergoing general surgery, SC tinzaparin 3500 anti-Xa IU/day was of equivalent thromboprophylactic efficacy to SC UFH 5000IU twice daily. Encouraging preliminary results have been obtained with tinzaparin in the prevention of DVT in patients with complete motor paralysis. In the initial treatment of acute proximal DVT and pulmonary embolism, SC tinzaparin 175 anti-Xa IU/kg/day was at least as effective as adjusted-dosage intravenous (IV) UFH. In the outpatient treatment of venous thromboembolism, tinzaparin has demonstrated similar efficacy to dalteparin sodium (dalteparin) and warfarin. Tinzaparin was effective in preventing clotting in haemodialysis circuits; the anticoagulant efficacy of tinzaparin in patients undergoing haemodialysis was similar to that of SC dalteparin and similar to or less than (although in this case the tinzaparin dose was too low for sufficient anticoagulant efficacy) that of IV UFH. Advantages of tinzaparin over UFH and warfarin include ease of administration and lack of need for laboratory monitoring. Tinzaparin is more cost effective than UFH in the treatment of established thromboembolic disease, and home-based treatment with tinzaparin may offer greater cost benefits than hospital-based therapy. Tinzaparin is well tolerated, including in elderly patients and those with renal impairment receiving long-term treatment. Incidences of major bleeding complications were low and reports of heparin-induced thrombocytopenia were infrequent in clinical studies. In conclusion, tinzaparin is a valuable LMWH in the prophylaxis and management of thromboembolic disease.

Age Factors↗
PubMed2002

Venous thromboembolism and oral contraceptives: current status and clinical implications.

Recent studies of currently available oral contraceptives indicate that the risk of major sequelae is low in young women (aged between 20 and 24 years). Venous thromboembolism remains one event that can occur in users independent of the presence of risk factors. However, the attributable risk is small, with a range of approximately 7 to 18 events per 100 000 women annually. This risk is directly proportional to estrogen dosage starting at levels of 30-35 microg. The type of progestogen (progestin) may also influence risk, though recent studies are controversial. In particular, there is debate surrounding whether desogestrel and gestodene carry a greater risk of thromboembolism than levonorgestrel. Modifiable risk factors for venous thromboembolism include hemostatic disorders, especially factor V Leiden, and possibly obesity. Cigarette smoking is not a significant risk factor in oral contraceptive users. With the exception of avoiding oral contraceptive use among women with a either a personal history of venous thromboembolism or a strong family history (until evaluated for hemostatic abnormalities), and perhaps limiting the use of desogestrel- or gestodene-containing oral contraceptives, there is little clinicians can do to reduce the risk of this disorder.

Adult↗
PubMed2001

Enoxaparin: in the prevention of venous thromboembolism in medical patients.

Enoxaparin (enoxaparin sodium) is a low-molecular-weight heparin that binds to and increases the activity of antithrombin III. The resulting complex inhibits prothrombinase-mediated thrombin generation and direct thrombin generation by binding to factor Xa and thrombin factor IIa. Enoxaparin, used as prophylaxis in medically ill patients at increased risk for thromboembolism, has shown significantly increased efficacy compared with placebo in reducing the incidence of deep vein thrombosis and pulmonary embolism. Indeed, 291 patients receiving subcutaneous enoxaparin 40 mg/day had a frequency of venous thromboembolism of 5.5% during 14 days of treatment, whereas 14.9% of the 288 placebo recipients experienced thromboemboli (p < 0.001). There was no reduction in the incidence of thromboembolism in the 287 recipients of enoxaparin 20 mg/day (15%). In other studies, prophylactic treatment for 7 days with subcutaneous enoxaparin 40 mg/day was at least as effective as unfractionated heparin in reducing the frequency of venous thromboembolism in 959 nonsurgical patients at increased risk for deep vein thrombosis and pulmonary embolism (total incidence = 0.2 and 1.4%, respectively). Moreover, enoxaparin recipients experienced fewer adverse events than did heparin recipients. The most frequent adverse events reported in medically ill and surgical patients receiving enoxaparin 40 mg/day were hemorrhage (17.4 vs 14.3% for placebo), hematoma at injection site, anemia, fever, peripheral edema, nausea, ecchymosis and edema (unspecified site).

Anticoagulants↗