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PubMed1999

Outpatient management of venous thromboembolism.

Low molecular weight heparins (LMWHs) have provided the necessary pharmacologic tool to facilitate the outpatient management of selected patients presenting with acute venous thromboembolism. A growing collection of clinical trial results supports the safety and efficacy of this cost-efficient management strategy. However, this approach requires careful patient selection and meticulous care planning. Several randomized multicenter trials have compared a primarily outpatient approach to treating uncomplicated proximal venous thrombosis with a LMWH administered subcutaneously once or twice daily to the inpatient use of unfractionated heparin (UFH). The results have been very encouraging and suggest that the use of subcutaneous LMWH in highly selected, uncomplicated venous thrombosis patients is as safe and effective as intravenous UFH, and that most patients can be treated as outpatient or be discharged early. Irrespective of parenteral anticoagulant approach, warfarin therapy was commenced on day 1 and continued for 3 months. A recent publication by Dedden and colleagues describes a 1-year experience with a pharmacy-managed program for the home treatment of patients presenting with proximal deep vein thrombosis. A plan for coordinated patient care was implemented which included a process for patient referrals, standardized protocol orders, a plan for holding area processing and home healthcare agency follow-up, and subsequent oral anticoagulation management. Results of the program demonstrate a significant healthcare savings (as compared with standard inpatient management) with no significant compromise in patient outcomes. Recently published trials by the Columbus Investigators and Simonneau and colleagues have looked beyond uncomplicated proximal venous thromboembolism to include patients presenting with recurrent venous thrombosis and pulmonary embolism. Results suggest the subcutaneous use of LMWH is as safe and effective as intravenous UFH. Such data begin to lay the scientific foundation for the expanded clinical base of patients who may be candidates for an outpatient management approach. In today's cost-conscience environment, managing the treatment of select venous thromboembolism patients with LMWH(s) and warfarin therapy in an outpatient environment represents an evolving approach that is economically logical, does not compromise patient outcomes, but requires considerable planning to address a myriad of logistical issues.

Fibrinolytic Agents↗
PubMed2000

Low-molecular-weight heparin in the treatment of venous thromboembolism.

The low-molecular-weight heparins (LMWHs) have been evaluated in the prevention and treatment of deep-vein thrombosis and pulmonary embolism. LMWHs have been found to be safe and effective in this clinical setting and have advantages over unfractionated heparin. These advantages include less serious and less frequent therapeutic complications. The favorable pharmacokinetic profile of LMWHs compared with heparin has allowed for safe, effective, and convenient treatment of patients with venous thromboembolism. Use of LMWHs ultimately results in considerable cost savings for the health care system.

Antifibrinolytic Agents↗
PubMed2002

Decrease in sensitivity of D-dimer for acute venous thromboembolism after starting anticoagulant therapy.

D-dimer testing is useful for the exclusion of acute venous thromboembolism (VTE). Anticoagulant therapy is expected to reduce D-dimer levels in patients with thrombosis and, consequently, it may not be safe to use D-dimer levels to exclude VTE after anticoagulant therapy has been started. The objectives of this study were to estimate the decrease in D-dimer levels after 24 h of heparin therapy and, applying this estimate to the results of a recent study, to calculate the expected reduction in sensitivity. Using pre-defined criteria, we first performed a literature review to determine whether, and by how much, D-dimer levels decrease within 24 h of starting heparin therapy in patients with acute VTE. Using D-dimer levels that were measured in a prospective study of patients with confirmed deep vein thrombosis and/or pulmonary embolism as baselines, we then determined the change in sensitivity (and specificity) that would result from the fall in D-dimer levels that the literature review suggested would have occurred after 24 h of heparin therapy. On the basis of the literature review, we calculated that mean D-dimer levels decrease by 25%, 24 h after starting heparin therapy in patients with acute VTE. This 25% decrease in D-dimer levels resulted in a decrease in sensitivity from 95.6% (95% confidence interval, 90.0-98.6) to 89.4% (95% confidence interval, 83.7-95.1). There is a decrease in D-dimer levels in patients with acute VTE 24 h after starting heparin therapy that is expected to result in a clinically important drop in sensitivity.

Adult↗
PubMed2001

Missed opportunities for prevention of venous thromboembolism: an evaluation of the use of thromboprophylaxis guidelines.

OBJECTIVES: To identify and characterize cases of potentially preventable venous thromboembolism (VTE): cases for which thromboprophylaxis was indicated, according to the American College of Chest Physicians (ACCP) consensus guidelines for VTE prevention, yet was administered inadequately. DESIGN: A historical cohort study to examine all cases of deep vein thrombosis and pulmonary embolism from 1996 to 1997 at a large teaching hospital. Of these, we determined the proportion that was potentially preventable. We examined the reasons for inadequacy of prophylaxis and the setting in which preventable VTE occurred. RESULTS: Of 253 objectively diagnosed cases of VTE in 245 patients, 44 cases (17.4%) were considered potentially preventable. This represented two thirds of all VTE cases for which thromboprophylaxis had been indicated (n = 65). Of preventable cases, the most frequent reason for inadequacy of prophylaxis was omission of prophylaxis (47.7%), followed by inadequate duration of prophylaxis (22.7%), and by incorrect type of prophylaxis (20.5%). Surgical and medical indications for thromboprophylaxis that were common among preventable cases included nonorthopedic surgery, admission to hospital for pneumonia, and stroke with lower limb paralysis. Underlying risk factors for VTE that were common among preventable cases included recent immobility, active cancer, and obesity. CONCLUSIONS: One of six cases of all VTE and two of three cases of VTE for which thromboprophylaxis had been indicated could potentially have been prevented had physicians followed the recommended ACCP guidelines. Inadequacy of prophylaxis was most often caused by omission of prophylaxis. Missed opportunities for prevention occurred most commonly in the settings of nonorthopedic surgery, pneumonia, and stroke.

Aged↗
PubMed2000

Postmenopausal hormone therapy increases risk for venous thromboembolic disease. The Heart and Estrogen/progestin Replacement Study.

BACKGROUND: Oral contraceptive use increases risk for venous thromboembolism, but data on the effect of postmenopausal hormone therapy are limited. OBJECTIVE: To determine the effect of therapy with estrogen plus progestin on risk for venous thromboembolic events in postmenopausal women. DESIGN: Randomized, double-blind, placebo-controlled trial. SETTING: 20 clinical centers in the United States. PARTICIPANTS: 2763 postmenopausal women younger than 80 years of age (mean age, 67 years) who had coronary heart disease but no previous venous thromboembolism and had not had a hysterectomy. INTERVENTION: Conjugated equine estrogens, 0.625 mg, plus medroxyprogesterone acetate, 2.5 mg, in one tablet (n = 1380) or placebo that was identical in appearance (n = 1383). MEASUREMENTS: Documented deep venous thrombosis or pulmonary embolism. RESULTS: During an average of 4.1 years of follow-up, 34 women in the hormone therapy group and 13 in the placebo group experienced venous thromboembolic events (relative hazard, 2.7 [95% CI, 1.4 to 5.0] [P = 0.003]; excess risk, 3.9 per 1000 woman-years [CI, 1.4 to 6.4 per 1000 woman-years]; number needed to treat for harm, 256 [CI, 157 to 692]). In multivariate analysis, the risk for venous thromboembolism was increased among women who had lower-extremity fractures (relative hazard, 18.1 [CI, 5.4 to 60.4]) or cancer (relative hazard, 3.9 [CI, 1.6 to 9.4]) and for 90 days after inpatient surgery (relative hazard, 4.9 [CI, 2.4 to 9.8]) or nonsurgical hospitalization (relative hazard, 5.7 [CI, 3.0 to 10.8]). Risk was decreased with aspirin (relative hazard, 0.5 [CI, 0.2 to 0.8]) or statin use (relative hazard, 0.5 [CI, 0.2 to 0.9]). CONCLUSIONS: Postmenopausal therapy with estrogen plus progestin increases risk for venous thromboembolism in women with coronary heart disease. This risk should be considered when the risks and benefits of therapy are being weighed.

Aged↗
PubMed2001

Clinical trials that have influenced the treatment of venous thromboembolism: a historical perspective.

In 1960, Barritt and Jordan performed the first randomized trial demonstrating the efficacy of anticoagulant therapy in the treatment of venous thromboembolism. Since then, important therapeutic advances have been made in the treatment of deep venous thrombosis and pulmonary embolism. This paper reviews the important clinical trials involving anticoagulant therapy and vena caval interruption. The studies are discussed from a historical perspective, and an attempt is made to analyze both the thought processes that prompted their design and the reasons why they changed practice.

Anticoagulants↗
PubMed2003

[Venous thrombosis and thrombophilic management of prevention and therapy].

Cardiovascular disease, to which venous thrombosis and pulmonary embolism contribute a major part, are the leading cause of death in industrialized countries. Thrombosis is caused by temporary risk factors or by thrombophilia. Increasing knowledge concerning the pathophysiology of thrombosis and new diagnostic tools allow a thrombotic risk assessment. In this paper thrombotic risk factors will be discussed with respect to their significance and diagnosis as well as methods of prophylaxis and treatment for patients at risk for or with diagnosed thrombosis. Furthermore, currently available as well as new anticoagulants (pentasaccharide, melagatran) will be discussed and their potential for patient-oriented and cost-efficient prophylaxis and treatment of thromboembolic complications outlined.

Enoxaparin↗
PubMed2006

Technique of anaesthesia in pulmonary hypertension and thrombophilia in early pregnancy.

Pulmonary hypertension in pregnancy is a rare condition but is associated with a high mortality. We report the case of a 29 year old female in early pregnancy with Protein C and S deficiency with recurrent deep venous thrombosis and pulmonary embolism and subsequent secondary pulmonary hypertension. The patient was counselled and consented for termination of pregnancy with tubal sterilization. She was administered continuous spinal anaesthesia with invasive monitoring. The successful anaesthetic management of this condition is described.

Abortion, Therapeutic↗
PubMed2006

Mid-term experience with the ALN retrievable inferior vena cava filter.

OBJECTIVE: To report the mid-term results of 63 patients who received a new commercially-available retrievable vena cava filter, ALN. METHODS: Between January 2001 and October 2005, 63 patients (mean age 65 +/- 15 years) underwent placement of ALN filters. Filter removal was performed when anti-thrombotic prophylaxis was considered unnecessary or when the patient could safely resume full anticoagulant therapy. RESULTS: Thirty-five patients (55%) had ilio-femoral venous thrombosis and 28 patients (45%) had ilio-caval thrombosis. Overall, 49% had pulmonary embolism. Technical success for filter insertion was 100%, without any complications. None of the procedures aborted or was converted due to technical difficulties. After a median follow-up of 21-months (range 1-48, median 18), there were no cases of pulmonary embolism or vena cava thrombosis. Two patients died of a cause unrelated to deep venous thrombosis during the follow-up period, without clinical evidence of pulmonary embolism or filter-associated complications. No device migration was observed. There were 20 (31.7%) retrieval attempts: in 16 cases filters were retrieved successfully, but 4 cases were aborted. The mean implantation period of the retrieved filter was 179 days (range 53-370). CONCLUSION: Our results confirm the clinical efficacy of the ALN filter for preventing potentially fatal pulmonary embolism whilst implanted and in absence of post-insertion complications, even when left in place indefinitely.

Adult↗
PubMed2004

[Acute thromboembolism].

The diagnosis of acute pulmonary embolism is based on the assessment of risk factors, consistent symptoms and signs, and the lack of an alternative clinical explanation for the condition of the patient. If the probability of pulmonary embolism is low or intermediate, the diagnosis can be reliably excluded by a negative D-dimer test. A positive D-dimer test requires further evaluation by spiral angio computed tomography technique to confirm or rule out pulmonary embolism. The angiocoexisting pulmonary diseases. If the clinical probability for pulmonary embolism is high an angio-CT rather then a D-dimer should be performed at the first place. If there are signs of deep leg vein thrombosis, massive pulmonary embolism with hemodynamic instability and in other special circumstances the diagnostic approach has to be adapted accordingly. A timely diagnosis and treatment with heparin and oral anticoagulation significantly reduces the acute and chronic morbidity and mortality of pulmonary embolism.

Acute Disease↗
PubMed2006

Venous thromboembolism: scope of the problem and the nurse's role in risk assessment and prevention.

Deep vein thrombosis and pulmonary embolism, comprising different manifestations of the same clinical entity referred to as venous thromboembolism, are a significant cause of morbidity and mortality. Despite pulmonary embolism being considered the most preventable cause of in-hospital death, the use of appropriate thromboprophylaxis remains suboptimal in many patients. Nurses are on the frontline of thrombosis prevention. By playing an essential role in diagnosis and risk assessment, applying timely preventive methods, and providing vital educational and psychologic support for patients with venous thromboembolism, skilled nursing intervention can save lives.

Humans↗
PubMed2006

Racial and gender differences in the incidence of recurrent venous thromboembolism.

Men have been reported to have a higher incidence of recurrent venous thromboembolism than women. However, it is not known if this gender effect holds among different racial/ethnic groups and for both venous thrombosis and pulmonary embolism. We conducted a retrospective analysis of 18- to 65-year-old Caucasian, African-American and Hispanic cases hospitalized in California with unprovoked venous thromboembolism. The principal outcome was recurrent venous thromboembolism 7-60 months after the index event. Among 11,514 cases that were followed for a mean of 3.0 years, men had a significantly higher rate (events/100 patient-years) of recurrent venous thromboembolism than women for both venous thrombosis [rate ratio (RR) = 1.5, 95% confidence interval (CI):1.3-1.8] and pulmonary embolism [RR = 1.3, 95%CI:1.0-1.6]. Among men the recurrence rate did not vary significantly between the racial/ethnic groups (p > 0.05). However, the recurrence rate among Hispanic women with venous thrombosis was significantly higher than in Caucasian women (p < 0.001) and was comparable to the rate in men. Both Hispanic and African-American women with pulmonary embolism had a higher recurrence rate compared with Caucasian women (p < 0.02) that was comparable to the rate in men. We conclude that women in California had a 40% lower risk of recurrent venous thromboembolism compared to men. Rates were comparable among men of different races, but there were significant inter-racial differences among women, which also varied with the type of initial event. The effect of gender on the risk of recurrent venous thromboembolism can not be generalized because it varies between racial/ethnic groups and with the type of index event.

Adolescent↗
PubMed2002

Computerized management of oral anticoagulant therapy: experience in major joint arthroplasty.

OBJECTIVE: Evaluation of the safety and potential cost savings of a computerized, laboratory-based program to manage inpatient warfarin thromboprophylaxis after major joint arthroplasty. DESIGN: A consecutive-case study of adults. SETTING: A tertiary care orthopedic institution. PATIENTS: Patients requiring joint arthroplasty who had no recent episodes of thromboembolic disease, no mechanical heart valve, atrial fibrillation, severe liver disease or baseline international normalized ratio [INR] greater than 1.3 admitted over a 54-month period (July 1994-December 1998). All patients received a standard regimen of warfarin beginning on the evening after the operation. Four hundred and thirty randomly selected patients managed by the program were followed up by telephone survey 3 months after discharge. Patients exhibiting erratic responses to warfarin were withdrawn from the program and managed individually thereafter. INTERVENTION: Major joint arthroplasty with warfarin therapy administered through the computerized program. MAIN OUTCOME MEASURES: Test results maintained within the desired therapeutic range (INR 2.0-3.0), clinically severe bleeding episodes, readmission rates, clinically symptomatic and venographically proven episodes of venous thrombosis or pulmonary embolism. RESULTS: Over the study period 5629 patients underwent joint arthroplasty; 5,372 patients were considered for the program; 332 patients were ineligible and were managed individually; 311 entered patients did not complete the program. This left 4,729 patients who completed the program. In 2932 (62%) patients test results were maintained in the desired therapeutic range. The major bleeding rate was less than 0.5%, the readmission rate was 3.8%, the deep venous thrombosis rate was 3.7% and the pulmonary embolism rate was 0.2% with no thromboembolic related deaths in the small sample cohort. CONCLUSIONS: The majority of patients requiring warfarin thromboprophylaxis can be safely and effectively managed by this laboratory-based computerized program while in hospital. Significant potential cost savings in nursing time could be achieved.

Anticoagulants↗
PubMedDate not supplied

Venous thrombosis after acute spinal cord injury: cost analysis of prophylaxis guidelines.

OBJECTIVE: Venous thrombosis and pulmonary embolisms are major complications associated with acute spinal cord injury. The purpose of this study was to perform a cost analysis on the two pharmacoprophylaxis regimens suggested for deep vein thrombosis prophylaxis in this population. METHODS: Efficacy and safety data were obtained from the literature. RESULTS: Results of the cost analysis demonstrates that adjusted dose unfractionated heparin produces a cost savings over enoxaparin at 30 mg every 12 hr. CONCLUSION: Further studies are needed to determine the most cost-effective therapy for preventing deep vein thrombi in this population.

Anticoagulants↗
PubMed1999

Placement of a spring filter during interventional treatment of deep venous thrombosis to reduce the risk of pulmonary embolism.

PURPOSE: To assess the efficacy of the Spring filter during interventional treatment of deep venous thrombosis in vivo. MATERIAL AND METHODS: A model of inferior vena cava thrombosis was used. Part I: The thrombus was treated by the pulse-spray technique (PT) (urokinase 250,000 IU; n=7) or a rotatory basket catheter, Thrombolizer (MT) (activated with compressed air at 7 atm; n=5). Part II: Following placement of a Spring filter, the animal underwent PT (n=5) or MT (n=5). Based on the results of part I, the treatment protocol was modified (PT, urokinase 500,000 IU; MT, compressed air at 8 atm). Embolus volumes trapped by the filter and found in the lungs were calculated and the filtering efficacy quantified. RESULTS: Part I: Pulmonary emboli (1 to 4 mm in diameter) were observed in 3 animals in the PT group and 1 animal in the MT group, respectively. Median reduction in thrombus volume was 21% and 4% by PT and MT, respectively. Part II: In the PT group, 58% and 100% of the total embolus load was trapped in 2 animals, while the filter failed to trap emboli (1 to 1.5 mm in diameter) in 1 animal. In the remaining 2 animals, no embolus was found trapped by the filter or in the lungs. In the MT group, 55 97% (median 83%) of the embolus load was trapped. Emboli found in the lungs did not exceed 4 mm in diameter. CONCLUSION: Preceding interventional treatment of venous thrombosis with placement of the Spring filter reduced the embolic burden on the lungs.

Angiography↗
PubMed2003

[D-dimers in the diagnosis of deep venous thrombosis].

D-dimers (D-d) are degeneration products of fibrin. According to some recommendations (Lee et al., Ann Rev Med, 2002; 53: 15-33) the vein thromboembolism may be excluded by the determination of D-dimers level especially when the probability of diagnosis of deep vein thrombosis is less strong. The determination of D-dimers with made possible was the development of monoclonal antibodies and their detection is based on the determination using the principle of ELISA or agglutination techniques. An increased D-d level is not completely specific for venous thrombo-embolism; it may be enhanced during tumorous diseases, infections, kidney failure etc. In contrast, a negative result of the test is highly sensitive for exclusion of deep vein thrombosis or pulmonary embolism (sensitivity 90% to 100%). The authors also present their own results of a prospective study on the dynamism of D-dimer level in plasma of patients with deep vein thrombosis demonstrated by sonography at the time of start and in the course of the anticoagulant therapy. D-dimers were determined by two methods, the quantitative agglutination latex method and the rapid VIDAS ELISA method. At the time of admission, an increased level was established in up to 80% of patients using the VIDAS method and in 70% using the latex method. In the period of five to seven days after the beginning of treatment the proportions were 75% and 60%, respectively, according to the method used. After six weeks, a slightly elevated level above normal may be expected in 1/3 of patients and less than in 1/5 of patients in the later months.

Biomarkers↗
PubMed2001

Genetic risk factors of venous thrombosis.

Venous thrombosis, whose main clinical presentations include deep vein thrombosis and pulmonary embolism, represents a major health problem worldwide. Numerous conditions are known to predispose to venous thrombosis and these conditions are commonly referred to as risk indicators or risk factors. Generally accepted or "classically" acquired risk factors for venous thromboembolism include advanced age, prolonged immobilisation, surgery, fractures, use of oral contraceptives and hormone replacement therapy, pregnancy, puerperium, cancer and antiphospholipid syndrome. In addition to these well-established risk factors for venous thrombosis, several lines of evidence that have emerged over the past few decades indicate a role of novel genetic risk factors, mainly related to the haemostatic system, in influencing thrombotic risk. The most significant breakthrough has been the confirmation of the concept that inherited hypercoagulable conditions are present in a large proportion of patients with venous thromboembolic disease. These include mutations in the genes that encode antithrombin, protein C and protein S, and the factor V Leiden and factor II G20210 A mutations. Moreover, plasmatic risk indicators, such as hyperhomocysteinemia and elevated concentrations of factors II, VIII, IX, XI and fibrinogen, have also been documented. This extensive list of genetic and acquired factors serves to illustrate that a single cause of venous thrombosis does not exist and that this condition should be considered as a complex or multifactorial trait. Complex traits can be understood by assuming an interaction between different mutations in candidate susceptibility genes. The risk that is associated with each genetic defect may be relatively low in isolation but the simultaneous presence of several mutations may dramatically increase disease susceptibility. Moreover, environmental factors may interact with one or more genetic variations to add further to the risk. The analysis of genetic risk factors and plasmatic factors, together with private life style and environmental factors, has contributed significantly to our understanding of the genetic predisposition to venous thrombosis.

Antithrombins↗