Antiplatelet agents for the treatment of deep venous thrombosis

Angioplasty or stenting for deep venous thrombosis

BACKGROUND

The best medical treatment (BMT) for treating deep venous thrombosis (DVT) includes anticoagulation and compression stockings. Angioplasty and stenting restore vessel patency and facilitate blood flow. In some people with DVT, angioplasty or stenting is used to minimise complications such as post-thrombotic syndrome (PTS), but their effects are under discussion.

OBJECTIVES

To assess the effects of adjunctive angioplasty or stenting on a background treatment of anticoagulation and thrombolysis, compared with BMT, sham procedure, thrombolysis, or any combination of these treatments, in people with DVT.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, LILACS, IBECS, CINAHL, and AMED databases, as well as the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers, to 20 April 2023. We checked the bibliographies of included trials for further references to relevant trials and contacted specialists in the field, manufacturers, and authors of the included trials for any unpublished data.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing angioplasty or stenting on a background treatment of anticoagulation and thrombolysis, compared with BMT, sham procedure, thrombolysis, or any combination of these treatments, in the management of people with acute obstruction due to DVT. We excluded participants who had a baseline PTS diagnosis or who had received any form of mechanical thrombectomy, as this was investigated in a separate Cochrane review.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. The primary outcomes were PTS and venous thromboembolism (VTE); secondary outcomes were mortality, major bleeding, secondary patency, duration of hospitalisation, quality of life (QoL), and adverse events. We used the Cochrane RoB 1 tool to assess the risk of bias for RCTs and GRADE to assess the certainty of evidence. We performed meta-analysis where appropriate.

MAIN RESULTS

We included two RCTs (134 participants) that were conducted in China and presented comparisons for acute obstruction after DVT based on length of follow-up (12 months (early), 24 months (intermediate), and 36 months (long term)). Angioplasty or stenting plus BMT and thrombolysis versus BMT and thrombolysis for acute obstruction due to DVT (intermediate time point) In the intermediate time point, angioplasty or stenting may have little to no effect on PTS (Venous Clinical Severity Score (VCSS): mean difference (MD) -3.21, 95% confidence interval (CI) -7.74 to 1.33; 2 studies, 133 participants; very low-certainty evidence) and adverse events (limb pain) (risk ratio (RR) 0.68, 95% CI 0.04 to 10.33; 1 study, 67 participants; very low-certainty evidence), but the evidence is very uncertain. Angioplasty or stenting may increase secondary patency (RR 0.26, 95% CI 0.11 to 0.59; 2 studies, 133 participants; very low-certainty evidence), but the evidence is very uncertain. The evidence is very uncertain about the effect of angioplasty or stenting on quality of life (MD 10.54, 95% CI -1.34 to 22.41; 2 studies, 133 participants; very low-certainty evidence), and is not estimable for VTE, mortality, or major bleeding. We downgraded the certainty of evidence for all reported outcomes in this comparison by two levels due to serious study limitations (risk of performance and other bias), and another level for imprecision (small numbers of events and participants). The imbalance between study group size and different vein access may also have contributed to the high heterogeneity seen in the analyses of these outcomes. We downgraded the certainty of evidence for PTS and quality of life by one level for inconsistency (no similarity of point estimates in any of the included studies, no overlap of CIs, and considerable heterogeneity in results). There is an additional difficulty with blinding personnel in this type of intervention, but the trialists should have reported blinding of outcome assessment.

AUTHORS' CONCLUSIONS

Although angioplasty or stenting may increase secondary patency in people with acute obstruction due to DVT, the evidence is very uncertain; the evidence is also very uncertain about the effect of angioplasty or stenting on PTS, quality of life, and adverse events in people with acute obstruction due to DVT. The effects on VTE, mortality, and major bleeding were not estimable or not assessed by the included studies. Future trials must be large enough to detect significant clinical outcomes, and provide data on original stenosis before angioplasty or stenting and differing times from the initial event, among other essential characteristics.

Luteolin inhibits GPVI-mediated platelet activation, oxidative stress, and thrombosis

Introduction: Luteolin inhibits platelet activation and thrombus formation, but the mechanisms are unclear. This study investigated the effects of luteolin on GPVI-mediated platelet activation in vitro and explored the effect of luteolin on thrombosis, coagulation, and platelet production in vivo. Methods: Washed human platelets were used for aggregation, membrane protein expression, ATP, Ca2+, and LDH release, platelet adhesion/spreading, and clot retraction experiments. Washed human platelets were used to detect collagen and convulxin-induced reactive oxygen species production and endogenous antioxidant effects. C57BL/6 male mice were used for ferric chloride-induced mesenteric thrombosis, collagen-epinephrine induced acute pulmonary embolism, tail bleeding, coagulation function, and luteolin toxicity experiments. The interaction between luteolin and GPVI was analyzed using solid phase binding assay and surface plasmon resonance (SPR). Results: Luteolin inhibited collagen- and convulxin-mediated platelet aggregation, adhesion, and release. Luteolin inhibited collagen- and convulxin-induced platelet ROS production and increased platelet endogenous antioxidant capacity. Luteolin reduced convulxin-induced activation of ITAM and MAPK signaling molecules. Molecular docking simulation showed that luteolin forms hydrogen bonds with GPVI. The solid phase binding assay showed that luteolin inhibited the interaction between collagen and GPVI. Surface plasmon resonance showed that luteolin bonded GPVI. Luteolin inhibited integrin αIIbβ3-mediated platelet activation. Luteolin inhibited mesenteric artery thrombosis and collagen- adrenergic-induced pulmonary thrombosis in mice. Luteolin decreased oxidative stress in vivo. Luteolin did not affect coagulation, hemostasis, or platelet production in mice. Discussion: Luteolin may be an effective and safe antiplatelet agent target for GPVI. A new mechanism (decreased oxidative stress) for the anti-platelet activity of luteolin has been identified.

Photosensitive Peptide Enabling Molecular Recognition Tandem Covalent Biosensing for Evaluating and Preventing Venous Thromboembolism in Dravet Syndrome

Venous thromboembolism (VTE) is a complication of Dravet syndrome, accounting for many unexpected deaths. To control VTE more tightly and to prevent such tragedies, a reliable and low-cost risk evaluation assay is urgently needed, so that the daily routine of VTE risk evaluation can be established. In this work, we have developed such an assay combining the photocatalytic activity of Bengal red to trigger the target-specific self-splicing of a peptide probe and subsequent cross-linking with P-selectin. Following this protocol, a robust and one-step detection can be achieved, without using any costly enzymes, antibodies, or nanomaterials, but the same level of sensitivity and robustness can be attained. Specifically, the effect of epilepsy on elevating platelet P-selectin can be observed by using the proposed assay. This may in the near future promise a new method for evaluating the side effects of P-selectin through relatively noninvasive peripheral blood sampling.

Prophylactic anticoagulants for non-hospitalised people with COVID-19

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has impacted healthcare systems worldwide. Multiple reports on thromboembolic complications related to COVID-19 have been published, and researchers have described that people with COVID-19 are at high risk for developing venous thromboembolism (VTE). Anticoagulants have been used as pharmacological interventions to prevent arterial and venous thrombosis, and their use in the outpatient setting could potentially reduce the prevalence of vascular thrombosis and associated mortality in people with COVID-19. However, even lower doses used for a prophylactic purpose may result in adverse events such as bleeding. It is important to consider the evidence for anticoagulant use in non-hospitalised people with COVID-19.

OBJECTIVES

To evaluate the benefits and harms of prophylactic anticoagulants versus active comparators, placebo or no intervention, or non-pharmacological interventions in non-hospitalised people with COVID-19.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 18 April 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing prophylactic anticoagulants with placebo or no treatment, another active comparator, or non-pharmacological interventions in non-hospitalised people with COVID-19. We included studies that compared anticoagulants with a different dose of the same anticoagulant. We excluded studies with a duration of under two weeks.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. Our primary outcomes were all-cause mortality, VTE (deep vein thrombosis (DVT) or pulmonary embolism (PE)), and major bleeding. Our secondary outcomes were DVT, PE, need for hospitalisation, minor bleeding, adverse events, and quality of life. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included five RCTs with up to 90 days of follow-up (short term). Data were available for meta-analysis from 1777 participants. Anticoagulant compared to placebo or no treatment Five studies compared anticoagulants with placebo or no treatment and provided data for three of our outcomes of interest (all-cause mortality, major bleeding, and adverse events). The evidence suggests that prophylactic anticoagulants may lead to little or no difference in all-cause mortality (risk ratio (RR) 0.36, 95% confidence interval (CI) 0.04 to 3.61; 5 studies; 1777 participants; low-certainty evidence) and probably reduce VTE from 3% in the placebo group to 1% in the anticoagulant group (RR 0.36, 95% CI 0.16 to 0.85; 4 studies; 1259 participants; number needed to treat for an additional beneficial outcome (NNTB) = 50; moderate-certainty evidence). There may be little to no difference in major bleeding (RR 0.36, 95% CI 0.01 to 8.78; 5 studies; 1777 participants; low-certainty evidence). Anticoagulants probably result in little or no difference in DVT (RR 1.02, 95% CI 0.30 to 3.46; 3 studies; 1009 participants; moderate-certainty evidence), but probably reduce the risk of PE from 2.7% in the placebo group to 0.7% in the anticoagulant group (RR 0.25, 95% CI 0.08 to 0.79; 3 studies; 1009 participants; NNTB 50; moderate-certainty evidence). Anticoagulants probably lead to little or no difference in reducing hospitalisation (RR 1.01, 95% CI 0.59 to 1.75; 4 studies; 1459 participants; moderate-certainty evidence) and may lead to little or no difference in adverse events (minor bleeding, RR 2.46, 95% CI 0.90 to 6.72; 5 studies, 1777 participants; low-certainty evidence). Anticoagulant compared to a different dose of the same anticoagulant One study compared anticoagulant (higher-dose apixaban) with a different (standard) dose of the same anticoagulant and reported five relevant outcomes. No cases of all-cause mortality, VTE, or major bleeding occurred in either group during the 45-day follow-up (moderate-certainty evidence). Higher-dose apixaban compared to standard-dose apixaban may lead to little or no difference in reducing the need for hospitalisation (RR 1.89, 95% CI 0.17 to 20.58; 1 study; 278 participants; low-certainty evidence) or in the number of adverse events (minor bleeding, RR 0.47, 95% CI 0.09 to 2.54; 1 study; 278 participants; low-certainty evidence). Anticoagulant compared to antiplatelet agent One study compared anticoagulant (apixaban) with antiplatelet agent (aspirin) and reported five relevant outcomes. No cases of all-cause mortality or major bleeding occurred during the 45-day follow-up (moderate-certainty evidence). Apixaban may lead to little or no difference in VTE (RR 0.36, 95% CI 0.01 to 8.65; 1 study; 279 participants; low-certainty evidence), need for hospitalisation (RR 3.20, 95% CI 0.13 to 77.85; 1 study; 279 participants; low-certainty evidence), or adverse events (minor bleeding, RR 2.13, 95% CI 0.40 to 11.46; 1 study; 279 participants; low-certainty evidence). No included studies reported on quality of life or investigated anticoagulants compared to a different anticoagulant, or anticoagulants compared to non-pharmacological interventions.

AUTHORS' CONCLUSIONS

We found low- to moderate-certainty evidence from five RCTs that prophylactic anticoagulants result in little or no difference in major bleeding, DVT, need for hospitalisation, or adverse events when compared with placebo or no treatment in non-hospitalised people with COVID-19. Low-certainty evidence indicates that prophylactic anticoagulants may result in little or no difference in all-cause mortality when compared with placebo or no treatment, but moderate-certainty evidence indicates that prophylactic anticoagulants probably reduce the incidence of VTE and PE. Low-certainty evidence suggests that comparing different doses of the same prophylactic anticoagulant may result in little or no difference in need for hospitalisation or adverse events. Prophylactic anticoagulants may result in little or no difference in risk of VTE, hospitalisation, or adverse events when compared with antiplatelet agents (low-certainty evidence). Given that there were only short-term data from one study, these results should be interpreted with caution. Additional trials of sufficient duration are needed to clearly determine any effect on clinical outcomes.

Should we add antiplatelet agents to current deep venous thrombosis treatments? A Cochrane Review summary with commentary

BACKGROUND

Venous thromboembolism (VTE) is an important complication in rehabilitation practice despite preventive measures. The management can be complicated because patients may have co-existing cardiovascular comorbidities.

OBJECTIVE

To assess the effects of antiplatelet agents in addition to current best medical practice (BMP) compared to current BMP (with or without placebo) for the treatment of deep venous thrombosis (DVT).

METHODS

A summary of the Cochrane Review by Flumignan et al. (2022), with comments from a rehabilitation perspective.

RESULTS

The review included six studies with 1625 eligible participants, with data up to 37.2 months of follow-up. When used after standard initial treatment with anticoagulants, antiplatelet agents such as aspirin in addition to BMP, may reduce recurrence of DVT or pulmonary embolism, when compared to BMP plus placebo in a chronic DVT setting and there may be a lower risk for post-thrombotic syndrome in patients with acute DVT. There is no clear difference in side effects, major bleeding, or pulmonary embolism (PE) with the use of antiplatelet agents.

CONCLUSION

Adding antiplatelet agents to standard anticoagulation treatment in patients with VTE could provide benefit without increasing risks in selected patient groups. However, high quality studies with a long-term follow up are needed, including patients in rehabilitation settings.

Pharmacological interventions for preventing venous thromboembolism in people undergoing bariatric surgery

BACKGROUND

Venous thromboembolism (VTE), which comprises deep vein thrombosis (DVT) and pulmonary embolism (PE), is the leading cause of preventable death in hospitalised people and the third most common cause of mortality in surgical patients. People undergoing bariatric surgery have the additional risk factor of being overweight. Although VTE prophylaxis in surgical patients is well established, the best way to prevent VTE in those undergoing bariatric surgery is less clear.

OBJECTIVES

To evaluate the benefits and harms of pharmacological interventions (alone or in combination) on venous thromboembolism and other health outcomes in people undergoing bariatric surgery compared to the same pharmacological intervention administered at a different dose or frequency, the same pharmacological intervention or started at a different time point, another pharmacological intervention, no intervention or placebo.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 1 November 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs in males and females of any age undergoing bariatric surgery comparing pharmacological interventions for VTE (alone or in combination) with the same pharmacological intervention administered at a different dose or frequency, the same pharmacological intervention started at a different time point, a different pharmacological intervention, no treatment or placebo.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. VTE and 2. major bleeding. Our secondary outcomes were 1. all-cause mortality, 2. VTE-related mortality, 3. PE, 4. DVT, 5. adverse effects and 6. quality of life. We used GRADE to assess certainty of evidence for each outcome.

MAIN RESULTS

We included seven RCTs with 1045 participants. Data for meta-analysis were available from all participants. Four RCTs (597 participants) compared higher-dose heparin to standard-dose heparin: one of these studies (139 participants) used unfractionated heparin (UFH) and the other three (458 participants) used low-molecular-weight heparin (LMWH). One study compared heparin versus pentasaccharide (198 participants), and one study compared starting heparin before versus after bariatric surgery (100 participants). One study (150 participants) compared combined mechanical and pharmacological (enoxaparin) prophylaxis versus mechanical prophylaxis alone. The duration of the interventions ranged from seven to 15 days, and follow-up ranged from 10 to 180 days. Higher-dose heparin versus standard-dose heparin Compared to standard-dose heparin, higher-dose heparin may result in little or no difference in the risk of VTE (RR 0.55, 95% CI 0.05 to 5.99; 4 studies, 597 participants) or major bleeding (RR 1.19, 95% CI 0.48 to 2.96; I2 = 8%; 4 studies, 597 participants; low-certainty) in people undergoing bariatric surgery. The evidence on all-cause mortality, VTE-related mortality, PE, DVT and adverse events (thrombocytopenia) is uncertain (effect not estimable or very low-certainty evidence). Heparin versus pentasaccharide Heparin compared to a pentasaccharide after bariatric surgery may result in little or no difference in the risk of VTE (RR 0.83, 95% CI 0.19 to 3.61; 1 study, 175 participants) or DVT (RR 0.83, 95% CI 0.19 to 3.61; 1 study, 175 participants). The evidence on major bleeding, PE and mortality is uncertain (effect not estimable or very low-certainty evidence). Heparin started before versus after the surgical procedure Starting prophylaxis with heparin 12 hours before surgery versus after surgery may result in little or no difference in the risk of VTE (RR 0.11, 95% CI 0.01 to 2.01; 1 study, 100 participants) or DVT (RR 0.11, 95% CI 0.01 to 2.01; 1 study, 100 participants). The evidence on major bleeding, all-cause mortality and VTE-related mortality is uncertain (effect not estimable or very low-certainty evidence). We were unable to assess the effect of this intervention on PE or adverse effects, as the study did not measure these outcomes. Combined mechanical and pharmacological prophylaxis versus mechanical prophylaxis alone Combining mechanical and pharmacological prophylaxis (started 12 hours before surgery) may reduce VTE events in people undergoing bariatric surgery compared to mechanical prophylaxis alone (RR 0.05, 95% CI 0.00 to 0.89; number needed to treat for an additional beneficial outcome (NNTB) = 9; 1 study, 150 participants; low-certainty). We were unable to assess the effect of this intervention on major bleeding or morality (effect not estimable), or on PE or adverse events (not measured). No studies measured quality of life.

AUTHORS' CONCLUSIONS

Higher-dose heparin may make little or no difference to venous thromboembolism or major bleeding in people undergoing bariatric surgery when compared to standard-dose heparin. Heparin may make little or no difference to venous thromboembolism in people undergoing bariatric surgery when compared to pentasaccharide. There are inadequate data to draw conclusions about the effects of heparin compared to pentasaccharide on major bleeding. Starting prophylaxis with heparin 12 hours before bariatric surgery may make little or no difference to venous thromboembolism in people undergoing bariatric surgery when compared to starting heparin after bariatric surgery. There are inadequate data to draw conclusions about the effects of heparin started before versus after surgery on major bleeding. Combining mechanical and pharmacological prophylaxis (started 12 hours before surgery) may reduce VTE events in people undergoing bariatric surgery when compared to mechanical prophylaxis alone. No data are available relating to major bleeding. The certainty of the evidence is limited by small sample sizes, few or no events, and risk of bias concerns. Future trials must be sufficiently large to enable analysis of relevant clinical outcomes, and should standardise the time of treatment and follow-up. They should also address the effect of direct oral anticoagulants and antiplatelets, preferably grouping them according to the type of intervention.