Long-term Prevention Of Recurrent Venous Thromboembolism Research Articles

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AbstractUnprovoked venous thromboembolism (VTE) - proximal venous thrombosis or pulmonary embolism - should be treated either 3 months or indefinitely if the risk of bleeding is low. This article summarizes the efficacy and safety of extended therapy of VTE with direct oral anticoagulants (DOAC) in comparison with warfarin, as well as the role of of acetylsalicylic acid (ASA) for the long-term prevention of recurrent VTE. As the Survet study showed, for some patients who have already completed at least 6 months of anticoagulant treatment for their index VTE event, an oral glycosaminoglycan - sulodexide associated with compression therapy is a good choice, because it decreases the incidence of recurrences of VTE without detectable risks for the patients’ safety.

Rivaroxaban vs. Aspirin to Prevent Recurrent Venous Thromboembolism

The duration of guideline-recommended antithrombotic therapy for patients with venous thromboembolism (VTE) ranges from 3 months to indefinite, depending on whether the VTE is provoked or unprovoked and on patients' bleeding risks (NEJM JW Emerg Med Feb 2016 and Chest 2016; 149:315). For long-term prevention of recurrent VTE, options include warfarin, direct-acting oral anticoagulants, and aspirin; among the anticoagulants, guidelines recommend direct-acting anticoagulants over warfarin, unless substantial renal impairment …

Commentary on: Rivaroxaban for Venous Thromboembolism Prophylaxis in Abdominoplasty: A Multicenter Experience.

We appreciate the opportunity to review this article by Dr Hunstad and his colleagues.1 The authors report on observed rates of venous thromboembolism (VTE) and reoperative hematoma in a case series of 132 abdominoplasty patients who received chemoprophylaxis with rivaroxaban 10 mg daily beginning 12 hours after surgery and continuing for ≥7 days. The oral direct inhibitors of factor Xa (FXa) are the newest class of anticoagulant drugs and have ever-expanding indications. Factor X can be activated (to FXa) via either the intrinsic or extrinsic clotting pathways. FXa promotes conversion of prothrombin to thrombin, resulting in clot formation. Enoxaparin accelerates the activity of antithrombin, which accelerates the rate of inactivation of FXa. Inactivation of FXa subsequently decreases thrombin generation. Fondaparinux, the effect of which is largely mediated through FXa inhibition (with some inhibition of Factor IXa), is also an effective anticoagulant. Clinical utility of fondaparinux identified FXa as an appealing target for anticoagulants because it represents a unifying pathway of the extrinsic and intrinsic clotting pathways.2 Rivaroxaban is an oral direct inhibitor of FXa. Rivaroxaban is approved by the United States Food and Drug Administration for prevention of stroke and systemic embolism for patients with nonvalvular atrial fibrillation, treatment of acute VTE, long-term prevention of recurrent VTE after an initial 6 months of therapy, and prevention of VTE after total knee or hip arthroplasty. Approval was based on large phase III trials showing noninferior or superior efficacy and similar or reduced rates of major, intracranial, and fatal bleeding compared with conventional anticoagulants (ie, enoxaparin and/or warfarin).3-7 For patients undergoing total knee arthroplasty, rivaroxaban 10 mg daily reduced the primary outcome of VTE and death compared with enoxaparin 40 mg daily (9.6% vs 18.9%, P < .001) without increased bleeding.6 Similar findings were observed after …

Improving prevention and treatment of venous thromboembolism: clinical trial results

Background:Venous thromboembolism (VTE) incurs considerable socioeconomic costs, partly owing to the fact that the treatment and prevention of VTE via effective thromboprophylaxis remains suboptimal in the inpatient and outpatient settings of many healthcare systems. A number of organizations—including the National Quality Forum, The Joint Commission, and the Centers for Medicare and Medicaid Services—have established measures to assess and reduce the healthcare burden of VTE. These improvement strategies focus on increasing the use of thromboprophylaxis, implementing existing guidelines, and improving awareness.Findings:Based on clinical trial results, the oral anti-coagulants rivaroxaban, apixaban, and dabigatran etexilate have been approved in many countries for the prevention of VTE in patients after elective hip or knee replacement surgery. Recently, dabigatran etexilate and rivaroxaban have also been approved in the US for the prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation. In addition, rivaroxaban is currently the only newer anti-coagulant that has been approved in Europe for the treatment of deep vein thrombosis and for the long-term prevention of recurrent VTE. These oral anti-coagulants have several advantages over established anti-coagulants, including no need for routine coagulation monitoring and only minimal food and drug interactions. These characteristics, together with convenient oral administration, may improve adherence and quality of life for patients, which could result in reductions in the rate of VTE.Conclusions:These three oral agents have several advantages over established anti-coagulants and could, therefore, address the unmet needs of patients, physicians, and healthcare systems, with the potential to reduce the burden of anti-coagulant management and the occurrence of VTE.

The study of Chinese optimal anticoagulant range of warfarin for venous thromboembolism

The aim of trial is to observe the Chinese bleeding frequency and frequency of recurrent VTE in different international normalized ratio (INR) range of warfarin for venous thromboembolism (VTE) including deep venous thrombosis (DVT) and pulmonary embolism (PE), and to search optimal INR range. We conducted a randomized, double-blind cohort trial, in which 180 patients were assigned to apply warfarin in a target INR of 1.50 to 1.99 (group A), a target INR of 2.00 to 2.50 (group B) or a target of INR of 2.51 to 3.00 (group C). Every group had respectively 60 patients. After they had completed warfarin therapy to be stability kept with those target INR range for two or more weeks, this study would be begun to observe the bleeding frequency and frequency of recurrent VTE. There was significant difference in recurrent VTE frequency between Group A (8.3%) and BC (1.7%, P = 0.042). The minor bleeding frequency of Group A, B and C is respectively 8.3%, 18.3% and 6.7% (P = 0.089). The moderate bleeding frequency of Group A and BC is respectively 3.3% and 7.5% (P = 0.341), and large bleeding frequency of them is respectively 0% and 3.3% (P = 0.303). To patients whose age above 62 year, major bleeding episode occurred respectively in 1 patient assigned to INR of 1.5-2.5 and in three patients assigned to Group C (hazard ratio, 12. 600; 95 percent confidence interval, 1.183-134.238). Warfarin therapy in INR of 2.0-3.0 is more effective than INR of 1.5-1.99 for the long-term prevention of recurrent VTE. And warfarin regimen in INR of 2.0-3.0 does not increase the risk of major bleeding either. So to general Chinese, INR ought to be recommended in 2.0-3.0. To patients whose age above 62 year, INR ought to be recommended between 2.0 to 2.5.

Long-Term Management of Patients After Venous Thromboembolism

Long-term treatment of venous thromboembolism (VTE) focuses mainly on the duration of anticoagulant therapy, usually with vitamin K (VK) antagonists. The duration of therapy should be individualized based on the risk of recurrent VTE if treatment were stopped and the risk of bleeding if treatment were continued. The risk of recurrence is low if thrombosis was provoked by a major reversible risk factor such as surgery; 3 months of treatment is usually adequate for such patients. The risk of recurrence is high if thrombosis was unprovoked ("idiopathic") or associated with an irreversible risk factor such as cancer; anticoagulant treatment for at least 6 months, and often indefinitely, is indicated for such patients. Risk of recurrence is intermediate if thrombosis was associated with a minor transient risk factor; such patients can be treated for 3 to 6 months. Within each of these categories, presentation as pulmonary embolism, >1 previous VTE, an underlying malignancy, an antiphospholipid antibody, or selected hereditary thrombophilic states favor more prolonged therapy, whereas isolated distal deep vein thrombosis, high risk of bleeding, and patient preference favor shorter treatment. The optimal intensity of anticoagulant therapy with VK antagonists corresponds to a target international normalized ratio of 2.5 (range, 2.0 to 3.0). Long-term treatment with low-molecular-weight heparin is an alternative to VK-antagonist therapy and is usually preferable in patients with active cancer. Oral direct thrombin inhibitors also appear suitable for long-term prevention of recurrent VTE but await regulatory approval and comparison with VK antagonists.