Duration Of Anticoagulant Treatment Research Articles

Coronary Stents and Chronic Anticoagulation

Case Presentation: A 76-year-old man was admitted with retrosternal chest pain. The ECG on admission showed inferolateral ST depression, and troponin levels were elevated, confirming the diagnosis of an acute coronary syndrome. The patient had a history of hypertension and aortic valve replacement with a metallic bileaflet valve 7 years before. He was being treated with warfarin and low-dose aspirin and had an international normalized ratio (INR) of 2.5. Coronary angiography revealed a long subocclusive lesion of the proximal right coronary artery. At that point, there was a question about the optimal treatment for this patient regarding the type of stent to be selected and the need for future combined antiplatelet and anticoagulation treatment. Oral anticoagulation was routinely used for coronary stent thrombosis prevention during the first era of stents.1 It has since been replaced by the combination of aspirin and a thienopyridine because studies have shown a definite advantage of the antiplatelet combination on coronary events2–4 and on reducing the risk of access-site bleeding complications. However, ≈5%5,6 of patients undergoing percutaneous coronary intervention (PCI) also present with an indication for oral anticoagulation therapy. In such cases, the type of stent selected; the use of oral anticoagulants, antiplatelets, or their combinations; the target INR; and the duration of treatment are essential considerations in relation to the risk of stent thrombosis/thromboembolic events and bleeding risk. With the introduction and widespread use of drug-eluting stents (DES) in recent years and given the necessity for longer duration of dual antiplatelet therapy, the issue of concurrent warfarin and antiplatelet therapy has become even more important. The existing guidelines do not offer a convincing solution to these issues. For acute coronary syndrome patients with an indication for anticoagulation, triple therapy (warfarin, aspirin, and clopidogrel) for the minimum time possible and a maintenance …

Duration of anticoagulant treatment and recurrence of venous thromboembolism in patients with and without thrombophilic abnormalities

Duration of anticoagulant treatment and recurrence of venous thromboembolism in patients with and without thrombophilic abnormalities -

Characteristics of bleeding complications in patients with anticoagulant treatment.

Anticoagulation treatment is effective in the prevention of stroke as well as deep venous thrombosis (DVT) and pulmonary embolism (PE). Its preventive benefit has to be balanced against possible bleeding complications. We sought to assess risk factors for the severity of bleeding events in patients under anticoagulant treatment. Clinical characteristics, type of anticoagulant treatment, bleeding site, risk factors and additional medication taken were analysed in patients with bleeding complications during an observation period of 12 months. Eighty-seven bleeding complications in 84 patients (mean age, 79 years; 51% female) were observed from January to December 2005 at the Department of Internal Medicine of the Cantonal Hospital of Aargau. Most bleeding complications occurred in the gastrointestinal tract (54%). The median time interval from the beginning of the anticoagulant treatment to the bleeding event was 34 months. Forty-nine percent of events occurred after a treatment time above 36 months. Age was not found to influence the severity of bleeding but the duration of anticoagulant treatment before the occurrence of a complication was significantly longer for older patients (p = 0.001). Our study shows no influence of age on severity of bleeding complications. Furthermore, in patients with advanced age complications occurred later in the treatment course than in younger patients. Overall we assessed various bleeding events in patients treated for over three years. Therefore we emphasize the importance of closely controlling patients on anticoagulant treatment in the later course of treatment and to take account of the anticoagulation when ordering new medication.

Characteristics of bleeding complications in patients with anticoagulant treatment.

Anticoagulation treatment is effective in the prevention of stroke as well as deep venous thrombosis (DVT) and pulmonary embolism (PE). Its preventive benefit has to be balanced against possible bleeding complications. We sought to assess risk factors for the severity of bleeding events in patients under anticoagulant treatment. Clinical characteristics, type of anticoagulant treatment, bleeding site, risk factors and additional medication taken were analysed in patients with bleeding complications during an observation period of 12 months. Eighty-seven bleeding complications in 84 patients (mean age, 79 years; 51% female) were observed from January to December 2005 at the Department of Internal Medicine of the Cantonal Hospital of Aargau. Most bleeding complications occurred in the gastrointestinal tract (54%). The median time interval from the beginning of the anticoagulant treatment to the bleeding event was 34 months. Forty-nine percent of events occurred after a treatment time above 36 months. Age was not found to influence the severity of bleeding but the duration of anticoagulant treatment before the occurrence of a complication was significantly longer for older patients (p = 0.001). Our study shows no influence of age on severity of bleeding complications. Furthermore, in patients with advanced age complications occurred later in the treatment course than in younger patients. Overall we assessed various bleeding events in patients treated for over three years. Therefore we emphasize the importance of closely controlling patients on anticoagulant treatment in the later course of treatment and to take account of the anticoagulation when ordering new medication.

Case Fatality Rates of Recurrent Venous Thromboembolism during and Following Anticoagulation Therapy

Background: The optimal duration of anticoagulation treatment in patients with unprovoked VTE is unknown. In order to counsel VTE patients on the risks and benefits of discontinuing anticoagulants, clinicians need to balance the long-term risk of recurrent VTE with major bleeding on anticoagulants. For all VTE patients on oral anticoagulant, the case-fatality rate of major bleeding was previously reported to be 13.4% (95% confidence intervals (CI): 9.4% to 17.4%). A major knowledge gap exists regarding the case-fatality rate of recurrent pulmonary embolism (PE) during and following anticoagulation therapy for VTE.Purpose: To summarize the case fatality rate of recurrent VTE during and following anticoagulation therapy.Data Source: A systematic literature search strategy was conducted using MEDLINE, EMBASE, the Cochrane Register of Controlled Trials and all EBM Reviews. Study Outcome: We selected 62 studies that reported the rates of fatal PE in patients with recurrent VTE. Fatal PE was defined asconfirmed autopsy report;death preceding with confirmed deep vein thrombosis (DVT) or non-fatal PE;sudden death not explained by a condition other than PE.Measurements: Pooled case fatality rates were generated. Ninety-five percent CI were calculated for each case fatality rate using averaged, inverse variance-weighted estimates from each study.Data Synthesis: 30,885 VTE patients were included (17,650 DVT, 8801 PE and 4434 DVT or PELimitations: Unable to determine the case fatality rate by etiology of VTE (i.e. provoked, unprovoked).Conclusion: Case fatality rates for recurrent VTE are elevated during and following anticoagulation treatment for VTE but appear lower than the case-fatality rate for major bleeding with oral anticoagulants. This information must be considered by clinicians when counseling patients on whether to continue or discontinue anticoagulant therapy following VTE. Not only must absolute recurrent VTE and major bleeding rates be compared between groups that continue and discontinue anticoagulants but the relative consequences (i.e. case fatality rates) must be also considered with more weight placed on major bleeding episodes.Initial eventDuring anticoagulation Treatment (%, 95% CI)Following anticoagulation Treatment (%, 95% CI)DVT10.6 (8.3–13.0)7.3 (5.0–9.7)PE12.3 (5.9–18.7)12.5 (6.4–28.7)Any event10.2 (7.9–12.5)9.0 (7.3–10.8)

Residual vein thrombosis to establish duration of anticoagulation after a first episode of deep vein thrombosis: the Duration of Anticoagulation based on Compression UltraSonography (DACUS) study

AbstractResidual vein thrombosis (RVT) indicates a prothrombotic state and is useful for evaluating the optimal duration of oral anticoagulant treatment (OAT). Patients with a first episode of deep vein thrombosis, treated with OAT for 3 months, were managed according to RVT findings. Those with RVT were randomized to either stop or continue anticoagulants for 9 additional months, whereas in those without RVT, OAT was stopped. Outcomes were recurrent venous thromboembolism and/or major bleeding. Residual thrombosis was detected in 180 (69.8%) of 258 patients; recurrent events occurred in 27.2% of those who discontinued (25/92; 15.2% person-years) and 19.3% of those who continued OAT (17/88; 10.1% person-years). The relative adjusted hazard ratio (HR) was 1.58 (95% confidence interval [CI], 0.85-2.93; P = .145). Of the 78 (30.2%) patients without RVT, only 1 (1.3%; 0.63% person-years) had a recurrence. The adjusted HR of patients with RVT versus those without was 24.9 (95% CI, 3.4-183.6; P = .002). One major bleeding event (1.1%; 0.53% person-years) occurred in patients who stopped and 2 occurred (2.3%; 1.1% person-years) in those who continued OAT. Absence of RVT identifies a group of patients at very low risk for recurrent thrombosis who can safely stop OAT. This trial was registered at http://www.ClinicalTrials.gov as no. NCT00438230.

Treatment of DVT: how long is enough and how do you predict recurrence

Currently available anticoagulants are effective in reducing the recurrence rate of venous thromboembolism (VTE). However, anticoagulant treatment is associated with an increased risk for bleeding complications. Thus, anticoagulation has to be discontinued when benefit of treatment no longer clearly outweigh its risks. The duration of anticoagulant treatment is currently framed based on the estimated individual risk for recurrent VTE. The incidence of recurrent VTE can be estimated through a two-step decision algorithm. Firstly, the features of the patient (gender), of the initial event (proximal or distal deep vein thrombosis or pulmonary embolism), and the associated conditions (cancer, surgery, etc) provide essential information on the risk for recurrence after anticoagulant treatment discontinuation. Secondly, at time of anticoagulant treatment discontinuation, D: -dimer levels and residual thrombosis have been indicated as predictors of recurrent VTE. Current evidence suggests that the risk of recurrence after stopping therapy is largely determined by whether the acute episode of VTE has been effectively treated and by the patient's intrinsic risk of having a new episode of VTE. All patients with acute VTE should receive oral anticoagulant treatment for three months. At the end of this treatment period, physicians should decide for withdrawal or indefinite anticoagulation. Based on intrinsic patient's risk for recurrent VTE and for bleeding complications and on patient preference, selected patients could be allocated to indefinite treatment with VKA with scheduled periodic re-assessment of the benefit from extending anticoagulation. Alternative strategies for secondary prevention of VTE to be used after conventional anticoagulation are currently under evaluation. Cancer patients should receive low molecular-weight heparin over warfarin in the long-term treatment of VTE. These patients should be considered for extended anticoagulation at least until resolution of underlying disease. The risk for recurrent venous thromboembolism can be estimated through a two-step algorithm. Firstly, the features of the patient (gender), of the initial event (proximal or distal deep vein thrombosis or pulmonary embolism), and the associated conditions (cancer, surgery, etc) are essential to estimate the risk for recurrence after anticoagulant treatment discontinuation. Secondly, a correlation has been shown between D: -dimer levels and residual thrombosis at time of anticoagulant treatment discontinuation and the risk of recurrence. Currently available anticoagulants are effective in reducing the incidence of recurrent venous thromboembolism, but they are associated with an increased risk for bleeding complications. All patients with acute venous thromboembolism should receive oral anticoagulant treatment for three months. At the end of this treatment period physicians should decide for definitive withdrawal or indefinite anticoagulation with scheduled periodic re-assessment of the benefit from extending anticoagulation.

Thromboses sur cathéter central chez le patient cancéreux

Increased incidence of cancers and the development of totally implanted venous access devices that contain their own port to deliver chemotherapy will lead to a greater than before numbers of central venous catheter related thrombosis (CVCT). Medical consequences include catheter dysfunction and pulmonary embolism. Compared with lower extremity deep venous thrombosis (DVT) (3 d) and with non CVC associated thrombosis (5 d), CVCT is associated with an increased duration of hospitalisation (9 d). CVCT oftentimes leads to the need to replace such ports at an average cost of 4500 euros. Vessel injury caused by the procedure of CVC insertion is the most important risk factor for development of CVCT. This event could cause the formation of a fresh thrombus, which is reversible in the large majority of patients. The incidence of CVC-related DVT assessed by venography has been reported to vary from 30 to 60% but catheter-related DVT in adult patients is symptomatic in only 5% of cases. The majority of patients with CVC-related DVT is asymptomatic or has non-specific symptoms: arm or neck swelling or pain, distal paresthesias, headache, congestion of subcutaneous collateral veins. In the case of clinical suspicion of CVC-related DVT, compressive ultrasonography (US), especially with Doppler and color imaging, currently is first used to confirm the diagnosis. The main criteria of color-Doppler US are visualization of mural thrombi or incompressibility of the veins. Consequently, contrast venography is reserved for clinical trials and difficult diagnostic situations. There is no consensus on the optimal management of patients with CVC-related DVT. Treatment of CVC-related VTE requires a 5- to 7-day course of adjusted-dose unfractionated heparin or LMWH followed by oral anticoagulants. Long-term LMWH that has been shown to be more effective than oral anticoagulant in cancer patients with lower limb DVT could be used in these patients. The optimal duration of oral anticoagulation treatment for CVC-related DVT is unknown, but patients with active cancer should be treated for at least 6 months or indefinitely. The efficacy and safety of pharmacologic prophylaxis for CVC related thrombosis is not established. Additional studies performed in high risk populations are needed to define if LMWH or oral anticoagulation is indicated in this clinical setting.

Association of Persistent Right Ventricular Dysfunction at Hospital Discharge After Acute Pulmonary Embolism With Recurrent Thromboembolic Events

In patients with acute pulmonary embolism, right ventricular dysfunction (RVD) on hospital admission is a predictor of adverse short-term clinical outcome. The aim of this study was to evaluate the prognostic value of RVD persistence at hospital discharge with regard to the likelihood of recurrent venous thromboembolism (VTE). Echocardiography was used to assess RVD on admission and before hospital discharge in 301 consecutive patients with the first episode of acute pulmonary embolism occurring from January 1998 through July 2004. Right ventricular dysfunction was diagnosed in the presence of 1 or more of the following: right ventricular dilation (without hypertrophy), paradoxical septal systolic motion, and Doppler evidence of pulmonary hypertension. Patients were followed up at 2, 6, and 12 months and yearly thereafter. The primary end point was symptomatic, recurrent fatal or nonfatal VTE. Patients were categorized as those (1) without RVD (155 patients [51.5%]), (2) with RVD regression (RVD on admission but not at discharge; 87 patients [28.9%]), and (3) with persistent RVD (RVD on admission and at discharge; 59 patients [19.6%]). After a mean +/- SD of 3.1 +/- 2.7 years, patients with RVD persistence showed an increased risk of recurrent VTE (14 patients, 9.2% patient-years) compared with those without RVD (15 patients, 3.1% patient-years) or RVD regression (3 patients, 1.1% patient-years) (P = .001). Six of 8 deaths related to pulmonary embolism occurred in patients with RVD persistence. At multivariate analysis, adjusted by anticoagulant treatment duration, RVD persistence was an independent predictor of recurrent VTE (hazard ratio, 3.79; P<.001). Persistent RVD at hospital discharge after an acute pulmonary embolism is associated with recurrent VTE.

Regional Anesthesia for a Parturient with Venous Sinus Thrombosis and Placental Abruption Undergoing Fractional Heparin Therapy

THE increased incidence of thrombosis and hypercoagu-lability during pregnancy are well recognized and require anticoagulation for symptomatic sequelae. The following case illustrates our perioperative treatment of a patient with vaginal bleeding while undergoing treatment for a transverse sinus thrombosis.

Effect of patient's sex on risk of recurrent venous thromboembolism: a meta-analysis

Individual risk of recurrent venous thromboembolism affects patient management and might differ between men and women. We did a meta-analysis to assess from available evidence whether men and women have the same risk of recurrent venous thromboembolism after stopping anticoagulant treatment. Eligible articles were identified by searches of MEDLINE (source PubMed, 1966 to February 2005), EMBase (1980 to February 2005), and the Cochrane database 2005, issue 1. Prospective cohort studies and randomised trials were eligible if they included patients with objectively diagnosed venous thromboembolism treated for a minimum of 1 month and followed up for recurrence after anticoagulant treatment was stopped. Data were extracted for study design, study quality, and the number, sex, and age of enrolled patients, risk factors for venous thromboembolism, treatment given, duration of follow-up, and the number of episodes of recurrent venous thrombosis. 15 studies (nine randomised controlled trials and six prospective observational studies) enrolling a total of 5416 individuals (2729 men), of whom 816 (523 men) had recurrent venous thromboembolism after stopping treatment, were eligible for inclusion. The pooled estimate of the relative risk (RR) of recurrent venous thromboembolism for men compared with for women was 1.6 (95% CI 1.2-2.0). Significant heterogeneity was shown among individual study findings; however, the higher risk of recurrent venous thromboembolism in men than in women was consistent across predefined subgroups. The relative risk for recurrence in men from randomised trials (RR 1.3; 95% CI 1.0-1.8) was lower than that from observational studies (2.1; 1.5-2.9). The lower risk of recurrent venous thromboembolism in women did not seem to be accounted for by a reduced rate of recurrence after venous thromboembolism associated with oestrogen treatment or pregnancy. Men seem to have a 50% higher risk than women of recurrent venous thromboembolism after stopping anticoagulant treatment. If confirmed by further prospective studies, this difference in risk of recurrence should be considered when duration of anticoagulant treatment is determined in individual patients.

Small Molecule Coagulation Cascade Inhibitors in the Clinic

Venous thromboembolic disease, including deep vein thrombosis and pulmonary embolism, is a cause of significant mortality and morbidity. For several decades, anticoagulant options for the treatment and prevention of thrombosis have been limited mainly to agents such as unfractionated heparin and oral vitamin K antagonists such as warfarin. Although these therapies have proven benefits, they also have important limitations that result in their underuse in routine clinical practice. A variety of novel anticoagulants with improved pharmacologic and clinical profiles are in development, offering benefits over traditional therapies. Specifically, progress has been made in the development of small molecule Factor Xa inhibitors and thrombin inhibitors. The most advanced drugs reviewed include DPC-423, DPC-602, razaxaban, GSK's 813893, Portola's Xa inhibitors (formerly Millennium), otamixaban, DU-176b, KFA-1982, BAY-59-7939, DX-9065a, YM-150, LY-517717, Exanta, 3DP's thrombin inhibitors, SSR-182289, LB-30057, LB-30870, BIBR-1048 and Merck's thrombin inhibitors. With their potentially consistent and predictable pharmacological profile, oral formulation, and decreased need for coagulation monitoring, these new agents will likely increase the use and duration of anticoagulation treatment in thromboembolic disorders and reduce the burden associated with long-term management.

Thrombophilia, Clinical Factors, and Recurrent Venous Thrombotic Events

Data on the recurrence rate of venous thrombotic events and the effect of several risk factors, including thrombophilia, remain controversial. The potential benefit of screening for thrombophilia with respect to prophylactic strategies and duration of anticoagulant treatment is not yet known. To estimate the recurrence rate of thrombotic events in patients after a first thrombotic event and its determinants, including thrombophilic abnormalities. Prospective follow-up study of 474 consecutive patients aged 18 to 70 years without a known malignancy treated for a first objectively confirmed thrombotic event at anticoagulation clinics in the Netherlands. The Leiden Thrombophilia Study (LETS) was conducted from 1988 through 1992 and patients were followed up through 2000. Recurrent thrombotic event based on thrombophilic risk factors, sex, type of initial thrombotic event (idiopathic or provoked), oral contraceptive use, elevated levels of factors VIII, IX, XI, fibrinogen, homocysteine, and anticoagulant deficiencies. A total of 474 patients were followed up for mean (SD) of 7.3 (2.7) years and complete follow-up was achieved in 447 (94%). Recurrence of thrombotic events occurred in 90 patients during a total of 3477 patient-years. The rate of thrombotic event recurrence was 25.9 per 1000 patient-years (95% confidence interval [CI], 20.8-31.8 per 1000 patient-years). The incidence rate of recurrence was highest during the first 2 years (31.9 per 1000 patient-years; 95% CI, 20.3-43.5 per 1000 patient-years). The risk of thrombotic event recurrence was 2.7 times (95% CI, 1.8-4.2 times) higher in men than in women. Patients whose initial thrombotic event was idiopathic had a higher risk of a thrombotic event recurrence than patients whose initial event was provoked (hazard ratio [HR], 1.9; 95% CI, 1.2-2.9). Women who used oral contraceptives during follow-up had a higher thrombotic event recurrence rate (28.0 per 1000 patient-years; 95% CI, 15.9-49.4 per 1000 patient-years) than those who did not (12.9 per 1000 patient-years; 95% CI, 7.9-21.2 per 1000 patient-years). Recurrence risks of a thrombotic event by laboratory abnormality ranged from an HR of 0.6 (95% CI, 0.3-1.1) in patients with elevated levels of factor XI to an HR of 1.8 (95% CI, 0.9-3.7) for patients with anticoagulant deficiencies. Prothrombotic abnormalities do not appear to play an important role in the risk of a recurrent thrombotic event. Testing for prothrombotic defects has little consequence with respect to prophylactic strategies. Clinical factors are probably more important than laboratory abnormalities in determining the duration of anticoagulation therapy.

Osteoporose bei Patienten unter oraler Antikoagulantien-Therapie

Osteoporosis is thought to be one possible side-effect of oral anticoagulant therapy, especially after long-term treatment. Nevertheless, data concerning this problem only exist from earlier years. Therefore, we decided to look for the incidence of osteoporosis in patients under long-term oral anticoagulant treatment. 30 patients (15 female, 15 male) - age between 38 and 77 years (average age 65,1+/-11,2 years) were examined. Group A: 10 patients with a capture time between 0,5 - 5 years, Group B: 10 patients with a capture time between 6 - 11 years, Group C: 10 patients with a capture time more than 11 years. The control group consisted 30 healthy persons - age between 39 and 81 years (18 female, 12 male, average age 61,5 +/- 12 years). In 21 out of 30 patients (9 female, 12 male) osteoporosis was found due to results of x-ray and bone-density-measurements. In 9 patients (6 female, 3 male) no osteoporosis was detected. No correlation between appearance of osteoporosis and duration of oral anticoagulant treatment was detected. Nevertheless, the number of patients presenting with osteoporosis in comparison with the control group was highly unexpected and astonishing. While treating patients with oral anticoagulants the possibility of appearing osteoporosis should be kept in view. In those circumstances the therapy should be supported by calcium and vitamin D.

Duration of warfarin sodium therapy prior to electrical cardioversion of atrial fibrillation.

To evaluate the duration of anticoagulation treatment with warfarin sodium before elective DC-cardioversion and to identify clinical variables predicting short-term versus long-term waiting times. Retrospective. Patients with a known start date for warfarin sodium, a known duration of atrial fibrillation (AF) and who underwent DC-cardioversion were included. Duration of treatment with warfarin sodium prior to DC-cardioversion. The hospital records of 288 consecutive patients with AF scheduled for elective cardioversion at two hospitals in Stockholm were reviewed. Only patients with a known start date for warfarin sodium and known duration of AF were included in the study. The median age was 70 (26-85) years and the duration of AF at time of cardioversion were 18 weeks (5-273) weeks. The median treatment duration prior to cardioversion with warfarin sodium was 12 weeks. Sinus rhythm was established in 224 (78%) patients of which 90 (40%) remained in sinus rhythm 1 month after cardioversion. In multivariate analysis, the only independent predictor of short waiting times for cardioversion (8 vs. 15 weeks) was if a cardiologist instituted the treatment with warfarin sodium (P < 0.001, 95% CI 5.0-9.0). The average waiting time from start of warfarin sodium treatment to elective cardioversion exceeds by far the recommended 3-4 weeks on therapeutic international normalized ratio (INR). In order to minimize the time period until cardioversion significant changes in the out-of-hospital care logistics has to be undertaken.

Predictors of residual venous obstruction after deep vein thrombosis of the lower limbs: a prospective cohort study

Introduction: Delayed thrombus regression after deep vein thrombosis (DVT) of the lower limbs is associated with increased risk of DVT recurrence. Predictors of residual venous occlusion are unknown. We hypothesized that obesity, which causes reduced fibrinolytic activity, can predict delayed thrombus regression. Materials and methods: In a prospective cohort study, 98 patients with objective diagnosis of DVT underwent compression ultrasonography (CUS) after 6 and 12 months. Persistent occlusion was arbitrarily defined as a thrombus occupying, at maximal point of compressibility, more than 20% of the vein area in the absence of compression. The body mass index (BMI) and waist circumference were measured at baseline and at follow up to assess individual patterns of body fat distribution. Information on antithrombotic treatment, family history of varicose veins, cigarette smoking, concomitant disorders, the presence of known risk factors for DVT, the duration of anticoagulant treatment and the use of elastic stockings was collected. Results: Post-thrombotic recanalization was documented in 34 patients (34.7%) at 6 months and in 44 patients (44.9%) at 12 months. There was no difference in the mean BMI ( p=0.469 at 12 months), in the prevalence of obesity ( p=0.479) and visceral pattern of body fat distribution ( p=0.239) between patients who did and did not show thrombus regression. The presence of a permanent risk factor for DVT was the only predictor of delayed thrombus regression (OR 11.0, 95% CI 1.359–61.978). Conclusions: Despite consistent evidence of impaired fibrinolysis, obesity is not associated with persistent venous obstruction.

Thrombophlébite de la veine ovarienne et fièvre du post-partum

Introduction. – Ovarian vein thrombophlebitis (OVT) is a rare but potentially threatening complication of the postpartum period. Diagnosing it may be of some difficulty especially in case of symptoms mimicking appendicitis or pyelonephritis. Exegesis. – We report 2 patients with postpartum right OVT. The clinical presentation included high grade fever, and pain, lumbar in one case, of the right flank in the other. Pulmonary embolism complicated both cases. Conclusion. – Diagnostic and therapeutic management of OVT was transformed by progresses in medical imaging during the 1980’. However, optimal duration of anticoagulant treatment and secondary prevention indications have to be determined.

The incidence of recurrent venous thromboembolism in carriers of factor V Leiden is related to concomitant thrombophilic disorders.

The duration of anticoagulant treatment after a first episode of venous thromboembolism primarily depends on the risk of recurrence. Variability of recurrence rates in factor (F) V Leiden carriers may be due to concomitant thrombophilic disorders. A retrospective study was performed in 329 FV Leiden carriers with a history of venous thromboembolism (262 probands, 67 relatives). The annual rate of first recurrence was estimated in relatives. The contribution of concomitant thrombophilic disorders to the recurrence rate was evaluated in probands and relatives by a nested case--control analysis in 105 matched pairs of carriers either with or without recurrence. The overall annual recurrence rate was 2.3 per 100 patient-years. The adjusted risk of recurrence for concomitant thrombophilic disorders was: 9.1 (1.3-62.8) for the FII mutation; 1.0 (0.2-4.9) for homozygosity for FV Leiden; 1.5 (0.2-9.5) for inherited deficiencies of protein C or S; 1.8 (0.7-4.9) for FVIII coagulant activity (FVIII:C) levels >122%; 5.4 (1.6-18.6) for fasting homocysteine levels >15.2 micromol/l; and 4.4 (1.0-18.7) for loading homocysteine levels >45.8 micromol/l. Of these disorders, only the FII mutation and hyperhomocysteinaemia significantly increased the risk of recurrence in FV Leiden carriers. The estimated recurrence rate ranged from 0.45 per 100 patient--years after a secondary first event in the absence of concomitant disorders to 4.8 per 100 patient-years when a spontaneous first event was combined with concomitant disorders. Our study provides supportive evidence that the incidence of recurrent venous thromboembolism in heterozygous FV Leiden carriers depends on the concomitance of other thrombophilic disorders, in addition to whether the first thrombotic event occurred spontaneously.

Persistence of the prothrombotic state after acute coronary syndromes: Implications for treatment

Background and Purpose Acute coronary syndromes (unstable angina and acute myocardial infarction) are generally caused by thrombosis over a disrupted atherosclerotic plaque. During the acute phase, antithrombotic therapy (including aspirin and heparin) has been shown to reduce the risk of death or myocardial infarction (MI). The purpose of this review is to examine the high-risk period for clinical thrombotic events that extends for several weeks after presentation and to review the treatments aimed at reducing these events. Results More than half of clinical events reported during the first month occur after the first 3 to 5 days that comprise the standard in-hospital treatment period. Several different antithrombotic approaches have been tested, including longer duration of antiplatelet therapy, anticoagulant treatment, and oral glycoprotein (GP) IIb/IIIa inhibitors. Aspirin is effective at reducing risk, and clopidogrel provides additional benefit, as does dalteparin for at least the first month. Warfarin in addition to aspirin, while generally disappointing, has not been adequately tested at higher doses. Oral GP IIb/IIIa inhibitors cause a paradoxic increased risk of death for unclear reasons. Conclusion Further reduction of risk during the weeks after presentation with acute coronary syndromes remains an important therapeutic goal. (Am Heart J 2002;143:205-16.)

Exploration hematologique chez un malade avec au moins un episode thrombotique veineux ou une embolie pulmonaire

The aim of the haematological work-up in patient with an episode of DVT/PE is to document a well-defined haematological disease, associated with a thrombotic risk (such as a myeloproliferative disorder), or one or more risk factors, whic can be related to the genetic background (such as a reduced effect of APC due to the Leiden variation of clotting factor V). Such findings may improve patient's management. The work-up usually begins with simple clinical and laboratory data, but referral to a specialist is often mandatory. At the present time it cannot be considered as the key element by itself to provide an appropriate answer to the main practical issue, which is the duration of anticoagulant treatment in order to prevent recurrence. Thus it is of utmost importance to consider the haematological work-up only as a part of an integrated, in-depth and systematic clinical approach.