Months Of Oral Anticoagulant Therapy Research Articles

Residual pulmonary embolism as a predictor for recurrence after a first unprovoked episode: Results from the REVERSE cohort study

BackgroundThe optimal duration of oral anticoagulant therapy after a first, unprovoked venous thromboembolism is controversial due to tightly balanced risks and benefits of indefinite anticoagulation. Risk stratification tools may assist in decision making. ObjectivesWe sought to determine the relationship between residual pulmonary embolism assessed by baseline ventilation-perfusion scan after completion of 5–7months of oral anticoagulant therapy and the risk of recurrent venous thromboembolism in patients with the first episode of unprovoked pulmonary embolism. MethodsWe conducted a multicentre prospective cohort study of participants with a first, unprovoked venous thromboembolism enrolled after the completion of 5–7months of oral anticoagulation therapy. The participants completed a mean 18-month follow-up. Participants with pulmonary embolism had baseline ventilation-perfusion scan before discontinuation of oral anticoagulant therapy and the percentage of vascular obstruction on baseline ventilation-perfusion scan was determined. During follow-up after discontinuation of oral anticoagulant therapy, all episodes of suspected recurrent venous thromboembolism were independently adjudicated with reference to baseline imaging. Measurements and main resultsDuring follow-up, 24 of 239 (10.0%) participants with an index event of isolated pulmonary embolism or pulmonary embolism associated with deep vein thrombosis and central assessment of percentage of vascular obstruction on baseline ventilation-perfusion scan had confirmed recurrent venous thromboembolism. As compared to participants with no residual pulmonary embolism on baseline ventilation-perfusion scan, the hazard ratio for recurrent venous thromboembolism was 2.0 (95% CI 0.5–7.3) for participants with percentage of vascular obstruction of 0.1%–4.9%, 2.1 (95% CI 0.5–7.8) for participants with percentage vascular obstruction of 5.0%–9.9% and 5.3 (95% CI 1.8–15.4) for participants with percentage vascular obstruction greater than or equal to 10%. ConclusionsResidual pulmonary embolism assessed by pulmonary vascular obstruction on baseline ventilation-perfusion performed after 5–7months of oral anticoagulant therapy for the first episode of unprovoked pulmonary embolism was associated with a statistically significant higher risk of subsequent recurrent venous thromboembolism. Percentage of pulmonary vascular obstruction assessment by ventilation-perfusion scans maybe a useful tool to help guide the duration of oral anticoagulant therapy after a first unprovoked pulmonary embolism. Trial registrationRegistered at www.clinicaltrials.gov identifier: NCT00261014.

Internal Jugular Vein and Transverse Sinus Thrombosis as a Complication of a Chronic Ethmoidal Sinusitis

Lemierre’s syndrome is rare jugular thrombosis associated with an oropharyngeal infection. The jugular thrombosis is from septic origin. This often happens in young males subjects. We described Lemierre’s syndrome in a 46 year-old man with a chronic ethmoidal sinusitis associated to the left jugular thrombosis extended to the transverse sinus with a partial recanalisation after three months of oral anticoagulant therapy.

Trombose venosa profunda num membro superior em mulher a fazer anticoncepcional oral e com trombofilia hereditária – Factor V Leiden

Introduction: Upper extremity deep vein thrombosis (DVT) represents 10% of all cases of DVT. Genetic and acquired factors contribute to DVT. Factor V Leiden is the most common inherited thrombophilia. The use of oral contraceptives is also a recognized risk factor for DVT. The case of a female patient receiving a combined oral contraceptive who developed a upper-extremity deep venous thrombosis is presented. Case report: A 34 year-old Caucasian female presented to the emergency department with pain and swelling of the right arm. These symptoms began suddenly less than 24 hours earlier. She denied shortness of breath or thoracic pain. She had not experienced recent trauma. The patient had no chronic medical problems. She had been taking a combined oral contraceptive for two months. Her family medical history was negative for thromboembolic events. Doppler ultrasonography showed a venous thrombosis of terminal portion of right subclavian vein with 4 cm of extension. Anticoagulation therapy was started in the emergency department with enoxaparin 1mg/kg/day. This was followed by 6 months of oral anticoagulation therapy with acenocoumarol with a target INR of 2.0-3.0. The combined oral contraceptive was stopped. Thrombophilia screening was performed after completing anticoagulation. The patient was found to be heterozygous for factor V Leiden. Discussion: Factor V Leiden contributes to the risk of venous thromboembolism often in combination with an additional risk factor, such as oral contraceptive use. Patients should be counseled about reducing or eliminating other risk factors that may contribute to the development of venous thromboembolism.

Laser sheath for tunneled dialysis catheters extraction

The number of patients with acute renal failure and end-stage renal disease undergoing hemodialysis (HD) has increased during the past years, and the management of vascular access is pivotal. Among tunneled dialysis catheters (TDC), Tesio twin-catheter system (Medcomp, Harleysville, PA, USA) provides good long-term survival with acceptably high blood flow and low complication rates [1, 2]. Unfortunately, catheter infection is still a serious and common complication related to temporary HD vascular access. When catheter infection and/or dysfunction occur, extraction is mandatory [3]. Although the development of a fibro-epithelial sheath is a common occurrence, TDC extraction is usually easily performed by traction or cut down technique [3, 4]. However, when the catheters are tethered or attached to central veins and/or to right atrium, these techniques could lead to their rupture and retention and could increase the risk of vascular or atrial wall avulsion. Laser extraction technique is usually adopted for pacing leads, but it can also be helpful in TDC extraction to avoid the previous mentioned complications. A circumferential Excimer laser beam applied at the tip of a specialized telescopic sheath is passed over the lead. The energy source comes from a xenon chloride laser with an output wave length of 308 nm. It is a cool cutting laser (50 C) with a very limited absorption depth; twothirds of the energy are absorbed within 0.06 mm from the tip of the sheath by proteins and lipids instead of water. These technical characteristics allow the ablation of the fibro-epithelial sheath surrounding TDC without damaging the endothelial wall and the catheter itself [5]. According to these assumptions, our laboratory has decided to adopt this technique to extract tethered TDCs. A woman of 57 years, affected by endstage renal disease, was admitted to our Department for a Tesio twin-catheter system-associated bacteraemia. A transesophageal echocardiographic evaluation showed a thrombus occluding the apex of the right atrial appendage. A valvular involvement was excluded. After 2 months of oral anticoagulation therapy, she underwent TDC extraction performed using an Excimer Laser system emitting energy at the tip of a flexible, fiber-optic 12F-sheath (Spectranetics Inc., Colorado Springs, CO, USA). The procedure was performed under assistant sedation with i.v. midazolam. First, the TDC was isolated. Then, an A. Curnis L. Bontempi M. Cerini F. Vassanelli A. Lipari N. Ashofair C. Pagnoni L. Dei Cas Division of Cardiology, EP Lab, Post Graduate School of Cardiology, Spedali Civili, University of Brescia, Brescia, Italy

Low prevalence of JAK2 V617F mutation in patients with first unprovoked venous thromboembolism

Low prevalence of <i>JAK2</i> V617F mutation in patients with first unprovoked venous thromboembolism

Unprovoked Venous Thromboembolism: Short term or Indefinite Anticoagulation? Balancing Long-Term Risk and Benefit

Whether to continue oral anticoagulant therapy indefinitely after completing 3 to 6 months of oral anticoagulant therapy for “unprovoked” venous thromboembolism (VTE), is one of the most important unanswered questions in VTE management. This long-term decision should be based on balancing the long-term mortality risk from recurrent VTE, largely preventable with oral anticoagulant therapy, against the long-term mortality risk of major bleeding, the principle complication of oral anticoagulant therapy. There exist important knowledge gaps in estimating the long-term mortality risk of recurrent VTE in patients with unprovoked VTE who discontinue therapy and the long-term mortality risk from major bleeding in those who continue oral anticoagulant therapy. These knowledge gaps, reviewed herein, are the source of uncertainty for patients and health care providers wrestling with this important question. One promising solution is recurrent VTE risk stratification where unprovoked VTE patients are categorised as low or high risk for recurrent VTE and clinical decision making is less ambiguous and ultimately will likely lead to better outcomes.

Incidence of recurrent venous thromboembolism and of chronic thromboembolic pulmonary hypertension in patients after a first episode of pulmonary embolism

After a first episode of pulmonary embolism (PE), two major problems need to be considered: risk of recurrence when anticoagulation is stopped, and risk of chronic thromboembolic pulmonary hypertension (CTPH). We followed prospectively consecutive patients who survived a first episode of PE, with or without deep vein thrombosis, to assess the incidence of venous thromboembolism (VTE) recurrences and of symptomatic and asymptomatic CTPH. After 3-6 months of oral anticoagulant therapy (OAT) patients underwent transthoracic echocardiography for measuring transtricuspid (rV-rA) gradient. When rV-rA gradient was >35 mmHg further evaluations were performed to rule in or out CTPH. During follow-up patients who developed persistent dyspnea were re-evaluated. In patients who underwent OAT withdrawal D-dimer (DD), prothrombin fragment 1 + 2 (F1 + 2), and thrombophilia were evaluated one month after warfarin discontinuation. Overall, 239 patients, 118 males, median age 59(16-89) years, were followed up for a median time of 36(9-192) months. Nine patients had rV-rA gradient >30 mmHg and ≤35 mmHg, and one of 37 mmHg. Among patients with normal rV-rA gradient, one developed persistent dyspnea 55 months after the first event and CPTH was confirmed. Among 206 patients who stopped OAT, 23(11.2%) had VTE recurrence, 11 PE(48%). Elevated DD and F1 + 2 levels after stopping OAT were significantly associated with recurrence. None of patients with recurrent VTE had elevated rV-rA gradient. In our series the incidence of CTPH after a first episode of PE was 0.4%. VTE recurrence and elevated DD and F1 + 2 levels seemed not to be related to the development of CTPH.

Identifying Unprovoked Thromboembolism Patients at Low Risk for Recurrence Who Can Discontinue Anticoagulant Therapy

Conclusion: Oral anticoagulation therapy can be safely discontinued after 6 months in woman who have zero or one potential predictor of recurrent venous thromboembolism (VTE). Summary: Optimal duration of anticoagulation after unprovoked VTE is controversial. In this study the authors sought to identify clinical predictors to identify patients at low risk of VTE recurrence after discontinuation of oral anticoagulants. This was a multicenter prospective cohort study involving 646 patients with a first unprovoked major VTE. Patients were enrolled during a 4-year period, and 600 completed a mean 18-month follow-up. Data were collected for 16 potential predictors of recurrent VTE during the time patients were taking oral anticoagulation therapy (5 to 7 months after initiation). After discontinuation of oral anticoagulation therapy, patients were monitored for recurrent VTE. During follow-up, 91 confirmed episodes of recurrent VTE were identified (annual risk, 9.3%; 95% confidence interval [CI], 7.1%-11.3%). The annual risk for men was 13.7% (95% CI, 10.8%-17.0%). No combination of clinical predictors could identify a low-risk subgroup of men. Zero or one of the following characteristics were present in 52% of women: D-dimer level >250 mg/L while taking warfarin; body mass index >30 kg/m2; hyperpigmentation, edema, or redness of either leg; or age >65 years. Women with zero or one of these predictors had an annual risk of VTE recurrence of 1.6% (95% CI, 0.3%-4.6%). Women with two or more of these predictors had an annual risk of VTE recurrence of 14.1% (95% CI, 10.9%-17.3%). Comment: This study is consistent with the previously determined adverse effect of male sex on the recurrence of VTE (Lancet 2006;368:371-8). There are three major points here. First, identification of risk factors after 5 to 7 months of oral anticoagulation therapy is a strong predictor of recurrent VTE. Second, D-dimer levels after stopping oral anticoagulation may not be sufficient to identify patients at low risk of recurrence, whereas D-dimer levels while taking oral anticoagulation may be a strong predictor of recurrent VTE. The point is particularly interesting in that it allows more efficient care of patients. Stopping anticoagulation and testing D-dimer levels 1 month later and subsequently restarting anticoagulation therapy if necessary is impractical and exposes potentially high-risk patients to a period without anticoagulation. Finally, the authors identified a clinical decision rule that identifies women at low risk of VTE.

Venous Thromboembolism Recurrence after a First Episode of Provoked Venous Thrombosis Due to a Transient Risk Factor. A Systematic Review of the Literature

Background: Venous thromboembolism (VTE) has a tendency to recur after anticoagulation is stopped. The optimal duration of anticoagulation is influenced by the risk of recurrence: indefinite anticoagulation is recommended after a first VTE associated with a persistent and strong risk factor (e.g. cancer), whereas three months of anticoagulation is adequate if VTE was provoked by a transient risk factor (e.g. surgery). The optimal duration of anticoagulation after a first unprovoked VTE is, however, still a matter of debate. An attractive approach is to identify subgroups of patients with unprovoked VTE who have a high risk of recurrence and treat them with prolonged anticoagulation, and subgroups with a lower risk of recurrence and treat them for only three months. A critical issue, therefore, is to determine a cut-off value for risk of recurrence that is low enough to justify stopping anticoagulant therapy at three months (i.e., a rate of recurrence that is acceptable to patients and physicians). We propose that the rate of recurrence after VTE that was provoked by a transient risk factor represents such a value.Aim of the study: To accurately estimate the risk of recurrence in patients with VTE provoked by a transient risk factor who have completed at least three months of anticoagulant therapy.Materials and Methods: Medline, Embase and Cochrane Collaboration Registry of Randomized Trials were searched for any studies reporting the recurrence rate of VTE after a first episode of VTE associated with a transient risk factor (surgery, trauma, plaster, bed rest, pregnancy, puerperium, hormone treatment). The references of retrieved articles were scanned for any additional relevant studies. Studies were included if enrolling patients met the following criteria:a first episode of VTE provoked by a transient risk factor;a course of at least three months of oral anticoagulant therapy;a follow up of 12 or 24 months after treatment discontinuation with assessment of VTE recurrence rate.Recurrence rate, or data that allowed its calculation, needed to be reported. An overall estimate of the recurrence rate was calculated following Laird (Stats Med 1990), having predefined to use a fixed-effect model if no heterogeneity was found among the studies or a random-effect model otherwise. The inverse variance method was used to calculate weights for the studies.Results: The literature search yield 1089 references. After careful scanning of the potentially relevant papers, 15 papers were included in the final analysis. All studies except one were prospective. 12/15 and 11/15 studies reported data about the recurrence rate at 12 and 24 months, respectively. Overall there were 106 events among of 2217 patients at 12 months and 160 events among 2321 patients at 24 months. The pooled recurrence rate was 4.0% (95% C.I. 3.0%–5.2%) at 12 months and 6.7% (95% C.I. 5.2%–8.6%) at 24 months.Conclusion: The cumulative risk of recurrence in patients with VTE provoked by a reversible risk factor is 6.7% (95% C.I. 5.2%–8.6%) two years after anticoagulant withdrawal. We suggest that it acceptable to stop anticoagulant therapy after three months in subgroups of patients with unprovoked VTE who have been shown to have a risk of recurrence that is similar to, or lower than, this rate.

Anticoagulación oral en enfermedad tromboembólica

Coumarin or anti-vitamin K oral anticoagulants have been used in anticoagulation therapy for more than 50 years. Well-designed studies have demonstrated the effectiveness of these drugs in the primary and secondary prevention of venous thromboembolic disease (VTD). Because of greater life expectancy and the increase in the indications for oral anticoagulation therapy (OAT), more and more patients are receiving this type of treatment. In Spain, approximately 1% of the population receives OAT. The mechanism of action of coumarin anticoagulants is based on inhibition of the interconversion of vitamin K and its 2,3-epoxide (vitamin K epoxide, which modulates gamma-carboxylation of the glutamic acid residues in the N-terminal regions of vitamin-K-dependent factors, namely, II, VII, IX, X, protein C, protein S and protein Z). Due to the lack of gamma-carboxylation, these factors lose their procoagulant activity. Major hemorrhagic complications of OAT in VTD after 3-6 months of treatment, with an INR of 2-3, occur in nearly 2% of patients. The hemorrhagic complications of OAT are related to the intensity of anticoagulation, patient characteristics, the concomitant use of drugs that interfere with hemostasis, and treatment duration. The risk of VTD recurrence after 3-6 months of OAT is high and can be more than 10% in patients with idiopathic thromboembolism or irreversible risk factors such as thrombophilia, cancer and other situations conferring permanent risk. The risk of recurrence is more frequent in men, in patients with thrombophilia especially in antithrombin deficiency, and in patients with cancer, residual venous obstruction, or elevated D dimer.

Absence of Residual Vein Thrombosis after an Episode of Idiopathic Deep Vein Thrombosis: Short-Term Anticoagulation Is Safe. The “Extended Dacus Study”.

Background. The optimal duration of Oral Anticoagulant Therapy (OAT) for Deep Vein Thrombosis (DVT) can be tailored by Residual Vein Thrombosis (RVT) (Siragusa S et al. Blood 2003; 102(11):OC183), a marker able to assess the individual risk for recurrent thrombosis. However, in patients with idiopathic DVT the safety of early interruption of OAT, because of absence of RVT, is still debated.Objective of the study. In the present study, we evaluated the safety of withholding OAT, in patients with idiopathic DVT and without RVT, three months after the index thrombotic episode.Study design. Prospective controlled study with two groups: patients without RVT stopped OAT after 3 months while those with RVT continued for additional 3 months.Materials and Methods. Consecutive patients with a first episode of idiopathic DVT of the lower limbs; patients with cancer or known thrombophilia were excluded. At the third months of OAT, RVT was assessed as previously described; briefly, RVT was considered absent when a clot occupying less than 40% of the vein lumen was detected by compression ultrasonography. Events, classified as recurrent DVT and/or Pulmonary Embolism (PE) and/or major and minor bleeding were evaluated; all patients were followed-up for at least 12 months after OAT discontinuation.Results. During the period 1999–2006, 518 patients were included in the study. In 206 (39.7%) RVT was considered absent (RVT negative group) and they stopped OAT; the remaining 312 patients continued anticoagulants for additional 3 months (RVT positive group). Total duration of follow-up (FU) was 184.7 years for RVT negative group (with a mean FU of 3.0 ± 0.83 years) and 191.3 years for RVT positive group (with a mean FU of 3.1 ± 0.89 years). The rate and type of events during FU is reported in table and figure.Conclusions. This investigation shows that in patients without RVT, three months of OAT are safe even after an episode of idiopathic DVT. This hold for at least 30% of the entire DVT population and has an important clinical impact; in fact, it is possible to select a group of patients with a very low risk for recurrences over a period of 3 years. This approach carries also a negligible risk for bleeding.Events between RVT Negative and Positive GroupsOutcomesRVT Neg. group (206)RVT Pos. group (312)"p" valueRecurrences, n/total (%)*2/206 (0.9)63/312 (20.2)<0.0005Recurrences, n/100 person-year (%)*2/184.7 (1.1)63/191.3 (32.9)<0.0005Type of recurrent VTEDVT143DVT + PE06Isolated PE03Controlateral111Major bleeding, n/total (%)**0/2063/312 (0.9)Major bleeding, n/100 person-Yr (%)**0/184.73/191.3 (1.5)*After OAT discontinuation, **During OAT [Display omitted]

Do We Need to Assess the Effect of Treatment Withdrawal?

See related article, pages 2652–2657 . In this issue of Stroke , Colivicchi et al observe the impact of statin discontinuation after an ischemic stroke1: they suggest this phenomenon is not only frequent, but also associated with a significant increase of total mortality. Usually considered as secondary, the question of treatment withdrawal becomes more and more important because of: (1) the regular increase of the number of treatments with a convincing demonstration of preventive effects; (2) the general extension of life expectancy in high income countries, which explains both a dramatic increase in the numbers of elderly, and of the length of exposure to treatment far beyond that over which their effect has been estimated; (3) the high prevalence of treatment discontinuation, as illustrated by Colivicchi.1 If treatment effect were constant over time, we would expect similar effects across various ages, which is not the case for blood pressure–lowering drugs. A significant 10% to 15% decrease in total mortality has been associated with these treatments in hypertension around 60 years of age, with either diuretics2 or ACE-inhibitors3 as first-line drugs. Preliminary results (both from a subgroup meta-analysis4 and from a specific pilot trial5 …

The new role of D-dimer as a predictor of recurrent venous thromboembolism D-Dimere: Ihre neue Rolle als Prädiktoren für rezidivierende venöse Thromboembolien

Abstract Venous thromboembolism (VTE) tends to recur after oral anticoagulant therapy (OAT) withdrawal, regardless of the duration of treatment. As a result, the optimal duration of OAT after VTE is still a matter of debate. Patients are currently stratified in risk categories for recurrence on the basis of the clinical characteristics of the index event. Distal deep vein thrombosis (DVT) or VTE due to a transient risk factor are associated with a low risk of recurrence and a brief three-month course of anticoagulation is usually recommended. An event which is either idiopathic or with known thrombophilic defects, such as FV Leiden or the G20120A prothrombin mutation, is associated with a high risk of recurrence and an OAT course of at least six months is recommended. More recently, D-dimer (D-d) levels have been shown to be additional risk factors for recurrence. D-d has been evaluated both during OAT and after its withdrawal. In some patients, after VTE D-d levels are persistently elevated during anticoagulation in spite of apparently adequate antithrombotic treatment, which could indicate insufficient anticoagulation. D-d is more frequently altered during anticoagulation in patients with idiopathic or cancer-associated VTE than with secondary VTE. After idiopathic DVT, the time spent at near normal International Normalized Ratio (INR) values (&lt;1.5) during the first three months of OAT is associated with higher D-d values measured during OAT and after its interruption and is a significant risk factor for late VTE recurrences. Moreover, altered D-d significantly increases the risk of recurrence associated with inherited thrombophilic conditions, while residual venous obstruction does not increase the risk of recurrence associated with abnormal D-d. Results of a management study (PROLONG study) indicate that subjects with negative D-d at one month after OAT withdrawal have a low risk of recurrence, while those with altered D-d have a significantly higher risk and deserve prolonged OAT treatment.

Selecting an anticoagulant for recurrent venous thromboembolism in cancer

Purpose. The thrombogenicity of newer anticancer agents and the challenges associated with managing cancer patients on warfarin have led to the evaluation of the low-molecular-weight heparins (LMWHs) for primary and secondary prophylaxis in this high-risk patient population. Summary. The first published trial of LMWH in cancer compared three months of warfarin therapy with enoxaparin in cancer patients with proximal deep venous thrombosis (DVT), pulmonary embolism (PE), or both. All patients received four days of enoxaparin 1.5 mg/kg and were then randomized to continue receiving enoxaparin or begin warfarin therapy. Due to inadequate patient enrollment, no statistically significant differences were detected between the two treatment groups. In a similar patient population, the Comparison of Low-Molecular-Weight Heparin versus Oral Anticoagulant Therapy for the Prevention of Recurrent Venous Thromboembolism in Patients with Cancer (CLOT) trial evaluated the use of long-term dalteparin for the prevention of recurrent venous thromboembolism (VTE) in patients with cancer. Cancer patients with proximal DVT, PE, or both were randomized to initial treatment with dalteparin followed by either six months of oral anticoagulant therapy or dalteparin monotherapy. The primary outcome was symptomatic, recurrent VTE, and secondary outcomes were bleeding events and survival time. The cumulative risk of recurrent VTE at six months was reduced from 17% in the oral anticoagulant group to 9% in the dalteparin group, a risk reduction of 52% (p=0.002). No significant differences in bleeding events or overall mortality occurred between the groups. Recent recommendations from the American College of Chest Physicians on the treatment of cancer-associated thrombosis are based in part on data from the CLOT trial and support the use of dalteparin and tinzaparin in the long-term treatment of patients with DVT and cancer. Finally, results of recent trials support the concept that antithrombotic therapy with dalteparin or nadroparin may have an antineoplastic effect, resulting in improved survival time. However, these results require further validation. Conclusion. Despite the absence of oncology-specific guidelines for cancer-associated thrombosis, pharmacists now have a number of new tools available for selecting an anticoagulant, including results from several clinical trials with LMWHs and recent reports from national meetings.

Incidence of cancer after a first episode of idiopathic venous thromboembolism treated with 3 months or 1 year of oral anticoagulation

A prolonged treatment with oral anticoagulants has been claimed to reduce the incidence of newly diagnosed cancer in the long-term follow-up of patients with venous thromboembolism. In a multicenter prospective study we assessed the incidence of newly diagnosed clinically overt cancer in patients with a first episode of idiopathic venous thromboembolism (VTE) treated with oral anticoagulants for 3 months or 1 year. Consecutive patients with an idiopathic venous thromboembolism who had completed 3 months of oral anticoagulant therapy without having a recurrence, bleeding or newly diagnosed cancer were randomized to discontinue oral anticoagulant therapy or to continue it for nine additional months. Idiopathic venous thromboembolism was defined as thrombosis occurring in the absence of known cancer, known thrombophilia, or temporary risk factors for venous thromboembolism. All patients were followed up for at least 1 year after randomization. A total of 429 patients, 265 patients with DVT and 164 with PE, were followed up for an average of 43.7 months after randomization. A newly diagnosed cancer occurred in 32 patients (7.5%), 13 (6.2%) of the 210 patients treated for 3 months and 19 (8.7%) of the 219 patients treated for 1 year (RR = 0.71, 95% confidence interval 0.36-1.41). The incidence of newly diagnosed clinically overt cancer is not reduced in patients with idiopathic venous thromboembolism treated with 1-year anticoagulant treatment compared with patients treated for 3 months.

Can we optimise treatment of thrombosis?

The occurrence of thromboembolism in patients with cancer complicates their management. Patients with cancer who have established venous thrombosis are at increased risk of recurrent venous thromboembolism and anticoagulant-associated bleeding compared with non-cancer patients. Low-molecular-weight heparins have largely replaced unfractionated heparin as the initial treatment for acute thrombosis and have the advantage that they can be administered at home. The use of oral anticoagulant for the long-term secondary prevention of recurrent venous thromboembolism can be problematic in the cancer patient due to unpredictable changes in the dose response because of poor nutrition, infection, concomitant medications and impaired hepatic function. A large randomised clinical trial has shown that 6 months of treatment with the low-molecular-weight heparin dalteparin in place of 6 months of oral anticoagulant therapy significantly reduces the risk of recurrent thrombosis (50% reduction in risk; p = 0.0017) in cancer patients without an increase in bleeding.

Duration of Oral Anticoagulation Therapy After a First PE

Patients with venous thromboembolism (VTE) associated with temporary risk factors are recommended to receive 3 months of oral anticoagulation therapy. However, most research on the optimal duration of anticoagulation therapy for VTE has focused on patients with deep-vein thrombosis. To determine the optimal duration after pulmonary embolism (PE), researchers in Italy randomized patients who had received 3 months of oral anticoagulation …

Difficultés diagnostiques d’un thrombus de la crosse aortique

Introduction. – Thrombosis of the aortic arch is a rare and often underdiagnosed source of peripherical arterial embolic events. Exegesis. – We report a case with a non-typical initial clinical presentation of polyarteritis nodosa. A mobile thrombus in the aortic arch was secondarily suspected when disseminated arterial embolism appeared. Transthoracic echocardiography failed twice to diagnosticate the source of embolism. The diagnosis was only performed with transesophageal echocardiography and confirmed by computed tomography and magnetic resonance imaging of the thoracic aorta.The thrombus completely disappeared after six months of oral anticoagulant therapy. Conclusion. – Although rare, this diagnosis mustn’t be disregarded in an etiologic view of recurrent and disseminated peripherical ischemic events (even clinically silent ones) under penalty of detrimental functional consequences due to a delayed diagnosis.

Long term and short term oral anticoagulation treatments were equivalent for venous thromboembolism

(2001) Circulation 103, 2453. Pinede L, Ninet J, Duhaut P . , et al, for the Investigators of the “Durée Optimale du Traitement AntiVitamines K” (DOTAVK) Study. . Comparison of...

Comparison of 3 and 6 months of oral anticoagulant therapy after a first episode of proximal deep vein thrombosis or pulmonary embolism and comparison of 6 and 12 weeks of therapy after isolated calf deep vein thrombosis

This study tested the link between daily body-related upward social comparisons (BUSCs) and exercise behavior, and examined how appearance evaluation and gender may impact this association.In a weeklong assessment, 87 participants (54% women) completed daily retrospective measures of social comparisons and exercise behavior, and a one-time trait measure of appearance evaluation.Based on findings from hierarchical linear modeling, men with more negative appearance evaluations reported higher exercise engagement on days when they made more (compared to less) BUSCs. Meanwhile, women with more negative appearance evaluations reported less exercise engagement on days when they engaged in more (compared to less) BUSCs.Among individuals who experience negative appearance evaluations, upward body comparisons are associated with more exercising among men, and lower exercise among women. BUSCs have an important role in promoting adaptive exercise behaviors and managing negative body image.