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Barco S, Virdone S, Götschi A, Ageno W, Arcelus JI, Bingisser R, Colucci G, Cools F, Duerschmied D, Gibbs H, Fumagalli RM, Gerber B, Haas S, Himmelreich JCL, Hobbs R, Hobohm L, Jacobson B, Kayani G, Lopes RD, MacCallum P, Micieli E, Righini M, Robert-Ebadi H, Rocha AT, Rosemann T, Sawhney J, Schellong S, Sebastian T, Spirk D, Stortecky S, Turpie AGG, Voci D, Kucher N, Pieper K, Held U, Kakkar AK. Enoxaparin for symptomatic COVID-19 managed in the ambulatory setting: An individual patient level analysis of the OVID and ETHIC trials. Thromb Res 2023; 230:27-32. [PMID: 37625200 DOI: 10.1016/j.thromres.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 08/09/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND Antithrombotic treatment may improve the disease course in non-critically ill, symptomatic COVID-19 outpatients. METHODS We performed an individual patient-level analysis of the OVID and ETHIC randomized controlled trials, which compared enoxaparin thromboprophylaxis for either 14 (OVID) or 21 days (ETHIC) vs. no thromboprophylaxis for outpatients with symptomatic COVID-19 and at least one additional risk factor. The primary efficacy outcome included all-cause hospitalization and all-cause death within 30 days from randomization. Both studies were prematurely stopped for futility. Secondary efficacy outcomes were major symptomatic venous thromboembolic events, arterial cardiovascular events, or their composite occurring within 30 days from randomization. The same outcomes were assessed over a 90-day follow-up. The primary safety outcome was major bleeding (ISTH criteria). RESULTS A total of 691 patients were randomized: 339 to receive enoxaparin and 352 to the control group. Over 30-day follow-up, the primary efficacy outcome occurred in 6.0 % of patients in the enoxaparin group vs. 5.8 % of controls for a risk ratio (RR) of 1.05 (95%CI 0.57-1.92). The incidence of major symptomatic venous thromboembolic events and arterial cardiovascular events was 0.9 % vs. 1.8 %, respectively (RR 0.52; 95%CI 0.13-2.06). Most cardiovascular thromboembolic events were represented by symptomatic venous thromboembolic events, occurring in 0.6 % vs. 1.5 % of patients, respectively. A similar distribution of outcomes between the treatment groups was observed over 90 days. No major bleeding occurred in the enoxaparin group vs. one (0.3 %) in the control group. CONCLUSIONS We found no evidence for the clinical benefit of early administration of enoxaparin thromboprophylaxis in outpatients with symptomatic COVID-19. These results should be interpreted taking into consideration the relatively low occurrence of events.
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Affiliation(s)
- Stefano Barco
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland; Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University Mainz, Germany.
| | | | - Andrea Götschi
- Department of Biostatistics at Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Switzerland
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Juan I Arcelus
- Department of Surgery, University of Granada, Granada, Spain
| | - Roland Bingisser
- Emergency Department, University Hospital Basel, Basel, Switzerland
| | - Giuseppe Colucci
- Service of Hematology, Clinica Luganese Moncucco, Lugano, Switzerland; Department of Hematology, University of Basel, Basel, Switzerland; Clinica Sant'Anna, Sorengo, Switzerland
| | - Frank Cools
- Department of Cardiology, General Hospital Klina, Brasschaat, Belgium
| | - Daniel Duerschmied
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany; European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany; Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Harry Gibbs
- Department of General Medicine, The Alfred Hospital, Melbourne, VIC, Australia
| | | | - Bernhard Gerber
- Clinic of Hematology, Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland; University of Zurich, Zurich, Switzerland
| | - Sylvia Haas
- Formerly Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Jelle C L Himmelreich
- Department of General Practice, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Richard Hobbs
- Oxford Primary Care, Radcliffe Observatory Quarter, University of Oxford, Oxford, UK; Cardiology Division, Geneva University Hospitals, Geneva, Switzerland
| | - Lukas Hobohm
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - Barry Jacobson
- Department of Haematology and Molecular Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Renato D Lopes
- Duke University Medical Center, Durham, USA; Brazilian Clinical Research Institute (BCRI), Sao Paulo, Brazil
| | - Peter MacCallum
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Evy Micieli
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Marc Righini
- Division of Angiology and Hemostasis, Department of Medicine, Geneva University Hospitals, Geneva, Switzerland; Faculty of Medicine, University of Geneva, Switzerland
| | - Helia Robert-Ebadi
- Division of Angiology and Hemostasis, Department of Medicine, Geneva University Hospitals, Geneva, Switzerland; Faculty of Medicine, University of Geneva, Switzerland
| | - Ana Thereza Rocha
- Department of Family Health, Federal University of Bahia, Salvador, Brazil; D'Or Institute for Research and Education, Rio de Janeiro, Brazil
| | - Thomas Rosemann
- Institute of Primary Care, University Hospital Zurich, Zurich, Switzerland
| | - Jitendra Sawhney
- Department of Cardiology, Sir Ganga Ram Hospital, New Delhi, India
| | - Sebastian Schellong
- Department of Internal Medicine, Municipal Hospital Dresden, Dresden, Germany
| | - Tim Sebastian
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - David Spirk
- Institute of Pharmacology, University of Bern, Bern, Switzerland
| | - Stefan Stortecky
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | | | - Davide Voci
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Nils Kucher
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | | | - Ulrike Held
- Department of Biostatistics at Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Switzerland
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Key NS, Khorana AA, Kuderer NM, Bohlke K, Lee AYY, Arcelus JI, Wong SL, Balaban EP, Flowers CR, Gates LE, Kakkar AK, Tempero MA, Gupta S, Lyman GH, Falanga A. Venous Thromboembolism Prophylaxis and Treatment in Patients With Cancer: ASCO Guideline Update. J Clin Oncol 2023; 41:3063-3071. [PMID: 37075273 DOI: 10.1200/jco.23.00294] [Citation(s) in RCA: 41] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023] Open
Abstract
PURPOSE To conduct an update of the ASCO venous thromboembolism (VTE) guideline. METHODS After publication of potentially practice-changing clinical trials, identified through ASCO's signals approach to updating, an updated systematic review was performed for two guideline questions: perioperative thromboprophylaxis and treatment of VTE. PubMed and the Cochrane Library were searched for randomized controlled trials (RCTs) published between November 1, 2018, and June 6, 2022. RESULTS Five RCTs provided information that contributed to changes to the 2019 recommendations. Two RCTs addressed direct factor Xa inhibitors (either rivaroxaban or apixaban) for extended thromboprophylaxis after surgery. Each of these postoperative trials had important limitations but suggested that these two oral anticoagulants are safe and effective in the settings studied. An additional three RCTs addressed apixaban in the setting of VTE treatment. Apixaban was effective in reducing the risk of recurrent VTE, with a low risk of major bleeding. RECOMMENDATIONS Apixaban and rivaroxaban were added as options for extended pharmacologic thromboprophylaxis after cancer surgery, with a weak strength of recommendation. Apixaban was also added as an option for the treatment of VTE, with high quality of evidence and a strong recommendation.Additional information is available at www.asco.org/supportive-care-guidelines.
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Affiliation(s)
- Nigel S Key
- University of North Carolina, Chapel Hill, NC
| | - Alok A Khorana
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Nicole M Kuderer
- Advanced Cancer Research Group and University of Washington, Seattle, WA
| | - Kari Bohlke
- American Society of Clinical Oncology, Alexandria, VA
| | - Agnes Y Y Lee
- University of British Columbia, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Juan I Arcelus
- Hospital Universitario Virgen de las Nieves, University of Granada, Granada, Spain
| | | | | | | | | | - Ajay K Kakkar
- Thrombosis Research Institute and University College, London, United Kingdom
| | - Margaret A Tempero
- University of California-San Francisco Pancreas Center, San Francisco, CA
| | | | - Gary H Lyman
- Fred Hutchinson Cancer Research Center and University of Washington, Seattle, WA
| | - Anna Falanga
- Department Medicine and Surgery, Hospital Papa Giovanni XXIII, University of Milan Bicocca, Bergamo, Italy
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Douketis JD, Spyropoulos AC, Murad MH, Arcelus JI, Dager WE, Dunn AS, Fargo RA, Levy JH, Samama CM, Shah SH, Sherwood MW, Tafur AJ, Tang LV, Moores LK. Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline. Chest 2022; 162:e207-e243. [PMID: 35964704 DOI: 10.1016/j.chest.2022.07.025] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/10/2022] [Accepted: 07/11/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The American College of Chest Physicians Clinical Practice Guideline on the Perioperative Management of Antithrombotic Therapy addresses 43 Patients-Interventions-Comparators-Outcomes (PICO) questions related to the perioperative management of patients who are receiving long-term oral anticoagulant or antiplatelet therapy and require an elective surgery/procedure. This guideline is separated into four broad categories, encompassing the management of patients who are receiving: (1) a vitamin K antagonist (VKA), mainly warfarin; (2) if receiving a VKA, the use of perioperative heparin bridging, typically with a low-molecular-weight heparin; (3) a direct oral anticoagulant (DOAC); and (4) an antiplatelet drug. METHODS Strong or conditional practice recommendations are generated based on high, moderate, low, and very low certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology for clinical practice guidelines. RESULTS A multidisciplinary panel generated 44 guideline recommendations for the perioperative management of VKAs, heparin bridging, DOACs, and antiplatelet drugs, of which two are strong recommendations: (1) against the use of heparin bridging in patients with atrial fibrillation; and (2) continuation of VKA therapy in patients having a pacemaker or internal cardiac defibrillator implantation. There are separate recommendations on the perioperative management of patients who are undergoing minor procedures, comprising dental, dermatologic, ophthalmologic, pacemaker/internal cardiac defibrillator implantation, and GI (endoscopic) procedures. CONCLUSIONS Substantial new evidence has emerged since the 2012 iteration of these guidelines, especially to inform best practices for the perioperative management of patients who are receiving a VKA and may require heparin bridging, for the perioperative management of patients who are receiving a DOAC, and for patients who are receiving one or more antiplatelet drugs. Despite this new knowledge, uncertainty remains as to best practices for the majority of perioperative management questions.
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Affiliation(s)
- James D Douketis
- Department of Medicine, St. Joseph's Healthcare Hamilton and McMaster University, Hamilton, ON, Canada.
| | - Alex C Spyropoulos
- Department of Medicine, Northwell Health at Lenox Hill Hospital, New York, NY; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; Institute of Health Systems Science at The Feinstein Institutes for Medical Research, Manhasset, NY
| | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN
| | - Juan I Arcelus
- Department of Surgery, Facultad de Medicina, University of Granada, Granada, Spain
| | - William E Dager
- Department of Pharmacy, University of California-Davis, Sacramento, CA
| | - Andrew S Dunn
- Division of Hospital Medicine, Department of Medicine, Mt. Sinai Health System, New York, NY
| | - Ramiz A Fargo
- Department of Internal Medicine, Loma Linda University Medical Center, Loma Linda, CA; Department of Internal Medicine, Riverside University Health System Medical Center, Moreno Valley, CA
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, NC
| | - C Marc Samama
- Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP, Centre-Université Paris-Cité-Cochin Hospital, Paris, France
| | - Sahrish H Shah
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN
| | | | - Alfonso J Tafur
- Department of Medicine, Cardiovascular, NorthShore University HealthSystem, Evanston, IL
| | - Liang V Tang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong, University of Science and Technology, Wuhan, China
| | - Lisa K Moores
- F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
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Douketis JD, Spyropoulos AC, Murad MH, Arcelus JI, Dager WE, Dunn AS, Fargo RA, Levy JH, Samama CM, Shah SH, Sherwood MW, Tafur AJ, Tang LV, Moores LK. Executive Summary: Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline. Chest 2022; 162:1127-1139. [PMID: 35964703 DOI: 10.1016/j.chest.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The American College of Chest Physicians Clinical Practice Guideline on the Perioperative Management of Antithrombotic Therapy addresses 43 Patients-Interventions-Comparators-Outcomes (PICO) questions related to the perioperative management of patients who are receiving long-term oral anticoagulant or antiplatelet therapy and require an elective surgery/procedure. This guideline is separated into four broad categories, encompassing the management of patients who are receiving: (1) a vitamin K antagonist (VKA), mainly warfarin; (2) if receiving a VKA, the use of perioperative heparin bridging, typically with a low-molecular-weight heparin; (3) a direct oral anticoagulant (DOAC); and (4) an antiplatelet drug. METHODS Strong or conditional practice recommendations are generated based on high, moderate, low, and very low certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology for clinical practice guidelines. RESULTS A multidisciplinary panel generated 44 guideline recommendations for the perioperative management of VKAs, heparin bridging, DOACs, and antiplatelet drugs, of which two are strong recommendations: (1) against the use of heparin bridging in patients with atrial fibrillation; and (2) continuation of VKA therapy in patients having a pacemaker or internal cardiac defibrillator implantation. There are separate recommendations on the perioperative management of patients who are undergoing minor procedures, comprising dental, dermatologic, ophthalmologic, pacemaker/internal cardiac defibrillator implantation, and GI (endoscopic) procedures. CONCLUSIONS Substantial new evidence has emerged since the 2012 iteration of these guidelines, especially to inform best practices for the perioperative management of patients who are receiving a VKA and may require heparin bridging, for the perioperative management of patients who are receiving a DOAC, and for patients who are receiving one or more antiplatelet drugs. Despite this new knowledge, uncertainty remains as to best practices for the majority of perioperative management questions.
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Affiliation(s)
- James D Douketis
- Department of Medicine, St. Joseph's Healthcare Hamilton and McMaster University, Hamilton, ON, Canada.
| | - Alex C Spyropoulos
- Department of Medicine, Northwell Health at Lenox Hill Hospital, New York, NY; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; Institute of Health Systems Science at The Feinstein Institutes for Medical Research, Manhasset, NY
| | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN
| | - Juan I Arcelus
- Department of Surgery, Facultad de Medicina, University of Granada, Granada, Spain
| | - William E Dager
- Department of Pharmacy, University of California-Davis, Sacramento, CA
| | - Andrew S Dunn
- Division of Hospital Medicine, Department of Medicine, Mt. Sinai Health System, New York, NY
| | - Ramiz A Fargo
- Department of Internal Medicine, Loma Linda University Medical Center, Loma Linda, CA; Department of Internal Medicine, Riverside University Health System Medical Center, Moreno Valley, CA
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, NC
| | - C Marc Samama
- Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP, Centre-Université Paris-Cité-Cochin Hospital, Paris, France
| | - Sahrish H Shah
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN
| | | | - Alfonso J Tafur
- Department of Medicine, Cardiovascular, NorthShore University HealthSystem, Evanston, IL
| | - Liang V Tang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong, University of Science and Technology, Wuhan, China
| | - Lisa K Moores
- F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
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Gwozdz AM, de Jong CMM, Fialho LS, Likitabhorn T, Sossi F, Jaber PB, Højen AA, Arcelus JI, Auger WR, Ay C, Barco S, Gazzana MB, Bayley J, Bertoletti L, Cate-Hoek AT, Cohen AT, Connors JM, Galanaud JP, Labropoulos N, Langlois N, Meissner MH, Noble S, Nossent EJ, de León Lovatón PP, Robert-Ebadi H, Rosovsky RP, Smolenaars N, Toshner M, Tromeur C, Wang KL, Westerlund E, de Wit K, Black SA, Klok FA. Development of an international standard set of outcome measures for patients with venous thromboembolism: an International Consortium for Health Outcomes Measurement consensus recommendation. Lancet Haematol 2022; 9:e698-e706. [PMID: 36055334 DOI: 10.1016/s2352-3026(22)00215-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 06/28/2022] [Accepted: 06/29/2022] [Indexed: 06/15/2023]
Abstract
The International Consortium for Health Outcomes Measurement assembled an international working group of venous thromboembolism experts and patient representatives to develop a standardised minimum set of outcomes and outcome measurements for integration into clinical practice and potentially research to support clinical decision making and benchmarking of quality of care. 15 core outcomes important to patients and health-care professionals were selected and categorised into four domains: patient-reported outcomes, long term consequences of the disease, disease-specific complications, and treatment-related complications. The outcomes and outcome measures were designed to apply to all patients with venous thromboembolism aged 16 years or older. A measurement tool package was selected for inclusion in the core standard set, with a minimum number of items to be measured at predefined timepoints, which capture all core outcomes. Additional measures can be introduced to the user by a cascade opt-in system that allows for further assessment if required. This set of outcomes and measurement tools will facilitate the implementation of the use of patient-centred outcomes in daily practice.
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Affiliation(s)
- Adam M Gwozdz
- Academic Department of Vascular Surgery, Section of Vascular Risk and Surgery, School of Cardiovascular Medicine and Science, Guy's and Saint Thomas' Hospital, King's College London, London, UK; Academic Section of Vascular Surgery, Department of Surgery and Cancer and Department of Vascular Surgery, Imperial College Healthcare NHS Trust, Imperial College London, London, UK
| | - Cindy M M de Jong
- Department of Medicine: Thrombosis and Haemostasis, Leiden University Medical Center, Leiden University, Leiden, Netherlands
| | - Luz Sousa Fialho
- International Consortium for Health Outcomes Measurement, London, UK
| | | | - Frieda Sossi
- International Consortium for Health Outcomes Measurement, London, UK
| | | | - Anette Arbjerg Højen
- Aalborg Thrombosis Research Unit, Department of Cardiology, Aalborg University Hospital, Aalborg University, Aalborg, Denmark
| | - Juan I Arcelus
- Department of Surgery, University of Granada Medical School, University of Granada, Granada, Spain
| | - William R Auger
- Department of Pulmonary Medicine, University of California, San Diego, CA, USA
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Stefano Barco
- Department of Angiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Centre for Thrombosis and Haemostasis, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Marcelo B Gazzana
- Department of Pulmonology and Thoracic Surgery, Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil; National Association of Private Hospitals, Porto Alegre, Rio Grande do Sul, Brazil
| | - Julie Bayley
- Lincoln Impact Literacy Institute, University of Lincoln, Lincoln, UK
| | - Laurent Bertoletti
- Department of Vascular and Therapeutic Medicine, University Hospital of Saint-Étienne, University of Saint-Étienne, Saint-Étienne, France; CIC-1408, INSERM, University Hospital of Saint-Étienne, University of Saint-Étienne, Saint-Étienne, France; French Clinical Research Infrastructure Network [F-CRIN] INNOvenous thromboembolism, University Hospital of Saint-Étienne, University of Saint-Étienne, Saint-Étienne, France; UMR1059, INSERM, Université Jean-Monnet, Saint-Étienne, France
| | - Arina Ten Cate-Hoek
- Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht University, Maastricht, Netherlands
| | - Alexander T Cohen
- Department of Haematological Medicine, Guy's and Saint Thomas' Hospital, King's College London, London, UK
| | - Jean M Connors
- Hematology Division, Brigham and Women's Hospital, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Jean-Philippe Galanaud
- Department of Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, ON, Canada
| | - Nicos Labropoulos
- Division of Vascular Surgery, Department of Surgery, Stony Brook Hospital, Stony Brook, NY, USA
| | - Nicole Langlois
- Department of Medicine, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Mark H Meissner
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Simon Noble
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK
| | - Esther J Nossent
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | | | - Helia Robert-Ebadi
- Division of Angiology and Haemostasis, Geneva University Hospitals, University of Geneva, Geneva, Switzerland; Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Rachel P Rosovsky
- Division of Hematology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Noa Smolenaars
- Department of Industrial Design, University of Technology Eindhoven, Eindhoven, Netherlands
| | - Mark Toshner
- Heart Lung Research Institute, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Cécile Tromeur
- French Clinical Research Infrastructure Network [F-CRIN] INNOvenous thromboembolism, University Hospital of Saint-Étienne, University of Saint-Étienne, Saint-Étienne, France; Department of Internal Medicine and Pneumology, University Hospital of Brest, Brest, France; Group d'etude de la thrombose de Bretagne Occidentale, Université de Bretagne Occidentale, Brest, France
| | - Kang-Ling Wang
- General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Eli Westerlund
- Department of Clinical Sciences, Karolinska Institutet; Danderyd Hospital, Danderyd, Sweden
| | - Kerstin de Wit
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada; Departments of Medicine and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Stephen A Black
- Academic Department of Vascular Surgery, Section of Vascular Risk and Surgery, School of Cardiovascular Medicine and Science, Guy's and Saint Thomas' Hospital, King's College London, London, UK
| | - Frederikus A Klok
- Department of Medicine: Thrombosis and Haemostasis, Leiden University Medical Center, Leiden University, Leiden, Netherlands.
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Cools F, Virdone S, Sawhney J, Lopes RD, Jacobson B, Arcelus JI, Hobbs FDR, Gibbs H, Himmelreich JCL, MacCallum P, Schellong S, Haas S, Turpie AGG, Ageno W, Rocha AT, Kayani G, Pieper K, Kakkar AK. Thromboprophylactic low-molecular-weight heparin versus standard of care in unvaccinated, at-risk outpatients with COVID-19 (ETHIC): an open-label, multicentre, randomised, controlled, phase 3b trial. Lancet Haematol 2022; 9:e594-e604. [PMID: 35779560 PMCID: PMC9243570 DOI: 10.1016/s2352-3026(22)00173-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 05/20/2022] [Accepted: 05/23/2022] [Indexed: 12/22/2022]
Abstract
Background COVID-19 is associated with inflammation and an increased risk of thromboembolic complications. Prophylactic doses of low-molecular-weight heparin have been used in hospitalised and non-critically ill patients with COVID-19. We aimed to evaluate the efficacy and safety of prophylactic low-molecular-weight heparin (enoxaparin) versus standard of care (no enoxaparin) in at-risk outpatients with COVID-19. Methods This open-label, multicentre, randomised, controlled, phase 3b trial (ETHIC) was done at 15 centres in six countries (Belgium, Brazil, India, South Africa, Spain, and the UK). We consecutively enrolled participants aged at least 30 years who had not received a COVID-19 vaccine and had symptomatic, confirmed COVID-19 in the outpatient setting plus at least one risk factor for severe disease. Within 9 days of symptom onset and by use of a web-based random block design (block size either 2 or 4), eligible participants were randomly assigned (1:1) to receive either subcutaneous enoxaparin for 21 days (40 mg once daily if they weighed <100 kg and 40 mg twice daily if they weighed ≥100 kg) or standard of care (without enoxaparin). The primary efficacy endpoint was the composite of all-cause hospitalisation and all-cause mortality at 21 days after randomisation and, in our main analysis, was analysed in the intention-to-treat population, which comprised all patients who were randomly assigned. Safety was also analysed in the intention-to-treat population for our main analysis. This trial is registered with ClinicalTrials.gov, NCT04492254, and is complete. Findings Following the advice of the Data and Safety Monitoring Board, this study was terminated early due to slow enrolment and a lower-than-expected event rate. Between Oct 27, 2020, and Nov 8, 2021, 230 patients with COVID-19 were assessed for eligibility, of whom 219 were enrolled and randomly assigned to receive standard of care (n=114) or enoxaparin (n=105). 96 (44%) patients were women, 122 (56%) were men, and one patient had missing sex data. 141 (65%) of 218 participants with data on race and ethnicity were White, 60 (28%) were Asian, and 16 (7%) were Black, mixed race, or Arab or Middle Eastern. Median follow-up in both groups was 21 days (IQR 21–21). There was no difference in the composite of all-cause mortality and hospitalisation at 21 days between the enoxaparin group (12 [11%] of 105 patients) and the standard-of-care group (12 [11%] of 114 patients; unadjusted hazard ratio 1·09 [95% CI 0·49–2·43]; log-rank p=0·83). At 21 days, two (2%) of 105 patients in the enoxaparin group (one minor bleed and one bleed of unknown severity) and one (1%) of 114 patients in the standard-of-care group (major abnormal uterine bleeding) had a bleeding event. 22 (21%) patients in the enoxaparin group and 13 (11%) patients in the standard-of-care group had adverse events. The most common adverse event in both groups was COVID-19-related pneumonia (six [6%] patients in the enoxaparin group and five [4%] patients in the standard-of-care group). One patient in the enoxaparin group died and their cause of death was unknown. Interpretation The ETHIC trial results suggest that prophylaxis with low-molecular-weight heparin had no benefit for at-risk outpatients with COVID-19. Although the trial was terminated early, our data, combined with data from similar studies, provide further insights to inform international guidelines and influence clinical practice. Funding The Thrombosis Research Institute and Sanofi UK.
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Affiliation(s)
- Frank Cools
- Department of Cardiology, General Hospital Klina, Brasschaat, Belgium
| | | | - Jitendra Sawhney
- Department of Cardiology, Sir Ganga Ram Hospital, New Delhi, India
| | - Renato D Lopes
- Department of Cardiology, Duke University Medical Center, Durham, NC, USA; Brazilian Clinical Research Institute, São Paulo, Brazil
| | - Barry Jacobson
- Department of Haematology and Molecular Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Juan I Arcelus
- Department of Surgery, University of Granada, Granada, Spain
| | - F D Richard Hobbs
- Oxford Primary Care, Radcliffe Observatory Quarter, University of Oxford, Oxford, UK
| | - Harry Gibbs
- Department of General Medicine, The Alfred Hospital, Melbourne, VIC, Australia
| | - Jelle C L Himmelreich
- Department of General Practice, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Peter MacCallum
- Department of Haematology, Queen Mary University of London, London, UK
| | - Sebastian Schellong
- Department of Heart and Circulatory Diseases, Städtisches Klinikum Dresden, Dresden, Germany
| | - Sylvia Haas
- Institute for Experimental Oncology and Therapeutic Research, Technical University of Munich, Munich, Germany
| | | | - Walter Ageno
- Department of Medicine, University of Insubria, Varese, Italy
| | - Ana Thereza Rocha
- Department of Family Health, Federal University of Bahia, Salvador, Brazil; D'Or Institute for Research and Education, Rio de Janeiro, Brazil
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Blondon M, Jimenez D, Robert‐Ebadi H, Del Toro J, Lopez‐Jimenez L, Falga C, Skride A, Font L, Vazquez FJ, Bounameaux H, Monreal M, Prandoni P, Brenner, B, Farge‐Bancel D, Barba R, Di Micco P, Bertoletti L, Schellong S, Tzoran I, Reis A, Bosevski M, Malý R, Verhamme P, Caprini JA, My Bui H, Adarraga MD, Agud M, Aibar J, Aibar MA, Alfonso J, Amado C, Arcelus JI, Baeza C, Ballaz A, Barba R, Barbagelata C, Barrón M, Barrón‐Andrés B, Blanco‐Molina A, Botella E, Camon AM, Castro J, Caudevilla MA, Cerdà P, Chasco L, Criado J, de Ancos C, de Miguel J, Demelo‐Rodríguez P, Díaz‐Peromingo JA, Díez‐Sierra J, Díaz‐Simón R, Domínguez IM, Encabo M, Escribano JC, Falgá C, Farfán AI, Fernández‐Capitán C, Fernández‐Reyes JL, Fidalgo MA, Flores K, Font C, Francisco I, Gabara C, Galeano‐Valle F, García MA, García‐Bragado F, García‐Mullor MM, Gavín‐Blanco O, Gavín‐Sebastián O, Gil‐Díaz A, Gómez‐Cuervo C, González‐Martínez J, Grau E, Guirado L, Gutiérrez J, Hernández‐Blasco L, Jara‐Palomares L, Jaras MJ, Jiménez D, Joya MD, Jou I, Lacruz B, Lecumberri R, Lima J, Lobo JL, López‐Brull H, López‐Jiménez L, López‐Miguel P, López‐Núñez JJ, López‐Reyes R, López‐Sáez JB, Lorente MA, Lorenzo A, Loring M, Madridano O, Maestre A, Marchena PJ, Martín del Pozo M, Martín‐Martos F, Martínez‐Baquerizo C, Mella C, Mellado M, Mercado MI, Moisés J, Morales MV, Muñoz‐Blanco A, Muñoz‐Guglielmetti D, Muñoz‐Rivas N, Nart E, Nieto JA, Núñez MJ, Olivares MC, Ortega‐Michel C, Ortega‐Recio MD, Osorio J, Otalora S, Otero R, Parra P, Parra V, Pedrajas JM, Pellejero G, Pérez‐Jacoiste A, Peris ML, Pesántez D, Porras JA, Portillo J, Reig L, Riera‐Mestre A, Rivas A, Rodríguez‐Cobo A, Rodríguez‐Matute C, Rogado J, Rosa V, Rubio CM, Ruiz‐Artacho P, Ruiz‐Giménez N, Ruiz‐Ruiz J, Ruiz‐Sada P, Sahuquillo JC, Salgueiro G, Sampériz A, Sánchez‐Muñoz‐Torrero JF, Sancho T, Sigüenza P, Sirisi M, Soler S, Suárez S, Suriñach JM, Tiberio G, Torres MI, Tolosa C, Trujillo‐Santos J, Uresandi F, Usandizaga E, Valle R, Vela JR, Vidal G, Vilar C, Villares P, Zamora C, Gutiérrez P, Vázquez FJ, Vanassche T, Vandenbriele C, Verhamme P, Hirmerova J, Malý R, Salgado E, Benzidia I, Bertoletti L, Bura‐Riviere A, Crichi B, Debourdeau P, Espitia O, Farge‐Bancel D, Helfer H, Mahé I, Moustafa F, Poenou G, Schellong S, Braester A, Brenner B, Tzoran I, Amitrano M, Bilora F, Bortoluzzi C, Brandolin B, Ciammaichella M, Colaizzo D, Dentali F, Di Micco P, Giammarino E, Grandone E, Mangiacapra S, Mastroiacovo D, Maida R, Mumoli N, Pace F, Pesavento R, Pomero F, Prandoni P, Quintavalla R, Rocci A, Siniscalchi C, Tufano A, Visonà A, Vo Hong N, Zalunardo B, Kalejs RV, Maķe K, Ferreira M, Fonseca S, Martins F, Meireles J, Bosevski M, Zdraveska M, Mazzolai L, Caprini JA, Tafur AJ, Weinberg I, Wilkins H, Bui HM. Comparative clinical prognosis of massive and non-massive pulmonary embolism: A registry-based cohort study. J Thromb Haemost 2021; 19:408-416. [PMID: 33119949 DOI: 10.1111/jth.15146] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 09/29/2020] [Accepted: 10/21/2020] [Indexed: 01/16/2023]
Abstract
AIMS Little is known about the prognosis of patients with massive pulmonary embolism (PE) and its risk of recurrent venous thromboembolism (VTE) compared with non-massive PE, which may inform clinical decisions. Our aim was to compare the risk of recurrent VTE, bleeding, and mortality after massive and non-massive PE during anticoagulation and after its discontinuation. METHODS AND RESULTS We included all participants in the RIETE registry who suffered a symptomatic, objectively confirmed segmental or more central PE. Massive PE was defined by a systolic hypotension at clinical presentation (<90 mm Hg). We compared the risks of recurrent VTE, major bleeding, and mortality using time-to-event multivariable competing risk modeling. There were 3.5% of massive PE among 38 996 patients with PE. During the anticoagulation period, massive PE was associated with a greater risk of major bleeding (subhazard ratio [sHR] 1.72, 95% confidence interval [CI] 1.28-2.32), but not of recurrent VTE (sHR 1.15, 95% CI 0.75-1.74) than non-massive PE. An increased risk of mortality was only observed in the first month after PE. After discontinuation of anticoagulation, among 11 579 patients, massive PE and non-massive PE had similar risks of mortality, bleeding, and recurrent VTE (sHR 0.85, 95% CI 0.51-1.40), but with different case fatality of recurrent PE (11.1% versus 2.4%, P = .03) and possibly different risk of recurrent fatal PE (sHR 3.65, 95% CI 0.82-16.24). CONCLUSION In this large prospective registry, the baseline hemodynamic status of the incident PE did not influence the risk of recurrent VTE, during and after the anticoagulation periods, but was possibly associated with recurrent PE of greater severity.
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Affiliation(s)
- Marc Blondon
- Division of Angiology and Hemostasis Geneva University Hospitals and Faculty of Medicine Geneva Switzerland
| | - David Jimenez
- Respiratory Department Hospital Ramón y Cajal and Medicine Department Universidad de Alcalá (IRYCIS) Madrid Spain
| | - Helia Robert‐Ebadi
- Division of Angiology and Hemostasis Geneva University Hospitals and Faculty of Medicine Geneva Switzerland
| | - Jorge Del Toro
- Department of Internal Medicine Hospital General Universitario Gregorio Marañón Madrid Spain
| | | | - Conxita Falga
- Department of Internal Medicine Hospital de Mataro Barcelona Spain
| | - Andris Skride
- Department of Cardiology Ospedale Pauls Stradins Clinical University Hospital Riga Latvia
| | - Llorenç Font
- Department of Haematology Hospital de Tortosa Verge de la Cinta Tarragona Spain
| | | | - Henri Bounameaux
- Division of Angiology and Hemostasis Geneva University Hospitals and Faculty of Medicine Geneva Switzerland
| | - Manuel Monreal
- Department of Internal Medicine Hospital Germans Trias i Pujol Badalona Spain
- Universidad Catolica de Murcia Murcia Spain
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Avnery O, Martin M, Bura-Riviere A, Barillari G, Mazzolai L, Mahé I, Marchena PJ, Verhamme P, Monreal M, Ellis MH, Aibar MA, Aibar J, Amado C, Arcelus JI, Ballaz A, Barba R, Barrón M, Barrón‐Andrés B, Bascuñana J, ina A, Camon AM, Cañas I, Carrasco C, Castro J, Ancos C, Toro J, Demelo P, Díaz‐Peromingo JA, Falgá C, Farfán AI, Fernández‐Capitán C, Fernández‐Criado MC, Fernández‐Núñez S, Fidalgo MA, Font C, Font L, Freire M, Gallego M, García MA, García‐Bragado F, García‐Morillo M, García‐Raso A, Gavín O, Gayol MC, Gil‐Díaz A, Gómez V, Gómez‐Cuervo C, González‐Martínez J, Grau E, Gutiérrez J, Hernández‐Blasco LM, Iglesias M, Jara‐Palomares L, Jaras MJ, Jiménez R, Jiménez‐Castro D, Jiménez‐López J, Joya MD, Lima J, Llamas P, Lobo JL, López‐Jiménez L, López‐Miguel P, López‐Núñez JJ, López‐Reyes R, López‐Sáez JB, Lorente MA, Lorenzo A, Loring M, Madridano O, Maestre A, Martín del Pozo M, Martín‐Guerra JM, Martín‐Romero M, Mellado M, Morales MV, Muñoz N, Nieto‐Cabrera MA, Nieto‐Rodríguez JA, Núñez‐Ares A, Núñez MJ, Olivares MC, Otalora S, Otero R, Pedrajas JM, Pellejero G, Pérez‐Rus G, Peris ML, Porras JA, Rivas A, Rodríguez‐Dávila MA, Rodríguez‐Hernández A, Rubio CM, Ruiz‐Artacho P, Ruiz‐Ruiz J, Ruiz‐Torregrosa P, Ruiz‐Sada P, Sahuquillo JC, Salazar V, Sampériz A, Sánchez‐Muñoz‐Torrero JF, Sancho T, Soler S, Sopeña B, Suriñach JM, Tolosa C, Torres MI, Trujillo‐Santos J, Uresandi F, Valle R, Vidal G, Villares P, Gutiérrez P, Vázquez FJ, Vilaseca A, Vanassche T, Vandenbriele C, Hirmerova J, Malý R, Salgado E, Benzidia I, Bertoletti L, Debourdeau P, Farge‐Bancel D, Hij A, Moustafa F, Schellong S, Braester A, Brenner B, Tzoran I, Sharif‐Kashani B, Bilora F, Bortoluzzi C, Bucherini E, Ciammaichella M, Dentali F, Di Micco P, Di Pangrazio M, Maida R, Mastroiacovo D, Pace F, Pallotti G, Parisi R, Pesavento R, Prandoni P, Quintavalla R, Rocci A, Siniscalchi C, Tufano A, Visonà A, Vo Hong N, Gibietis V, Skride A, Strautmane S, Bosevski M, Zdraveska M, Bounameaux H, Fresa M, Ney B, Caprini J, Bui HM, Pham KQ. D-dimer levels and risk of recurrence following provoked venous thromboembolism: findings from the RIETE registry. J Intern Med 2020; 287:32-41. [PMID: 31394000 DOI: 10.1111/joim.12969] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patients with venous thromboembolism (VTE) secondary to transient risk factors may develop VTE recurrences after discontinuing anticoagulation. Identifying at-risk patients could help to guide the duration of therapy. METHODS We used the RIETE database to assess the prognostic value of d-dimer testing after discontinuing anticoagulation to identify patients at increased risk for recurrences. Transient risk factors were classified as major (postoperative) or minor (pregnancy, oestrogen use, immobilization or recent travel). RESULTS In December 2018, 1655 VTE patients with transient risk factors (major 460, minor 1195) underwent d-dimer measurements after discontinuing anticoagulation. Amongst patients with major risk factors, the recurrence rate was 5.74 (95% CI: 3.19-9.57) events per 100 patient-years in those with raised d-dimer levels and 2.68 (95% CI: 1.45-4.56) in those with normal levels. Amongst patients with minor risk factors, the rates were 7.79 (95% CI: 5.71-10.4) and 3.34 (95% CI: 2.39-4.53), respectively. Patients with major risk factors and raised d-dimer levels (n = 171) had a nonsignificantly higher rate of recurrences (hazard ratio [HR]: 2.14; 95% CI: 0.96-4.79) than those with normal levels. Patients with minor risk factors and raised d-dimer levels (n = 382) had a higher rate of recurrences (HR: 2.34; 95% CI: 1.51-3.63) than those with normal levels. On multivariate analysis, raised d-dimers (HR: 1.74; 95% CI: 1.09-2.77) were associated with an increased risk for recurrences in patients with minor risk factors, not in those with major risk factors. CONCLUSIONS Patients with raised d-dimer levels after discontinuing anticoagulant therapy for VTE provoked by a minor transient risk factor were at an increased risk for recurrences.
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Affiliation(s)
- O Avnery
- Meir Medical Center, Hematology Institute and Blood Bank, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - M Martin
- Hospital Infanta Sofia San Sebastian de los Reyes and Universidad Europea de Madrid, Madrid, Spain
| | - A Bura-Riviere
- Department of Vascular Medicine, Hôpital de Rangueil, Toulouse, France
| | - G Barillari
- Department of Internal Medicine, Ospedale S. Maria della Misericordia, Udine, Italy
| | - L Mazzolai
- Department of Angiology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - I Mahé
- Department of Internal Medicine, Hôpital Louis Mourier, Colombes (APHP), University Paris 7, Colombes, France
| | - P J Marchena
- Department of Internal Medicine and Emergency, Parc Sanitari Sant Joan de Deu-Hospital General, Barcelona, Spain
| | - P Verhamme
- Vascular Medicine and Haemostasis, University of Leuven, Leuven, Belgium
| | - M Monreal
- Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - M H Ellis
- Meir Medical Center, Hematology Institute and Blood Bank, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Key NS, Khorana AA, Kuderer NM, Bohlke K, Lee AYY, Arcelus JI, Wong SL, Balaban EP, Flowers CR, Francis CW, Gates LE, Kakkar AK, Levine MN, Liebman HA, Tempero MA, Lyman GH, Falanga A. Venous Thromboembolism Prophylaxis and Treatment in Patients With Cancer: ASCO Clinical Practice Guideline Update. J Clin Oncol 2019; 38:496-520. [PMID: 31381464 DOI: 10.1200/jco.19.01461] [Citation(s) in RCA: 816] [Impact Index Per Article: 163.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE To provide updated recommendations about prophylaxis and treatment of venous thromboembolism (VTE) in patients with cancer. METHODS PubMed and the Cochrane Library were searched for randomized controlled trials (RCTs) and meta-analyses of RCTs published from August 1, 2014, through December 4, 2018. ASCO convened an Expert Panel to review the evidence and revise previous recommendations as needed. RESULTS The systematic review included 35 publications on VTE prophylaxis and treatment and 18 publications on VTE risk assessment. Two RCTs of direct oral anticoagulants (DOACs) for the treatment of VTE in patients with cancer reported that edoxaban and rivaroxaban are effective but are linked with a higher risk of bleeding compared with low-molecular-weight heparin (LMWH) in patients with GI and potentially genitourinary cancers. Two additional RCTs reported on DOACs for thromboprophylaxis in ambulatory patients with cancer at increased risk of VTE. RECOMMENDATIONS Changes to previous recommendations: Clinicians may offer thromboprophylaxis with apixaban, rivaroxaban, or LMWH to selected high-risk outpatients with cancer; rivaroxaban and edoxaban have been added as options for VTE treatment; patients with brain metastases are now addressed in the VTE treatment section; and the recommendation regarding long-term postoperative LMWH has been expanded. Re-affirmed recommendations: Most hospitalized patients with cancer and an acute medical condition require thromboprophylaxis throughout hospitalization. Thromboprophylaxis is not routinely recommended for all outpatients with cancer. Patients undergoing major cancer surgery should receive prophylaxis starting before surgery and continuing for at least 7 to 10 days. Patients with cancer should be periodically assessed for VTE risk, and oncology professionals should provide patient education about the signs and symptoms of VTE.Additional information is available at www.asco.org/supportive-care-guidelines.
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Affiliation(s)
- Nigel S Key
- University of North Carolina, Chapel Hill, NC
| | | | - Nicole M Kuderer
- Advanced Cancer Research Group and University of Washington, Seattle, WA
| | - Kari Bohlke
- American Society of Clinical Oncology, Alexandria, VA
| | - Agnes Y Y Lee
- BC Cancer Agency, Vancouver, British Columbia, Canada
| | | | | | | | | | - Charles W Francis
- James P Wilmot Cancer Center and University of Rochester, Rochester, NY
| | | | - Ajay K Kakkar
- Thrombosis Research Institute and University College, London, United Kingdom
| | | | - Howard A Liebman
- University of Southern California and Norris Comprehensive Cancer Center, Los Angeles, CA
| | | | - Gary H Lyman
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, WA
| | - Anna Falanga
- Hospital Papa Giovanni XXIII, Bergamo; and University of Milan Bicocca, Milan, Italy
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10
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Arcelus JI. Prevention of Venous Thromboembolism in Colorectal Surgery With Enoxaparin: Are We Using the Right Dose? JAMA Surg 2019; 154:704-705. [PMID: 31116369 DOI: 10.1001/jamasurg.2019.1166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Juan I Arcelus
- Division of General and Gastrointestinal Surgery, Hospital Universitario Virgen de las Nieves, University of Granada, Granada, Spain
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11
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Gutiérrez Guisado J, Trujillo-Santos J, Arcelus JI, Bertoletti L, Fernandez-Capitán C, Valle R, Hernandez-Hermoso JA, Erice Calvo-Sotelo A, Nieto JA, Monreal M. Prognosis of venous thromboembolism in orthopaedic surgery or trauma patients and use of thromboprophylaxis. Rev Clin Esp 2018; 218:399-407. [PMID: 29929734 DOI: 10.1016/j.rce.2018.04.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 04/24/2018] [Accepted: 04/26/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND There is scarce evidence about the prognosis of venous thromboembolism in patients undergoing orthopedic surgery and in patients suffering non-surgical trauma. METHODS We used the RIETE database (Registro Informatizado de pacientes con Enfermedad Trombo Embólica) to compare the prognosis of venous thromboembolism and the use of thromboprophylaxis in patients undergoing different orthopedic procedures and in trauma patients not requiring surgery. RESULTS From March 2001 to March 2015, a total of 61,789 patients were enrolled in RIETE database. Of these, 943 (1.52%) developed venous thromboembolism after elective arthroplasty, 445 (0.72%) after hip fracture, 1,045 (1.69%) after non-major orthopedic surgery and 2,136 (3.46%) after non-surgical trauma. Overall, 2,283 patients (50%) initially presented with pulmonary embolism. Within the first 90 days of therapy, 30 patients (0.66%; 95% CI 0.45-0.93) died from pulmonary embolism. The rate of fatal pulmonary embolism was significantly higher after hip fracture surgery (n = 9 [2.02%]) than after elective arthroplasty (n = 5 [0.53%]), non-major orthopedic surgery (n = 5 [0.48%]) or non surgical trauma (n = 11 [0.48%]). Thromboprophylaxis was more commonly used for hip fracture (93%) or elective arthroplasty (94%) than for non-major orthopedic surgery (71%) or non-surgical trauma (32%). Major bleeding was significantly higher after hip fracture surgery (4%) than that observed after elective arthroplasty (1.6%), non-major orthopedic surgery (1.5%) or non-surgical trauma (1.4%). CONCLUSIONS Thromboprophylaxis was less frequently used in lower risk procedures despite the absolute number of fatal pulmonary embolism after non-major orthopedic surgery or non-surgical trauma, exceeded that observed after high risk procedures.
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Affiliation(s)
- J Gutiérrez Guisado
- Departamento de Medicina Interna, Hospital ASEPEYO, Universidad Francisco de Vitoria, Coslada, Madrid, España.
| | - J Trujillo-Santos
- Departamento de Medicina Interna, Hospital General Universitario Santa Lucía, Murcia, España
| | - J I Arcelus
- Departamento de Cirugía General, Hospital Universitario Virgen de las Nieves, Granada, España
| | - L Bertoletti
- Departamento de Medicina y Terapéutica, Hôpital Nord-CHU de Saint-Étienne, Saint Etienne, Francia
| | - C Fernandez-Capitán
- Departamento de Medicina Interna, Hospital Universitario La Paz, Madrid, España
| | - R Valle
- Departamento de Medicina Interna, Hospital Sierrallana, Torrelavega, Cantabria, España
| | - J A Hernandez-Hermoso
- Servicio de Cirugía Ortopédica, Hospital Universitario Germans Trias i Pujol, Badalona, Barcelona, España
| | - A Erice Calvo-Sotelo
- Departamento de Medicina Interna, Hospital ASEPEYO, Universidad Francisco de Vitoria, Coslada, Madrid, España
| | - J A Nieto
- Departamento de Medicina Interna, Hospital General Virgen de la Luz, Cuenca, España
| | - M Monreal
- Departamento de Medicina Interna, Hospital Universitario Germans Trias i Pujol, Badalona, Barcelona, España
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Tafur AJ, Caprini JA, Arcelus JI. The limited utility of currently available venous thromboembolism risk assessment tools in gynecological oncology patients. Am J Obstet Gynecol 2017; 216:326. [PMID: 27773716 DOI: 10.1016/j.ajog.2016.10.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Accepted: 10/11/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Alfonso J Tafur
- Thrombophilia Clinic, NorthShore University Health System, 1301 Central St, Evanston, IL 60201
| | - Joseph A Caprini
- Thrombophilia Clinic, NorthShore University Health System, 1301 Central St, Evanston, IL 60201.
| | - Juan I Arcelus
- Department of Surgery, University of Granada Medical School, Granada, Spain
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13
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Arcelus JI, Domènech P, Fernández-Capitan MDC, Guijarro R, Jiménez D, Jiménez S, Lozano FS, Monreal M, Nieto JA, Páramo JA. Rivaroxaban in the Treatment of Venous Thromboembolism and the Prevention of Recurrences. Clin Appl Thromb Hemost 2014; 21:297-308. [DOI: 10.1177/1076029614561321] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Anticoagulation therapy is the standard treatment of patients with symptomatic venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism. Until recently, treatment of VTE was based on parenteral or low-molecular-weight heparin for initial therapy (5-10 days) and oral vitamin K antagonists for long-term therapy. Those treatments have some limitations, including parenteral administration (heparins), the need for frequent monitoring and dose adjustments, interactions with several medications, and dietary restrictions (vitamin K antagonists). Rivaroxaban is a new oral direct factor Xa inhibitor with a wide therapeutic window, predictable anticoagulant effect, no food interactions, and few drug interactions. Consequently, no periodic monitoring of anticoagulation is needed, and fixed doses can be prescribed. EINSTEIN program demonstrated that rivaroxaban was as effective as and significantly safer than standard therapy for treatment of VTE. Rivaroxaban was recently authorized so doubts exist about how to use it in daily clinical practice. This document aims to clarify common questions formulated by clinicians regarding the use of this new drug.
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Affiliation(s)
- Juan I. Arcelus
- Department of Surgery, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Pere Domènech
- Haemostasis and Thrombosis Department. Bellvitge's University Hospital. Hospitalet de Llobregat, Barcelona, Spain
| | | | - Ricardo Guijarro
- Internal Medicine Department, Regional University Hospital of Malaga (Carlos Haya Hospital), Málaga, Spain
| | - David Jiménez
- Respiratory Department, Ramon y Cajal Hospital, Alcala de Henares University, Madrid, Spain
| | - Sonia Jiménez
- Emergency Department, Hospital Clínic and IDIBAPS, Barcelona, Spain
| | | | - Manel Monreal
- Internal Medicine Department, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - José A. Nieto
- Internal Medicine Service, Hospital Virgen de la Luz, Cuenca, Spain
| | - José A. Páramo
- Hematology Service, Clínica Universidad de Navarra, Pamplona, Spain
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14
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Arcelus JI. Elective splenectomy for hematologic diseases: can we predict complications? JAMA Surg 2014; 149:1030. [PMID: 25142711 DOI: 10.1001/jamasurg.2014.310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Juan I Arcelus
- Division of General and Gastrointestinal Surgery, Department of Surgery, Hospital Universitario Virgen de las Nieves, University of Granada, Granada, Spain
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15
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Cote LP, Greenberg S, Caprini JA, Stone J, Arcelus JI, López-Jiménez L, Rosa V, Schellong S, Monreal M. Outcomes in neurosurgical patients who develop venous thromboembolism: a review of the RIETE registry. Clin Appl Thromb Hemost 2014; 20:772-8. [PMID: 24798686 DOI: 10.1177/1076029614532008] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES Registro Informatizado de Enfermedad TromboEmbólica (RIETE) database was used to investigate whether neurosurgical patients with venous thromboembolism (VTE) were more likely to die of bleeding or VTE and the influence of anticoagulation on these outcomes. METHODS Clinical characteristics, treatment details, and 3-month outcomes were assessed in those who developed VTE after neurosurgery. RESULTS Of 40 663 patients enrolled, 392 (0.96%) had VTE in less than 60 days after neurosurgery. Most patients in the cohort (89%) received initial therapy with low-molecular-weight heparin, (33% received subtherapeutic doses). In the first week, 10 (2.6%) patients died (8 with pulmonary embolism [PE], no bleeding deaths; P = .005). After the first week, 20 (5.1%) patients died (2 with fatal bleeding, none from PE). Overall, this cohort was more likely to develop a fatal PE than a fatal bleed (8 vs 2 deaths, P = .058). CONCLUSIONS Neurosurgical patients developing VTE were more likely to die from PE than from bleeding in the first week, despite anticoagulation.
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Affiliation(s)
- Lauren P Cote
- Department of Nursing/Critical Care, Evanston Hospital, NorthShore University HealthSystem, Chicago, IL, USA
| | - Steven Greenberg
- Department of Anesthesia/Critical Care, Evanston Hospital, NorthShore University HealthSystem, Chicago, IL, USA
| | - Joseph A Caprini
- Division of Vascular Surgery, Evanston Hospital, NorthShore University HealthSystem, Chicago, IL, USA
| | - James Stone
- Department of Neurosurgery, Evanston Hospital, NorthShore University HealthSystem, Chicago, IL, USA
| | - Juan I Arcelus
- Department of General Surgery, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | | | - Vladimir Rosa
- Department of Internal Medicine, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Sebastian Schellong
- Department of Internal Medicine, Municipal Hospital of Dresden Friedrichstadt, Dresden, Germany
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
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16
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Arcelus JI. ACP Journal Club. A weighted risk index had moderate ability to predict VTE requiring treatment after outpatient surgery. Ann Intern Med 2013; 158:JC12. [PMID: 23420249 DOI: 10.7326/0003-4819-158-4-201302190-02012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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17
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Traverso CI, Caprini JA, Arcelus JI. Application of thromboelastography in other medical and surgical states. Semin Thromb Hemost 2012; 21 Suppl 4:50-2. [PMID: 8747688 DOI: 10.1055/s-0032-1313621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- C I Traverso
- Department of Surgery and Related Specialties, University of Granada Hospital, Spain
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18
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Affiliation(s)
- J I Arcelus
- Department of Surgery, Hospital General de la Axarquía, Vélez-Málaga, Spain
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19
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Affiliation(s)
- J A Caprini
- Department of Surgery, Glenbrook Hospital, Glenview, Illinois 60025, USA
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20
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Traverso CI, Arcelus JI, Caprini JA. Role of thromboelastography in evaluating other anticoagulant agents: warfarin and heparin-dihydroergotamine. Semin Thromb Hemost 2012; 21 Suppl 4:59-62. [PMID: 8747690 DOI: 10.1055/s-0032-1313623] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- C I Traverso
- Department of Surgery and Related Specialties, University of Granada Hospital, Spain
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21
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Traverso CI, Caprini JA, Arcelus JI, Arcelus IM. Thromboelastographic modifications induced by intravenous and subcutaneous heparin administration. Semin Thromb Hemost 2012; 21 Suppl 4:53-8. [PMID: 8747689 DOI: 10.1055/s-0032-1313622] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- C I Traverso
- Department of Surgery and Related Specialties, University of Granada Hospital, Spain
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22
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Affiliation(s)
- C I Traverso
- Department of Surgery and Related Specialties, University of Granada Hospital, Spain
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23
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Abstract
The knowledge of these sources of error together with strict methodology assure reliable results and avoid what some authors consider limitations of the test. These so-called limitations are actually due to incomplete information or insufficient experience. It is our opinion that the key for success when using TEG is to use the test in those cases for which it has been indicated. Also, the fact that TEG is a global test of coagulation should be kept in mind and therefore the need for additional hemostatic tests should be evaluated when applicable (Fig.3). According to this review, the established applications of TEG are as follows: (1) detection of hypercoagulable states, particularly in the postoperative period and for patients with malignancies; (2) management of patients who are administered intravenous heparin; (3) monitoring the coagulation state during liver transplantation; (4) monitoring the coagulation state and management of patients during cardiopulmonary bypass; and (5) diagnosis and treatment of hematologic dysfunctions, particularly hemophilia. Management of patients under warfarin administration, as well as monitoring of the adjustment of subcutaneous heparin prophylaxis in several surgical procedures, should probably belong to this list, but further studies are needed to confirm these roles. Used by experienced hands, TEG is a valuable hemostatic test, the future of which is already present.
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Affiliation(s)
- J A Caprini
- Department of Surgery, Glenbrook Hospital, Glenview, Illinois, USA
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24
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Gould MK, Garcia DA, Wren SM, Karanicolas PJ, Arcelus JI, Heit JA, Samama CM. Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e227S-e277S. [PMID: 22315263 PMCID: PMC3278061 DOI: 10.1378/chest.11-2297] [Citation(s) in RCA: 1350] [Impact Index Per Article: 112.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2011] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND VTE is a common cause of preventable death in surgical patients. METHODS We developed recommendations for thromboprophylaxis in nonorthopedic surgical patients by using systematic methods as described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement. RESULTS We describe several alternatives for stratifying the risk of VTE in general and abdominal-pelvic surgical patients. When the risk for VTE is very low (< 0.5%), we recommend that no specific pharmacologic (Grade 1B) or mechanical (Grade 2C) prophylaxis be used other than early ambulation. For patients at low risk for VTE (∼1.5%), we suggest mechanical prophylaxis, preferably with intermittent pneumatic compression (IPC), over no prophylaxis (Grade 2C). For patients at moderate risk for VTE (∼3%) who are not at high risk for major bleeding complications, we suggest low-molecular-weight heparin (LMWH) (Grade 2B), low-dose unfractionated heparin (Grade 2B), or mechanical prophylaxis with IPC (Grade 2C) over no prophylaxis. For patients at high risk for VTE (∼6%) who are not at high risk for major bleeding complications, we recommend pharmacologic prophylaxis with LMWH (Grade 1B) or low-dose unfractionated heparin (Grade 1B) over no prophylaxis. In these patients, we suggest adding mechanical prophylaxis with elastic stockings or IPC to pharmacologic prophylaxis (Grade 2C). For patients at high risk for VTE undergoing abdominal or pelvic surgery for cancer, we recommend extended-duration, postoperative, pharmacologic prophylaxis (4 weeks) with LMWH over limited-duration prophylaxis (Grade 1B). For patients at moderate to high risk for VTE who are at high risk for major bleeding complications or those in whom the consequences of bleeding are believed to be particularly severe, we suggest use of mechanical prophylaxis, preferably with IPC, over no prophylaxis until the risk of bleeding diminishes and pharmacologic prophylaxis may be initiated (Grade 2C). For patients in all risk groups, we suggest that an inferior vena cava filter not be used for primary VTE prevention (Grade 2C) and that surveillance with venous compression ultrasonography should not be performed (Grade 2C). We developed similar recommendations for other nonorthopedic surgical populations. CONCLUSIONS Optimal thromboprophylaxis in nonorthopedic surgical patients will consider the risks of VTE and bleeding complications as well as the values and preferences of individual patients.
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Affiliation(s)
- Michael K Gould
- Keck School of Medicine, University of Southern California, Los Angeles, CA.
| | - David A Garcia
- University of New Mexico School of Medicine, Albuquerque, NM
| | | | - Paul J Karanicolas
- Surgical Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | - John A Heit
- College of Medicine, Mayo Clinic, Rochester, MN
| | - Charles M Samama
- Department of Anaesthesiology and Intensive Care, Hotel-Dieu University Hospital, Paris, France
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Bergqvist D, Arcelus JI, Felicissimo P. Post-discharge compliance to venous thromboembolism prophylaxis in high-risk orthopaedic surgery: results from the ETHOS registry. Thromb Haemost 2011; 107:280-7. [PMID: 22186771 DOI: 10.1160/th11-07-0464] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Accepted: 11/01/2011] [Indexed: 11/05/2022]
Abstract
Venous thromboembolism (VTE) risk persists for several weeks following high-risk orthopaedic surgery (HROS). The ETHOS registry evaluated post-operative VTE prophylaxis prescribed, and actual VTE prophylaxis received, compared with the 2004 American College of Chest Physicians (ACCP) guidelines in HROS patients. We performed a subanalysis of ETHOS to assess patient compliance with ACCP-adherent prophylaxis after discharge and the factors predicting poor compliance. Consecutive patients undergoing hip fracture surgery, total hip arthroplasty, or knee arthroplasty were enrolled at discharge from 161 centres in 17 European countries if they had received adequate in-hospital VTE prophylaxis. Data on prescribed and actual prophylaxis received were obtained from hospital charts and patient post-discharge diaries. Good compliance was defined as percentage treatment intake ≥80% with no more than two consecutive days without treatment. A total of 3,484 patients (79.4%) received ACCP-adherent anticoagulant prescription at discharge and 2,999 (86.0%) had an evaluable patient diary. In total, 87.7% of evaluable patients were compliant with prescribed treatment after discharge. The most common reason for non-compliance (33.4%) was "drug was not bought". Injection of treatment was not a barrier to good compliance. Main factors affecting compliance related to purchase of and access to treatment, patient education, the person responsible for administering injections, country, and type of hospital ward at discharge. Within our study population, patient compliance with ACCP-adherent thromboprophylaxis prescribed at discharge was good. Improvements in patient education and prescribing practices at discharge may be important in further raising compliance levels in high-risk orthopaedic surgery patients.
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Affiliation(s)
- David Bergqvist
- Department of Surgery, Uppsala Academic Hospital, Uppsala, Sweden.
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26
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Lozano FS, Arcelus JI, Ramos JL, Alós R, Espín E, Rico P, Ros E. [Risk of venous thromboembolic disease in general surgery]. Cir Esp 2009; 85 Suppl 1:45-50. [PMID: 19589410 DOI: 10.1016/s0009-739x(09)71628-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Despite preventive efforts, venous thromboembolic disease (VTED) is still a major problem for surgeons due to its frequency and the morbidity, mortality and enormous resource consumption caused by this entity. However, the most important feature of VTED is that it is one of the most easily preventable complications and causes of death. To take appropriate prophylactic decisions (indication, method, initiation, duration, etc.), familiarity with the epidemiology of VTED in general surgery and some of its most significant populations (oncologic, laparoscopic, bariatric, ambulatory and short-stay) is essential. These factors must also be known to determine the distinct risk factors in these settings with a view to stratifying preoperative risk.
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Affiliation(s)
- Francisco S Lozano
- Servicio de Angiología y Cirugía Vascular, Hospital Universitario, Salamanca, España.
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27
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Arcelus JI. Current status of venous thromboembolism prophylaxis. Surg Technol Int 2009; 18:55-62. [PMID: 19585415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Postoperative venous thromboembolism (VTE) represents a serious and potentially fatal complication that affects 40% to 60% of patients undergoing major orthopedic surgery and not receiving antithrombotic prophylaxis. Several prophylactic modalities, including pharmacological agents such as oral vitamin K antagonists (VKA) and low molecular weight heparins (LMWH), have been shown to be effective and safe for most patients at high risk for VTE. However, some patients undergoing cancer or major orthopedic surgery remain at some residual VTE risk despite the use of these methods. Approaches to improve the results of prophylaxis include optimizing the timing and duration of pharmacological prophylaxis, combining mechanical methods with anticoagulants, and the development of new antithrombotics.
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Affiliation(s)
- Juan I Arcelus
- Hospital Virgen de las Nieves, University of Granada Medical School, Granada, Spain
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28
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Cohen AT, Agnelli G, Anderson FA, Arcelus JI, Bergqvist D, Brecht JG, Greer IA, Heit JA, Hutchinson JL, Kakkar AK, Mottier D, Oger E, Samama MM, Spannagl M. Venous thromboembolism (VTE) in Europe. The number of VTE events and associated morbidity and mortality. Thromb Haemost 2008. [PMID: 17938798 DOI: 10.1160/th07-03-0212] [Citation(s) in RCA: 708] [Impact Index Per Article: 44.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Venous thromboembolism (VTE) is often asymptomatic, mis-diagnosed, and unrecognized at death, and there is a lack of routine postmortem examinations. These factors are thought to result in marked underestimates ofVTE incidence. The objective of our study was to estimate the total burden of VTE within the European Union (EU) per annum. An epidemiological model was constructed to estimate the number of community- and hospital-acquired incidents and recurrent cases (attack rate) of nonfatal VTE and VTE-related deaths, as well as incident and prevalent cases of post-thrombotic syndrome (PTS) and chronic thromboembolic pulmonary hypertension (PH) occurring in the EU per annum. Individual models were developed for six EU countries. The models were populated with data from published literature and, where necessary, expert opinions. The findings were tested using probabilistic sensitivity analyses. The estimated total number of symptomaticVTE events (range based on probabilistic sensitivity analysis) per annum within the six EU countries was 465,715 (404,664-538,189) cases of deep-vein thrombosis, 295,982 (242,450-360,363) cases of pulmonary embolism (PE), and 370,012 (300,193-483,108) VTE-related deaths. Of these deaths, an estimated 27,473 (7%) were diagnosed as being antemortem; 126,145 (34%) were sudden fatal PE, and 217,394 (59%) followed undiagnosed PE. Almost three-quarters of all VTE-related deaths were from hospital-acquired VTE. VTE is a major health problem in the EU, with over one million VTE events or deaths per annum in the six countries examined. Given the availability of effective VTE prophylaxis, many of these events and deaths could have been prevented. These results have important implications for the allocation of healthcare resources.
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Affiliation(s)
- Alexander T Cohen
- Vascular Medicine, Department of Surgery, King's College Hospital, London, SE5 9RS, UK.
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29
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Cohen AT, Agnelli G, Anderson FA, Arcelus JI, Bergqvist D, Brecht JG, Greer IA, Heit JA, Hutchinson JL, Kakkar AK, Mottier D, Oger E, Samama MM, Spannagl M. Venous thromboembolism (VTE) in Europe. The number of VTE events and associated morbidity and mortality. Thromb Haemost 2007. [PMID: 17938798 DOI: 10.1160/th07] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Venous thromboembolism (VTE) is often asymptomatic, mis-diagnosed, and unrecognized at death, and there is a lack of routine postmortem examinations. These factors are thought to result in marked underestimates ofVTE incidence. The objective of our study was to estimate the total burden of VTE within the European Union (EU) per annum. An epidemiological model was constructed to estimate the number of community- and hospital-acquired incidents and recurrent cases (attack rate) of nonfatal VTE and VTE-related deaths, as well as incident and prevalent cases of post-thrombotic syndrome (PTS) and chronic thromboembolic pulmonary hypertension (PH) occurring in the EU per annum. Individual models were developed for six EU countries. The models were populated with data from published literature and, where necessary, expert opinions. The findings were tested using probabilistic sensitivity analyses. The estimated total number of symptomaticVTE events (range based on probabilistic sensitivity analysis) per annum within the six EU countries was 465,715 (404,664-538,189) cases of deep-vein thrombosis, 295,982 (242,450-360,363) cases of pulmonary embolism (PE), and 370,012 (300,193-483,108) VTE-related deaths. Of these deaths, an estimated 27,473 (7%) were diagnosed as being antemortem; 126,145 (34%) were sudden fatal PE, and 217,394 (59%) followed undiagnosed PE. Almost three-quarters of all VTE-related deaths were from hospital-acquired VTE. VTE is a major health problem in the EU, with over one million VTE events or deaths per annum in the six countries examined. Given the availability of effective VTE prophylaxis, many of these events and deaths could have been prevented. These results have important implications for the allocation of healthcare resources.
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Affiliation(s)
- Alexander T Cohen
- Vascular Medicine, Department of Surgery, King's College Hospital, London, SE5 9RS, UK.
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Abstract
Guidelines recommend thromboprophylaxis for at least 10 days to prevent venous thromboembolism in patients undergoing high-risk orthopedic surgery, such as total hip arthroplasty (THA) or total knee arthroplasty (TKA). Furthermore, the recently updated ACCP guidelines also recommend extending the duration of thromboprophylaxis for 28 to 35 days following THA or hip fracture surgery as the risk for venous thromboembolism persists for up to 3 months after surgery. Extended-duration thromboprophylaxis (up to 6 weeks) with low-molecular-weight heparin is significantly more effective in preventing venous thromboembolism in orthopedic surgery patients than the recommended practice of at least 10 days. Extended-duration thromboprophylaxis may require risk stratification to identify high-risk patients. Current risk-assessment models have limitations and are not specific to orthopedic surgery patients; therefore, improvements may facilitate the use of extended-duration thromboprophylaxis in high-risk patients, thereby reducing the burden of venous thromboembolism.
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Affiliation(s)
- Juan I Arcelus
- University of Granada Medical School and Hospital San Juan de Dios, Granada, Spain
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31
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Cohen AT, Alikhan R, Arcelus JI, Bergmann JF, Haas S, Merli GJ, Spyropoulos AC, Tapson VF, Turpie AGG. Assessment of venous thromboembolism risk and the benefits of thromboprophylaxis in medical patients. Thromb Haemost 2005; 94:750-9. [PMID: 16270626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Hospitalized patients with acute medical conditions are at significant risk of venous thromboembolism (VTE): approximately 10-30% of general medical patients may develop deep-vein thrombosis or pulmonary embolism, and the latter is a leading contributor to deaths in hospital. Despite consensus-group recommendations that at-risk medical patients should receive thromboprophylaxis, there is currently no consensus as to which patients are at risk, and many patients may not receive appropriate thromboprophylaxis. This paper reviews evidence for the risk of VTE associated with different medical conditions and risk factors, and presents a risk-assessment model for risk stratification in medical patients. Medical conditions associated with a moderate to high risk of VTE include cardiac disease, cancer, respiratory disease, inflammatory bowel disease, and infectious diseases. Importantly, analyses of data from the MEDENOX study show that thromboprophylaxis significantly reduces the risk of VTE in these patient subgroups. Risk factors in medical patients include a history of VTE, history of malignancy, increasing age, thrombophilia, prolonged immobility, and obesity. These medical conditions and risk factors are included in a risk-assessment model which is hoped will provide a simple means of assisting clinicians in deciding whether thromboprophylaxis should be used in an individual patient.
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Affiliation(s)
- Alexander T Cohen
- Vascular Medicine, Department of Surgery, Guy's, King's and St Thomas' School of Medicine, London, UK.
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Cohen AT, Alikhan R, Arcelus JI, Bergmann JF, Haas S, Merli GJ, Spyropoulos AC, Tapson VF, Turpie AGG. Assessment of venous thromboembolism risk and the benefits of thromboprophylaxis in medical patients. Thromb Haemost 2005. [DOI: 10.1160/th05-06-0385] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Arcelus JI, Caprini JA, Monreal M, Suárez C, González-Fajardo J. The management and outcome of acute venous thromboembolism: a prospective registry including 4011 patients. J Vasc Surg 2003; 38:916-22. [PMID: 14603194 DOI: 10.1016/s0741-5214(03)00789-4] [Citation(s) in RCA: 102] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To obtain a realistic overview of management and clinical outcomes of patients with venous thromboembolism (VTE) in Spain on the basis of data from a national multicenter registry. METHODS A prospective registry was initiated in Spain in March 2001. Data were collected from patients with objectively confirmed deep vein thrombosis (DVT) and/or pulmonary embolism (PE) and entered into the online registry by physicians who were responsible for the management of these patients. RESULTS As of August 2002, 4011 patients with confirmed VTE were included in the registry: 60% with DVT, 23% with PE, and 17% with both DVT and PE. Diagnostic methods for VTE included compression ultrasonography (86%), venography (10%), V/Q lung scans (42%), computed tomography scan (28%), and pulmonary angiography (0.9%). D-dimer testing was performed in 61% of cases and was positive in 92% of patients with confirmed VTE. The majority of DVT (95%) were located in the lower extremities (82% proximal and 4% bilateral), while 4.8% were located in the upper extremities or neck veins. Most patients (90.5%) were admitted to hospital. In the acute phase, treatment consisted of low molecular weight heparin (LMWH) in 88%, unfractionated heparin (UFH) in 11%, and fibrinolysis in 0.8%. Cava filters were inserted in 2% of patients, mainly because of active bleeding (13%), increased hemorrhagic risk (38%), or recurrent VTE (29%). Absolute bed rest was recommended to 63% of patients. Secondary prevention of VTE included oral anticoagulants (75%) and LMWH (24.5%). Therapeutic compression stockings were prescribed to 53% of patients at the time of hospital discharge. Regarding the main clinical outcomes during an average (+/-SD) follow-up period of 156 +/- 95 days, 19% had adverse events: 12.5% of patients died, 5.5% had clinically confirmed VTE recurrence, and 9.8% suffered bleeding complications (44% with major bleeding). CONCLUSIONS This prospective observational multicenter registry provides a large database reflecting the actual day-to-day clinical practice regarding VTE management in a European country. The most important findings were the increasing use of spiral computed tomography for PE diagnosis, the unexpectedly high proportion of patients admitted to hospital despite the use of LMWH in almost 90% of cases in the acute phase, and the utilization of LMWH for secondary prevention in almost 25% of cases. On the other hand, this large-scale prospective registry permits on-line consultation of high-risk situations to assess how difficult cases were treated and what their outcomes were. This will provide a most useful tool for the practicing physician responsible for the management of VTE patients.
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Affiliation(s)
- Juan I Arcelus
- Hospital Virgen de las Nieves, University of Granada, Spain
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Caprini JA, Arcelus JI, Maksimovic D, Glase CJ, Sarayba JG, Hathaway K. Thrombosis prophylaxis in orthopedic surgery: current clinical considerations. J South Orthop Assoc 2003; 11:190-6. [PMID: 12597062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
Thrombosis prophylaxis in orthopedic surgery is an important consideration in order to avoid the morbidity and mortality of venous thromboembolism (VTE). Patients who do not receive prophylaxis, or receive inadequate prophylaxis, may be at risk for clinical or fatal pulmonary emboli, and a fatality, although rare, may be the first sign of a VTE. Although the surgeon may have corrected the patient's orthopedic problem, a symptomatic or asymptomatic venous thrombosis may become a new threat to the patient's quality of life. This problem places such patients at risk for recurrent VTE, as well as post-thrombotic syndrome, a progressive, lifelong disability. Methods of prophylaxis that prevent the most clots result in the fewest venous thromboembolic events, but no one method of prophylaxis is suitable for all patients. In order to select the appropriate modality, a careful risk assessment of each patient is necessary. Those at low or moderate risk levels do not require the same modalities that may be used in a patient with a previous history of thrombosis or with many risk factors. The purpose of this brief review is to examine the complications associated with venous thromboembolism and to discuss, in detail, the risk of thrombosis in orthopedic patients. In addition, thrombosis prophylaxis modalities are discussed and suggestions made based on current Chest Consensus Guidelines and FDA-approved products.
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Affiliation(s)
- Joseph A Caprini
- Department of Surgery, Evanston Northwestern Healthcare, Evanston, IL 60201, USA.
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Arcelus JI, Caprini JA, Sehgal LR, Reyna JJ. Home use of impulse compression of the foot and compression stockings in the treatment of chronic venous insufficiency. J Vasc Surg 2001; 34:805-11. [PMID: 11700479 DOI: 10.1067/mva.2001.119504] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE The use of intermittent pneumatic compression, in addition to elastic bandages or stockings, accelerates the healing of leg ulcers in patients with severe chronic venous insufficiency (CVI). There is recent evidence that impulse compression of the plantar venous plexus reduces post-traumatic ankle swelling and prevents postoperative venous thromboembolism. The purpose of this study was to evaluate the clinical and hemodynamic responses after home use of impulse foot compression for 3 months in patients already using therapeutic compression stockings for the management of CVI. METHODS Twelve extremities from 9 patients with documented CVI, class 4 to 5 according to the Clinical, Etiology, Anatomy, Pathophysiology classification system, were included in this prospective cohort study. All patients were instructed to use a foot pump device at home for 2 hours a day for 3 months in addition to therapeutic compression stockings (30-40 mm Hg) worn during the day. The device was set to three cycles (3 seconds) of compression (120 mm Hg) per minute. A clinical scoring system was completed before foot compression and 1, 2, and 3 months thereafter. In addition, all patients underwent air plethysmography studies at the same time intervals, including venous volume, venous filling index, ejection fraction, and residual volume fraction. RESULTS Patients reported significant improvement in their scores for swelling (P <.05) and pain (P <.04). Air plethysmography showed a reduction in venous volume and venous filling index, although these differences were not significant. Ejection fraction remained unchanged and residual volume fraction was significantly reduced (P <.05) compared with baseline. The foot compression devices were well tolerated by all the patients in the study. CONCLUSIONS The use of home foot impulse compression plus elastic stockings significantly reduced the residual volume fraction as measured by air-plethysmography in a group of patients with severe CVI. This favorable hemodynamic response could, in part, explain the clinical improvement achieved by this combined treatment. However, this represents a preliminary pilot study that needs to be confirmed in future randomized controlled studies with more patients included.
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Affiliation(s)
- J I Arcelus
- Department of Surgery, Hospital de la Axarquía, Vélez-Málaga, Spain
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Abstract
Effective and safe methods of preventing venous thromboembolism (VTE) are now widely available, but a significant proportion of patients develop VTE either because thromboprophylaxis has not been used or because the intensity of thromboprophylaxis is not matched to the level of risk. Thromboembolic risk varies widely according to the clinical setting and presence of underlying risk factors, but VTE may not be suspected even in high-risk patients. Clinical risk factors for VTE include recent surgery, cancer, stroke, previous VTE, immobilization, and advanced age. Recent attention has focused on the role of inherited and acquired molecular factors in determining overall thromboembolic risk. These factors include the classic thrombophilias-deficiencies of antithrombin III, protein C, and protein S-and several newly described molecular risk factors: factor V Leiden, the prothrombin 20210A gene mutation, and hyperhomocysteinemia. Based on emerging knowledge of risk factors, several risk assessment models (RAMs) have been devised that stratify patients according to overall VTE risk, allowing thromboprophylaxis to be tailored appropriately. Compared with older risk assessment formulas, current RAMs are simpler and include specific recommendations for thromboprophylaxis based on the available scientific evidence. Consensus documents on VTE prevention classify patients into low-, moderate-, and high-risk categories. More recently, a new risk group, very high risk, has been described. Very-high-risk patients are especially prone to thromboembolic complications and need intensive and in some cases prolonged thromboprophylaxis.
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Affiliation(s)
- J A Caprini
- Department of Surgery, Evanston Northwestern Healthcare, Evanston, IL 60201, USA
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Caprini JA, Arcelus JI, Reyna JJ. Effective risk stratification of surgical and nonsurgical patients for venous thromboembolic disease. Semin Hematol 2001. [DOI: 10.1053/shem.2001.25184] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Arcelus JI, Caprini JA, Reyna JJ. Finding the right fit: effective thrombosis risk stratification in orthopedic patients. Orthopedics 2000; 23:s633-8. [PMID: 10875427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Patients undergoing orthopedic surgery are at increased risk of venous thromboembolic events. Proven prophylactic measures are available but are generally underused. However, even one of the most effective therapies available, low-molecular-weight heparin, fails to prevent deep vein thrombosis in approximately 15% of patients undergoing total hip replacement. Clinical outcomes and cost-effectiveness of venous thromboembolism prophylaxis may be optimized by tailoring the treatment to the level of risk of each patient. Overall thromboembolic risk depends on the interactions among multiple factors, such as those that relate to the current clinical status and underlying susceptibility of the patient. Presently, risk assessment models that consider these factors may be of practical assistance in stratifying patients. Improving identification of patients with additional risk factors is a goal of future models. Novel therapies, such as the recombinant hirudin desirudin, or strategies, such as prolonged postoperative prophylaxis, may provide improved protection in these patients and should be considered in the future.
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Affiliation(s)
- J I Arcelus
- Department of Surgery, Hospital Comarcal de la Axarquía, Vélez-Málaga, Spain
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Affiliation(s)
- G D Motykie
- Department of Surgery, Evanston Northwestern Healthcare, Evanston, IL 60201, USA
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Motykie GD, Caprini JA, Arcelus JI, Zebala LP, Lee CE, Finke NM, Tamhane A, Reyna JJ. Risk factor assessment in the management of patients with suspected deep venous thrombosis. INT ANGIOL 2000; 19:47-51. [PMID: 10853685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
BACKGROUND To evaluate the prevalence of thrombosis risk factors in a group of patients undergoing venous duplex scanning (VDS) and to design a risk factor stratification model with the ability to improve the diagnostic yield of VDS. METHODS Risk factor assessment and VDS were performed on 1,000 patients with clinically suspected lower extremity deep vein thrombosis (DVT) and patients were divided into two groups based upon the outcome of their scan: those with and those without confirmed DVT. Univariate and multivariate logistic regression analyses were performed in order to determine the significance of each risk factor in relation to having a confirmed DVT. RESULTS There were 181 patients (18.1%) with confirmed DVT. A prior history of DVT/pulmonary embolism, malignancy, prior immobilization, and age over 70 were the most important risk factors associated with having a DVT confirmed on VDS. A novel risk factor stratification model was created utilizing the odds ratios of those factors found to be significant and the prevalence of DVT was found to be 92.4% in the high risk category, 11.5% in the moderate risk category, and 3.2% in the low risk category using this model. CONCLUSIONS Venous duplex scanning is established as the screening test of choice when one suspects the diagnosis of DVT despite the significant cost of performing and interpreting the test. We suggest that a better clinical model utilizing risk factor assessment may be the key to increasing the yield rate and cost-effectiveness of VDS by excluding low-risk patients from undergoing unnecessary testing.
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Affiliation(s)
- G D Motykie
- Department of Surgery, Evanston Northwestern Healthcare, IL 60201, USA
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Caprini JA, Arcelus JI, Motykie G, Kudrna JC, Mokhtee D, Reyna JJ. The influence of oral anticoagulation therapy on deep vein thrombosis rates four weeks after total hip replacement. J Vasc Surg 1999; 30:813-20. [PMID: 10550178 DOI: 10.1016/s0741-5214(99)70005-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
PURPOSE The purpose of this study was to assess the rate of postoperative deep vein thrombosis (DVT) as a function of oral anticoagulation therapy after total hip replacement surgery. METHODS A total of 125 patients completed the study. All the patients received sequential gradient pneumatic compression over elastic stockings until hospital discharge. In addition, all the patients underwent postoperative heparin therapy followed by oral warfarin therapy, adjusted in dose to maintain a goal international normalized ratio (INR) level of 2.0 to 3.0. Warfarin therapy and compression stockings were continued for 1 month after surgery. Bilateral duplex scanning was performed 1 and 4 weeks after surgery to assess the rate of DVT. RESULTS Nineteen of the 125 patients had DVT develop (15.2%). Of those thromboses, six (31.6%) and 13 (68%) were detected 1 week and 1 month after surgery, respectively. The rate of proximal DVT was 2.4% (3 of 125) 1 week after surgery and rose to 8.2% (10 of 122) 1 month after surgery. Most DVT cases (64%; 12 of 19) were asymptomatic. The patients in whom DVT developed had significantly lower INR values during the second to fourth postoperative weeks than did those patients without thrombosis, and no differences in INR values were found during the first postoperative week. CONCLUSION The risk of the development of DVT extends beyond hospital discharge in patients who undergo total hip replacement, despite a regimen of prolonged oral anticoagulation therapy. This is particularly true in patients whose INR values did not reach therapeutic range during the first postoperative month. Therefore, thrombosis prophylaxis regimens on the basis of the administration of warfarin should try to maintain INR values within therapeutic range during the entire first postoperative month to minimize the incidence of DVT.
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Affiliation(s)
- J A Caprini
- Department of Surgery, Evanston Northwestern Healthcare, Evanston, Illinois, USA
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Abstract
OBJECTIVE The purpose of this study was to assess the rate of deep vein thrombosis (DVT) resolution and DVT outcomes as functions of the level of oral anticoagulation therapy achieved with warfarin. METHODS In 33 consecutive patients, a series of 35 limbs with acute symptomatic DVT was followed throughout 1 year of anticoagulation therapy. All the patients underwent 5 days of intravenous unfractionated sodium heparin therapy that was adjusted in dose to prolong the activated thromboplastin time to 2.0 to 2.5 times the control. In addition, warfarin was administered for a period of 6 months, with a target international normalized ratio (INR) between 2.0 and 3.0. All the patients underwent venous duplex scanning and physical examination at the time of diagnosis and at 1 week, 1 month, 3 months, 6 months, and 1 year. RESULTS At the end of the 1-year study period, the rate of complete DVT resolution was 68%. The median INR values in patients with complete DVT resolution were significantly higher than those of patients with incomplete DVT resolution after 1, 3, and 6 months of treatment with warfarin. In addition, the proportion of patients with INR values below therapeutic range was significantly higher in patients with incomplete DVT resolution than in patients with complete DVT resolution after 1, 3, and 6 months of treatment with warfarin. The presence of occlusive thrombi was associated with incomplete DVT resolution. Of the patients with occlusive thrombi, 62% had chronic venous insufficiency symptoms develop, whereas only 11% of the patients with nonocclusive thrombi (P =.003) had these symptoms develop. CONCLUSION Despite 6 months of oral anticoagulant therapy, almost one third of thrombi did not resolve completely. The INR values were significantly higher in those patients with complete DVT resolution. These results suggest that the maintenance of an INR level between 2.0 and 3.0 throughout oral anticoagulation therapy will minimize the rate of incomplete DVT resolution.
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Affiliation(s)
- J A Caprini
- Departments of Surgery, Evanston Northwestern Healthcare and Northwestern University Medical School, Evanson, Illinois, USA
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Haas S, Agnelli G, Arcelus JI, Davidson BL, Lassen MR, Planés A. Workshop II: The future of prolonged thromboprophylaxis. Blood Coagul Fibrinolysis 1999; 10 Suppl 2:S103-6. [PMID: 10493238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Affiliation(s)
- S Haas
- Institute for Experimental Oncology and Therapeutic Research, Technical University of Munich, Germany
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Arcelus JI, Caprini JA, Motykie GD, Reyna JJ. Matching risk with treatment strategies in deep vein thrombosis management. Blood Coagul Fibrinolysis 1999; 10 Suppl 2:S37-43. [PMID: 10493229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
Successful and cost-effective prophylaxis against venous thromboembolism (VTE) depends on the availability of safe and effective antithrombotic methods, and the ability to match these to patients according to their level of thromboembolic risk. The last 20 years have seen significant developments in methods of thromboprophylaxis but, despite use of the best available methods, VTE still occurs in a significant proportion of patients. Efforts are now focused both on developing more effective pharmacological and physical methods, and improving assessment of thromboembolic risk in clinical practice, with the goal of avoiding unnecessary prophylaxis in low-risk patients and providing enhanced protection to high-risk patients. Factors known to exert a direct effect on thromboembolic risk include previous VTE, advancing age, surgery, malignancy, immobility, and the presence of thrombophilic states. Other less well-defined risk factors include obesity, pregnancy, and leg varicosities. Various risk assessment models (RAMs) have been devised based on these factors, but most of the resulting risk assessment formulae, some of them based on laboratory test results, have been too complicated to gain acceptance in routine clinical practice. Reflecting the need to refine the use of thromboprophylaxis in clinical practice, a number of RAMs have been developed recently, based on epidemiological evidence. Some models include specific recommendations for prophylaxis, based on evidence from randomized, controlled trials.
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Affiliation(s)
- J I Arcelus
- Department of Surgery, Hospital de la Axarquía, Vélez-Málaga, Spain.
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Motykie GD, Caprini JA, Arcelus JI, Reyna JJ, Overom E, Mokhtee D. Evaluation of therapeutic compression stockings in the treatment of chronic venous insufficiency. Dermatol Surg 1999; 25:116-20. [PMID: 10037516 DOI: 10.1046/j.1524-4725.1999.08095.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Chronic venous insufficiency (CVI) affects a significant portion of the world's population, causing substantial morbidity and medical expenditure. Its pathophysiology is based on venous hypertension in the lower extremities, with vascular compression therapy remaining the foundation of its medical management. OBJECTIVE To evaluate the effectiveness of therapeutic compression stockings in the treatment of lower extremity CVI. METHODS A group of 112 patients with CVI received graduated-compression stockings and rated the severity of their symptoms on a five-point scale before wearing the stockings, and then again after 1 and 16 months of treatment. Patient complaints associated with stocking use and patient compliance rates were also recorded at 1 and 16 months. RESULTS A statistically significant improvement (p < 0.001) was reported in patient severity scores for lower extremity swelling, pain, skin discoloration, activity tolerance, depression and sleeping problems after 1 and 16 months of treatment with compression stockings. CONCLUSION Therapeutic graduated-compression stockings are an effective treatment for CVI of the lower extremities.
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Affiliation(s)
- G D Motykie
- Department of Surgery, Evanston Northwestern Healthcare, Illinois 60201, USA
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Arcelus JI, Caprini JA, Hoffman KN, Fink N, Size GP, Fareed J, Hoppensteadt D. Laboratory assays and duplex scanning outcomes after symptomatic deep vein thrombosis: preliminary results. J Vasc Surg 1996; 23:616-21. [PMID: 8627897 DOI: 10.1016/s0741-5214(96)80041-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE The purpose of this article was to assess a number of hematologic and fibrinolytic assays at the time of diagnosis of deep vein thrombosis (DVT) and at several intervals over a period of 6 months afterward and to correlate these results with the results of serial duplex scanning. METHODS Thirty-five patients (average age 61, range 18 to 82) with acute symptomatic DVT confirmed by duplex scanning were included. On diagnosis, blood was drawn, and plasma levels of tissue-type plasminogen activator (t-PA), plasminogen activator inhibitor (PAI), D-dimer (DD), and tissue factor pathway inhibitor (TFPI) were determined. Duplex scanning and all laboratory assays were repeated 1 week, 1 month, 3 months, and 6 months thereafter. RESULTS The rate of DVT complete resolution 6 months after diagnosis was 57%. Whereas plasma levels of PAI were similar throughout the 6-month follow-up period, t-PA increased significantly 1 week after diagnosis and decreased thereafter. Both DD and TFPI levels decreased significantly after diagnosis compared with presentation values. Comparing these assay levels between patients with complete resolution versus partial or no resolution, PAI levels were significantly higher during the first week in patients with poor outcome. Plasma levels of t-PA were higher in cases with good outcome, and DD levels were higher in patients with poor outcome. TFPI levels were similar in both outcome groups. CONCLUSIONS Patients with complete DVT resolution on duplex scanning at 6 months had significantly lower levels of PAI on presentation and after 1 week than did those with incomplete lysis. Although differences were not significant, t-PA levels were higher and DD lower in patients with good outcome. Our results suggest that certain plasma fibrinolytic assays might correlate with the outcome of DVT, as assessed by duplex ultrasonography.
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Affiliation(s)
- J I Arcelus
- Department of Surgery, Glenbrook Hospital, Glenview, IL 60025, USA
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Arcelus JI, Caprini JA, Hoffman KN, Traverso CI, Hoppensteadt D, Fareed J. Modifications of plasma levels of tissue factor pathway inhibitor and endothelin-1 induced by a reverse Trendelenburg position: influence of elastic compression--preliminary results. J Vasc Surg 1995; 22:568-72. [PMID: 7494357 DOI: 10.1016/s0741-5214(95)70039-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
PURPOSE The purpose of this study was to assess the effects of the passive 45-degree reverse Trendelenburg position and graduated compression stockings (GCS) on plasma tissue factor pathway inhibitor (TFPI) and endothelin-1 levels in a group of volunteers. METHODS Ten healthy subjects lay on an examining table for 30 minutes while baseline measurements were made. The table was then tilted to a 45-degree upright position for 60 minutes, and measurements were repeated. On a different day, subjects were tilted again, but on this occasion they wore thigh-length GCS. Blood was drawn before and 60 minutes after tilting during both sessions, and plasma TFPI and endothelin-1 were obtained. Cross-sectional areas of the calf medial gastrocnemius vein, before and after tilting, were measured by a duplex scanner. RESULTS Upright tilting induced a significant dilation of the medial gastrocnemius veins that was partially corrected by the use of elastic stockings. Similarly, endothelin-1 levels significantly increased after tilting. The use of GCS did not modify these differences. On the other hand, although TFPI levels were not affected by tilting without stockings, they were significantly elevated after tilting when GCS were used. CONCLUSIONS Upright passive tilting induces significant dilation of the deep calf veins and is associated with a significant increase in plasma levels of endothelin-1, whereas TFPI levels remain unchanged. The use of elastic stockings reduces the degree of calf distention but does not prevent an increase in endothelin-1. TFPI levels are significantly increased after tilting when GCS are used. This might represent a previously unknown mechanism of action of elastic stockings with interesting potential for deep vein thrombosis prophylaxis. More studies are warranted in a larger series to confirm these results.
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Affiliation(s)
- J I Arcelus
- Department of Surgery, Glenbrook Hospital, Glenview, IL 60025, USA
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Caprini JA, Arcelus JI, Hoffman KN, Size G, Laubach M, Traverso CI, Coats R, Finke N, Reyna JJ. Venous duplex imaging follow-up of acute symptomatic deep vein thrombosis of the leg. J Vasc Surg 1995; 21:472-6. [PMID: 7877229 DOI: 10.1016/s0741-5214(95)70289-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE The purpose of this study was to evaluate the rate of resolution of deep vein thrombosis (DVT) in the leg, by means of duplex imaging, in patients with symptoms during a 6-month period after initial diagnosis. METHODS Seventy-three limbs in 69 patients with acute DVT diagnosed by duplex imaging received conventional heparin and warfarin treatment and underwent subsequent duplex studies 1, 4, 12, and 24 weeks after the initial diagnosis. The objectives of the study were to document (1) the rate or complete resolution of DVT, (2) the proportion of unstable, floating thrombi, and (3) the development of chronic damage as a result of vessel wall scarring. RESULTS The rate of normalization of DVT 6 months after diagnosis was 78% in the common femoral vein, 70% in the superficial femoral vein, 75% in the popliteal vein, and 70% in the calf veins examined at the scheduled intervals. Twenty-six percent of thrombi were considered unstable on the baseline examination. The average number of days necessary for these thrombi to become stable was 10.7 days. Damage to the vessel wall or valves was documented in 44% of the patients. CONCLUSIONS Rates of resolution of DVT were similar for the different veins of the leg studied. There was a high proportion of unstable thrombi, which present a high potential risk of embolization. Serial duplex scanning after DVT renders important information with regard to thrombus resolution, propagation, and attachment to the vein wall.
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Affiliation(s)
- J A Caprini
- Department of Surgery, Glenbrook Hospital, Glenview, IL 60025
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Caprini JA, Arcelus JI, Laubach M, Size G, Hoffman KN, Coats RW, Blattner S. Postoperative hypercoagulability and deep-vein thrombosis after laparoscopic cholecystectomy. Surg Endosc 1995; 9:304-9. [PMID: 7597604 DOI: 10.1007/bf00187774] [Citation(s) in RCA: 86] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Patients who undergo laparoscopic cholecystectomy (LC) are operated on under general anesthesia, in a reverse Trendelenburg position, with 12-15-mmHg pneumoperitoneum. All of these factors can induce venous stasis of the legs, which may lead to postoperative deep-vein thrombosis (DVT). The objectives of this study were to assess the degree of hypercoagulability and to determine the rate of postoperative DVT in a group of 100 patients in whom LC was completed. Whole-blood thrombelastography (TEG) and plasma-activated partial thromboplastin time (PTT) determination were carried out preoperatively and on the 1st postoperative day. All patients received pre-, intra-, and postoperative graduated compression stockings and sequential pneumatic compression devices until fully ambulatory. Twenty-six percent of the patients with a risk score > 4, or a post-operative TEG index > +5.0, received subcutaneous heparin (5,000 units b.i.d.), beginning in the postoperative period and continuing for 4 weeks as an outpatient. A complete venous duplex scan of both legs was performed on the 7th postoperative day, at the time of their office visit. Our results revealed significant postoperative hypercoagulability for the TEG index (P < 0.005) and for PTT (P < 0.05). One patient had an asymptomatic DVT (1%), and no side effects from the mechanical or pharmacological prophylaxis occurred in this series. These data suggest that the low incidence of thrombosis in the face of theoretical and laboratory evidence of postoperative hypercoagulability may reflect an effective prophylactic regime.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- J A Caprini
- Department of Surgery, Glenbrook Hospital, Glenview, IL 60025, USA
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Caprini JA, Arcelus JI, Hoffman K, Mattern T, Laubach M, Size GP, Traverso CI, Coats R. Prevention of venous thromboembolism in North America: results of a survey among general surgeons. J Vasc Surg 1994; 20:751-8. [PMID: 7966811 DOI: 10.1016/s0741-5214(94)70188-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
PURPOSE The purpose of this study was to analyze current attitudes toward the prevention of postoperative venous thromboembolism among North American general surgeons. METHODS A survey regarding awareness of the problem of venous thromboembolism and preferred modalities of prophylaxis was sent to 3500 randomly selected Fellows of the American College of Surgeons. RESULTS A total of 1018 (29.1%) surveys was returned. Most of the responding surgeons consider venous thromboembolism a serious health problem. Ninety percent of the surgeons use prophylaxis against venous thromboembolism routinely. The most frequently used modalities are intermittent pneumatic compression, low-dose heparin, and elastic stocking. A combination of physical and pharmacologic methods is used by one fourth of respondents, and only 50% start pharmacologic prophylaxis before the surgical procedure. The thrombosis risk factors that are most frequently considered by surgeons when deciding about using prophylaxis are history of venous thromboembolism, immobility, and length of operation. CONCLUSIONS North American surgeons who responded to this survey are well aware of the problem of venous thromboembolism and their approach to prevention has been significantly modified in the last 10 years. Compared with similar European surveys this survey reveals a higher implementations of physical methods such as intermittent pneumatic compression and elastic stockings. Because of the limited response rate and possibility of sampling bias, these findings should be interpreted with caution.
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Affiliation(s)
- J A Caprini
- Department of Surgery, Glenbrook Hospital, IL 60025
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