Prevention Of Venous Thromboembolic Disease Research Articles

Venous Thromboembolism In Cancer Patients: "From Evidence to Care".

This article seeks to review the current status of treatment and prevention of venous thromboembolic disease (VTE) in cancer patients after the addition of direct oral anticoagulants (DOAC) to the therapeutic arsenal available. The suitability of DOAC use in complex clinical situations, poorly represented in clinical trials, is controversial and difficult for care activity, making the recommendations in clinical practice guidelines the focus of special attention in this area. Recently, several randomized trials have compared low molecular weight heparin (LMWH) to DOAC for the management of CAT. Potential drug interactions with DOACs or the increased risk of bleeding in intraluminal tumors require special precautions, as do metastatic or primary brain disease and comorbid conditions, such as renal or liver failure, which are not suitably represented in pivotal studies. Furthermore, few data are available for situations involving elevated bleeding risk, with thrombocytopenia levels below the inclusion criterion of clinical trials, or recurrence during active anticoagulant therapy. Similarly, it is less clear that patients and physicians accept the presumption that oral DOAC administration is more convenient than subcutaneous LMWH, particularly when drug absorption may be compromised. The non-inclusion or under-representation of patients at higher risk for complications with anticoagulation in randomized clinical trials, makes their use complex in certain situations in health care. This paper provides a practical review of current clinical guideline recommendations regarding LMWH and/ or DOAC to treat and prevent CAT, as well as the most controversial clinical conditions for their use.

Data of Real-Life Anticoagulant Treatment in Patients Diagnosed with Nonvalvular Atrial Fibrillation and Secondary Prevention of Venous Thromboembolic Disease with Edoxaban: Experience in Our Center

INTRODUCTIONAtrial fibrillation (AF) is one the most common disturbance of cardiac rhythm in adults and it is a major healthcare problem as it is associated with the risk of ischemic stroke. The prevalence of AF is estimated to affect at least 1% of the population in developed countries. In patients with AF, the risk of stroke is higher, according to the stroke risk stratification schemes CHADS2 and CHA2DS2-VASc. Oral anticoagulation therapy is a well-established treatment to prevent strokes in patients with AF who are at moderate to high risk of stroke, and the non-vitamin K antagonist oral anticoagulants have been recommended as alternatives to warfarin for stroke prevention in patients with non-valvular atrial fibrillation (NVAF) in various treatment guidelines.Edoxaban (Lixiana®, Daiichi-Sankyo) is an oral, reversible, direct factor Xa inhibitor with a linear and predictable pharmacokinetic. The edoxaban dose regimen consisted of 60 mg/24h, that was reduced to 30 mg/24h for estimated creatinine clearance of 15-50mL/min, body weight <60 kg or concomitant use of potent P-glycoprotein inhibitors. It was found not to be inferior to warfarin for prevention of stroke or systemic embolic events (SEE) in patients with AF and to reduce major bleeding, including a signicant reduction of intracranial haemorrhage and cardiovascular death.OBJECTIVEThe primary objective of the study is to evaluate the efficacy of Edoxaban in the prevention of stroke and Embolism Systemic. Besides, the secondary objective is to assess its safety, in function of the major bleeding defined according to the criteria of the International Society of Thrombosis and Hemostasis (ISTH).METHODSThis is a descriptive study. We have included a total of 102 patients with NVAF and venous thromboembolic disease (TED). The indication for anticoagulation was NVFA with 97 cases and 5 patients for secondary prevention of TED.The risk of stroke is assessed according to the scale CHA2DS2-VASc (average 3,83). Figure 1.We also evaluated the risk of bleeding according to the scale HAS-BLED (average 2.85). Figure 2.We have included 85 cases with doses of 60 mg/24h and 17 cases at a dose of 30 mg/24h. According to sex, it was about 56 women and 46 men, aged between 51 and 88 years old (average 72.2).All patients had received prior treatment with Anti-Vitamin K (AVK). The main reason of suspension of Anti-Vitamin K and its replacement with Edoxaban was because therapeutic time in range (TTR) was <65% (88 patients) and bleeding diathesis caused by anti-vitamin K (AVK) (14 patients). Of the patients included, 18 had presented previous stroke under treatment with AVK.We have evaluated complications in both bleeding and thrombosis during the treatment.The treatment time has been between 1 and 6 months (average of 4 months). Figure 3.RESULTSIt has not been reported any case of Stroke, Systemic Embolism, or Major Bleeding (criteria of ISTH) during the follow-up time of the patients treated.The only complications described were:- 1 case of small bruise on the thigh in a patient treated at a dose of 60 mg/24h. In the follow-up visit we performed a new evaluation of the Creatinine Clearance and we found that the figures were 44 ml/min, which was reduced at the dose of 30 mg/24h, as indicated in the Technical Data Sheet.- 1 patient attended the emergency department due to Delirium, which, after ruling out pathology-related (stroke, ischaemic or haemorrhagic, and TED by means of the relevant studies), or cause-effect relationship with the drug continued with the treatment with Edoxaban.- 1 patient presented self-limited Hemoptysis that did not require suspension of the treatment.During the study, a patient was diagnosed with lung cancer and the anticoagulant treatment was suspended. The patient died later by this oncology pathology.CONCLUSIONThe results obtained confirm the efficacy and safety of using Edoxaban in the prevention of stroke in the NVAF and in the few cases of TED.This is a small sample and with a short time of follow-up, due to the fact that the drug was approved in our country a few months ago.Our experience support the results of the trials. We believe that there is a good alternative to oral anticoagulation in patients with NVAF, being effective in the prevention of stroke and Systemic Embolism. It has a good safety profile with a clinical net benefit mainly at the expense of absence of bleeding.Subsequent studies will provide data confirmation. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Manejo perioperatorio de la anticoagulación en cirugía cardíaca: ¿un lugar para los anticoagulantes directos?

Anticoagulation in the postoperative period of cardiac surgery constitutes a challenge. The timing of initiation, the anticoagulation dose to be used and the type of anticoagulant will depend on the procedure performed, the association of thrombotic and/or hemorrhagic risk factors, and strict clinical monitoring in order to achieve an adequate level of protection and avoid complications during hospital stay. We will analyze three postoperative situations: patients with valve prostheses, atrial fibrillation and prevention of venous thromboembolic disease as well as prevention and management of bleeding complications, adapting treatment to INR levels and presence of bleeding. Multi and interdisciplinary teamwork and the protocolization of the measures to be taken, facilitate the management of these patients and reduces complications, many of which are totally avoidable

Improving compliance to clinical practice guidelines with a multifaceted quality improvement program for the prevention of venous thromboembolic disease in nonsurgical patients

To evaluate the change in compliance to thromboprophylaxis guidelines before and after the implementation of a multifaceted patient safety program. Longitudinal before and after study. Teaching hospital, Hospital Universitario San Ignacio, Bogotá (Colombia). Adult nonsurgical hospitalized patients. A multifaceted program for the prevention of venous thromboembolic (VTE) disease among adult nonsurgical hospitalized patients. The strategies of the program included (i) update and communication of thromboprophylaxis guidelines, (ii) the implementation of risk-assessment tools in electronic medical records, (iii) nursing staff activities and (iv) education to health personnel and patients for maintenance of the program. Appropriate use of thromboprophylaxis. 221 and 236 patients were evaluated in the pre- and postimplementation periods, respectively. Global appropriate thromboprophylaxis prescription went from 74.66 to 82.6% (P=0.064). Adequate thromboprophylaxis in high-risk patients did not increase significantly (77.70 vs 80.62%, P=0.528), but a significant reduction in inappropriate thromboprophylaxis formulation in low-risk patients was found, decreasing from 20.55 to 5.26% (P=0.005). Implementing a quality improvement multifaceted program improves the formulation of adequate thromboprophylaxis. Reducing the inappropriate prescription of VTE prophylaxis in patients at low risk of thrombosis can lead to a reduction in bleeding complications and a better use of economic and human resources.

Proposal of the French Society of Vascular Medicine for the prevention, diagnosis and treatment of venous thromboembolic disease in outpatients with COVID-19.

The proposal is intended to help physicians treating patients with COVID-19 for the diagnosis, treatment and prevention of venous thromboembolic disease either when leaving the hospital or treated as outpatients. This document is a synthesis of opinions of a working group from the French Society of Vascular Medicine (SFMV) composed of private practice and hospital-based physicians. This proposal is based on a limited level of evidence. This proposal is likely to evolve with the knowledge of the disease.

Impact of an intervention on the practice of venous thromboprophylaxis recommendations in a geriatric setting.

The practice of prevention of venous thromboembolic disease in hospitalized elderly patients does not comply with published recommendations, in 30% of cases. The objective of this study was to evaluate the impact of recalling the recommendations on the venous thromboprophylaxis.

The American Society of Colon and Rectal Surgeons Clinical Practice Guideline for the Prevention of Venous Thromboembolic Disease in Colorectal Surgery.

The American Society of Colon and Rectal Surgeons Clinical Practice Guideline for the Prevention of Venous Thromboembolic Disease in Colorectal Surgery.

New Anticoagulants for the Prevention and Treatment of Venous Thromboembolism

Anticoagulant drugs, like vitamin K antagonists and heparin, have been the mainstay for the treatment and prevention of venous thromboembolic disease for many years. Although effective if appropriately used, traditional anticoagulants have several limitations such as unpredictable pharmacologic and pharmacokinetic responses and various adverse effects including serious bleeding complications. New oral anticoagulants have recently emerged as an alternative because of their rapid onset/offset of action, predictable linear dose-response relationships and fewer drug interactions. However, they are still associated with problems such as bleeding, lack of reversal agents and standard laboratory monitoring. In an attempt to overcome these drawbacks, key steps of the hemostatic pathway are investigated as targets for anticoagulation. Here we reviewed the traditional and new anticoagulants with respect to their targets in the coagulation cascade, along with their therapeutic advantages and disadvantages. In addition, investigational anticoagulant drugs currently in the development stages were introduced.

Oral anticoagulants for primary prevention, treatment and secondary prevention of venous thromboembolic disease, and for prevention of stroke in atrial fibrillation: systematic review, network meta-analysis and cost-effectiveness analysis.

Warfarin is effective for stroke prevention in atrial fibrillation (AF), but anticoagulation is underused in clinical care. The risk of venous thromboembolic disease during hospitalisation can be reduced by low-molecular-weight heparin (LMWH): warfarin is the most frequently prescribed anticoagulant for treatment and secondary prevention of venous thromboembolism (VTE). Warfarin-related bleeding is a major reason for hospitalisation for adverse drug effects. Warfarin is cheap but therapeutic monitoring increases treatment costs. Novel oral anticoagulants (NOACs) have more rapid onset and offset of action than warfarin, and more predictable dosing requirements. To determine the best oral anticoagulant/s for prevention of stroke in AF and for primary prevention, treatment and secondary prevention of VTE. Four systematic reviews, network meta-analyses (NMAs) and cost-effectiveness analyses (CEAs) of randomised controlled trials. Hospital (VTE primary prevention and acute treatment) and primary care/anticoagulation clinics (AF and VTE secondary prevention). Patients eligible for anticoagulation with warfarin (stroke prevention in AF, acute treatment or secondary prevention of VTE) or LMWH (primary prevention of VTE). NOACs, warfarin and LMWH, together with other interventions (antiplatelet therapy, placebo) evaluated in the evidence network. Efficacy Stroke, symptomatic VTE, symptomatic deep-vein thrombosis and symptomatic pulmonary embolism. Safety Major bleeding, clinically relevant bleeding and intracranial haemorrhage. We also considered myocardial infarction and all-cause mortality and evaluated cost-effectiveness. MEDLINE and PREMEDLINE In-Process & Other Non-Indexed Citations, EMBASE and The Cochrane Library, reference lists of published NMAs and trial registries. We searched MEDLINE and PREMEDLINE In-Process & Other Non-Indexed Citations, EMBASE and The Cochrane Library. The stroke prevention in AF review search was run on the 12 March 2014 and updated on 15 September 2014, and covered the period 2010 to September 2014. The search for the three reviews in VTE was run on the 19 March 2014, updated on 15 September 2014, and covered the period 2008 to September 2014. Two reviewers screened search results, extracted and checked data, and assessed risk of bias. For each outcome we conducted standard meta-analysis and NMA. We evaluated cost-effectiveness using discrete-time Markov models. Apixaban (Eliquis®, Bristol-Myers Squibb, USA; Pfizer, USA) [5 mg bd (twice daily)] was ranked as among the best interventions for stroke prevention in AF, and had the highest expected net benefit. Edoxaban (Lixiana®, Daiichi Sankyo, Japan) [60 mg od (once daily)] was ranked second for major bleeding and all-cause mortality. Neither the clinical effectiveness analysis nor the CEA provided strong evidence that NOACs should replace postoperative LMWH in primary prevention of VTE. For acute treatment and secondary prevention of VTE, we found little evidence that NOACs offer an efficacy advantage over warfarin, but the risk of bleeding complications was lower for some NOACs than for warfarin. For a willingness-to-pay threshold of > £5000, apixaban (5 mg bd) had the highest expected net benefit for acute treatment of VTE. Aspirin or no pharmacotherapy were likely to be the most cost-effective interventions for secondary prevention of VTE: our results suggest that it is not cost-effective to prescribe NOACs or warfarin for this indication. NOACs have advantages over warfarin in patients with AF, but we found no strong evidence that they should replace warfarin or LMWH in primary prevention, treatment or secondary prevention of VTE. These relate mainly to shortfalls in the primary data: in particular, there were no head-to-head comparisons between different NOAC drugs. Calculating the expected value of sample information to clarify whether or not it would be justifiable to fund one or more head-to-head trials. This study is registered as PROSPERO CRD42013005324, CRD42013005331 and CRD42013005330. The National Institute for Health Research Health Technology Assessment programme.

Bleeding and Thrombotic Outcomes Following Perioperative Interruption of Direct Oral Anticoagulants in Patients with Prior Venous Thromboembolic Disease

▪Introduction: The use of Direct Oral Anticoagulants (DOACs) for the prevention and treatment of Venous Thromboembolic Disease (VTE) is increasingly common. Patients on longstanding anticoagulation for the prevention of VTE frequently undergo invasive procedures that necessitate interruption of anticoagulation in order to avoid excessive bleeding during the procedure. There is little evidence surrounding the safety of perioperative DOAC interruption in patients with VTE.Methods: This study represents a retrospective analysis of adult patients on DOAC therapy for prior VTE, who underwent temporary interruption of anticoagulation therapy for inpatient or outpatient invasive procedures. The timing to hold and resume DOAC anticoagulation was based on the estimated half-life of the DOAC, as well as the bleeding risk of the procedure (Standard vs High). Our primary outcomes included the 30-day thromboembolic complication rate, as well as the 30-day major bleeding rate (ISTH non-surgical and surgical major bleeding criteria). Secondary outcomes included clinically relevant non-major bleeding (CRNMB) and overall mortality.Results: To date, a total of 87 patients have been included in the analysis, 68% of which were male. The mean age of the cohort was 58.3 years. All patients were on DOAC anticoagulation for acute treatment or secondary prevention of recurrent VTE. A large majority of patients (94%) were anticoagulated with rivaroxaban. Procedures were performed on an inpatient or outpatient basis in 24 and 63 patients, respectively. Forty six patients underwent procedures with standard bleeding risk. Mean time to anticoagulation discontinuation for standard and high bleeding risk procedures was 41.3 (SD = 20.8) and 49.3 (SD = 17.7) hours, respectively. The 30-day thromboembolic complication rate was 1.2% (95% CI: 0.2 to 6.2%), whereas the 30-day major bleeding rate was 0% (95% CI: 0 to 4.2%). The rate of CRNMB was 3.5% (95% CI: 1.2 to 9.7%). Overall mortality was 0% (95% CI: 0 to 4.2%).Conclusion: The perioperative interruption of direct oral anticoagulation for invasive procedures in patients with prior VTE appears to be associated with a relatively low risk of major bleeding, as well as recurrent VTE. Prospective studies are needed to evaluate the benefits and risks of perioperative interruption of direct oral anticoagulation in patients with prior VTE. DisclosuresCarrier:BMS: Research Funding; Leo Pharma: Research Funding.

Improvement of the safety of a clinical process using failure mode and effects analysis: Prevention of venous thromboembolic disease in critical patients

ObjectiveTo improve critical patient safety in the prevention of venous thromboembolic disease, using failure mode and effects analysis as safety tool. DesignA contemporaneous cohort study covering the period January 2014–March 2015 was made in 4 phases: (phase 1) prior to failure mode and effects analysis; (phase 2) conduction of mode analysis and implementation of the detected improvements; (phase 3) evaluation of outcomes, and (phase 4) post-checklist introduction impact. SettingPatients admitted to the adult polyvalent ICU of a third-level hospital center. PatientsA total of 196 patients, older than 18 years, without thromboembolic disease upon admission to the ICU and with no prior anticoagulant treatment. InterventionsA series of interventions were implemented following mode analysis: training, and introduction of a protocol and checklist to increase preventive measures in relation to thromboembolic disease. Variables of interestIndication and prescription of venous thrombosis prevention measures before and after introduction of the measures derived from the failure mode and effects analysis. ResultsA total of 59, 97 and 40 patients were included in phase 1, 3 and 4, respectively, with an analysis of the percentage of subjects who received thromboprophylaxis. The failure mode and effects analysis was used to detect potential errors associated to a lack of training and protocols referred to thromboembolic disease. An awareness-enhancing campaign was developed, with staff training and the adoption of a protocol for the prevention of venous thromboembolic disease. The prescription of preventive measures increased in the phase 3 group (91.7 vs. 71.2%, p=0.001). In the post-checklist group, prophylaxis was prescribed in 97.5% of the patients, with an increase in the indication of dual prophylactic measures (4.7, 6.7 and 41%; p<0.05). There were no differences in complications rate associated to the increase in prophylactic measures. ConclusionsThe failure mode and effects analysis allowed us to identify improvements in the prevention of thromboembolic disease in critical patients. We therefore consider that it may be a useful tool for improving patient safety in different processes.

Reversal of Dabigatran with Idarucizumab

ABSTRACTIntroduction: The use of novel oral anticoagulants such as dabigatran has been increasing over the last five years. Indicated for use in the prevention of thromboembolic complications from non-valvular atrial fibrillation and for the treatment and prevention of venous thromboembolic disease, dabigatran is increasingly encountered clinically. Lack of an efficacious reversal agent has been a challenge for increased clinical 10 adoption, and for management of patients with bleeding complications while taking dabigatran, or those requiring urgent procedures while taking dabigatran. Idarucizumab, a monoclonal antibody fragment, has recently been approved for use to reverse anticoagulation with dabigatran in patients with serious bleeding.Areas covered: Herein we discuss the development and early clinical data evaluating the use of idarucizumab for dabigatran reversal.Expert commentary: Idarucizumab has been shown to be an efficacious reversal agent for patients receiving dabigatran. The drug provides a novel and clinically useful agent for patients with significant bleeding while receiving dabigatran, or those needing urgent invasive procedures.

Mejora en la seguridad de un proceso clínico utilizando el análisis modal de fallos y efectos: profilaxis de la enfermedad tromboembólica venosa en pacientes críticos

ObjectiveTo improve critical patient safety in the prevention of venous thromboembolic disease, using failure mode and effects analysis as safety tool. DesignA contemporaneous cohort study covering the period January 2014-March 2015 was made in 4 phases: phase 1) prior to failure mode and effects analysis; phase 2) conduction of mode analysis and implementation of the detected improvements; phase 3) evaluation of outcomes, and phase 4) (post-checklist introduction impact. SettingPatients admitted to the adult polyvalent ICU of a third-level hospital center. PatientsA total of 196 patients, older than 18 years, without thromboembolic disease upon admission to the ICU and with no prior anticoagulant treatment. InterventionsA series of interventions were implemented following mode analysis: training, and introduction of a protocol and checklist to increase preventive measures in relation to thromboembolic disease. Variables of interestIndication and prescription of venous thrombosis prevention measures before and after introduction of the measures derived from the failure mode and effects analysis. ResultsA total of 59, 97 and 40 patients were included in phase 1, 3 and 4, respectively, with an analysis of the percentage of subjects who received thromboprophylaxis. The failure mode and effects analysis was used to detect potential errors associated to a lack of training and protocols referred to thromboembolic disease. An awareness-enhancing campaign was developed, with staff training and the adoption of a protocol for the prevention of venous thromboembolic disease. The prescription of preventive measures increased in the phase 3 group (91.7 vs. 71.2%, P=.001). In the post-checklist group, prophylaxis was prescribed in 97.5% of the patients, with an increase in the indication of dual prophylactic measures (4.7, 6.7 and 41%; P<.05). There were no differences in complications rate associated to the increase in prophylactic measures. ConclusionsThe failure mode and effects analysis allowed us to identify improvements in the prevention of thromboembolic disease in critical patients. We therefore consider that it may be a useful tool for improving patient safety in different processes.

Network Meta-Analysis of Oral Anticoagulants for Primary Prevention, Treatment and Secondary Prevention of Venous Thromboembolic Disease, and for Prevention of Stroke in Atrial Fibrillation

Network Meta-Analysis of Oral Anticoagulants for Primary Prevention, Treatment and Secondary Prevention of Venous Thromboembolic Disease, and for Prevention of Stroke in Atrial Fibrillation

A Cost-Effectiveness Analysis of Novel Oral Anticoagulants for Primary Prevention of Venous Thromboembolic Disease

A Cost-Effectiveness Analysis of Novel Oral Anticoagulants for Primary Prevention of Venous Thromboembolic Disease

Does the duration of anticoagulant therapy have an influence on the prevention of venous thromboembolic disease?

Following the landmark study by Barritt and Jordan in 1960, in which patients with venous thromboembolism (VTE) were randomized to no treatment or a combination of heparin and warfarin, antithrombotic therapy for this disease became widely accepted. This study was stopped prematurely because half of the non-treated patients had recurrent pulmonary embolism (PE), or died. It was subsequently found that after a VTE, patients given warfarin alone had a 3–4-fold higher incidence of recurrent VTE than patients given both heparin and warfarin. Since the 1990s, standard therapy for VTE has comprised an initial 5–7-day course of parenteral anticoagulant plus warfarin continued for at least 3 months. The first breakthrough was the introduction low molecular weight heparin (LMWH), which by its virtue of a fixed dose regimen given subcutaneously, allowed out of hospital treatment. The second breakthrough concerns the development of several orally active small molecules, which have been evaluated in the treatment of VTE, including a direct thrombin inhibitor and direct Factor Xa inhibitors. Other novel oral agents are also in development for VTE treatment, as well as a long-acting, reversible parenteral agent. Although the DTI ximelagatran, the first oral agent to be introduced since warfarin was withdrawn from the market in Europe because of hepatotoxicity, evidence from clinical trial evaluating other single target-specific oral agents in the treatment of VTE is convincing. It is therefore likely that use of heparin/warfarin in the treatment and secondary prevention of VTE will decrease now that these novel oral agents have been introduced for these indications. The first study in VTE with dabigatran was published in December 2009. The last large trial with edoxaban has been published in 2013. The clinical evidence from all these studies will be reviewed as well as what will be next.

Risk stratification and prevention of venous thromboembolic disease in cancerology

Patients with cancer are at high risk of venous thromboembolism (VTE), which leads to significantly increased morbidity and mortality. The rates of VTE vary between 0.5% and 20% per year and depend mainly on cancer-specific and treatment-related risk factors. Also individual risk factors related to patientś characteristics contribute to occurrence of cancer-associated VTE. Risk factors and biomarkers may help identify patients at high risk of developing VTE. In several clinical studies, risk factors for the occurrence of VTE events in patients with cancer have been investigated. The type and stage of cancer have been found to be amongst the most important risk factor for VTE occurrence. Also the histological grade of a tumor has been reported to be associated with the occurrence of VTE. In other investigations, venous diseases including a history of previous VTE, a history of superficial thrombophlebitis and the presence of varicose veins, have been associated with the risk of VTE. Some studies have recently focused on the identification of biomarkers or laboratory parameters predictive of future VTE occurrence. Parameters of blood count analysis (such as elevated leukocyte and platelet count and decreased hemoglobin) have turned out to be useful in risk stratification for VTE. In a prospective and observational cohort study, the Vienna Cancer and Thrombosis Study (CATS), associations between elevated levels and risk of future VTE have been found for D-dimer, prothrombin fragment 1 + 2, and soluble P-selectin and also for clotting factor VIII and the thrombin generation potential. The role of circulating microparticles for predicting risk of VTE in patients with cancer is unclear and has to be further investigated. Risk assessment models for prediction of VTE were developed including clinical and laboratory markers. First, Khorana and colleagues published a risk assessment score that incorporates readily available parameters: primary site of cancer, pre-chemotherapy platelet count of 350 × 109/L or more, haemoglobin level less than 10 g/dL and/or use of erythropoiesis stimulating agents, pre-chemotherapy leukocyte count of more than 11 × 109/L, and a body mass index of 35 kg/m2 or more. This score was validated in other studies. In CATS the score was expanded by adding two biomarkers (D-dimer and soluble P-selectin), and the prediction of VTE was considerably improved. In the high risk categories, patients with a VTE rate up to a 20% or higher within 6 months can be identified. In recent randomized controlled trials including cancer patients with different malignancies – without applying specific VTE risk assessment – it was shown that thromboprophylaxis is safe and effective. However, the overall VTE rates were low in these studies. To date, no data is available from interventional studies applying thromboprophylaxis in cancer patients categorized into high-risk groups on the basis of risk assessment scores. In conclusion, risk stratification for VTE is feasible in cancer patients. Further improvement in risk stratification would help better identify patients for VTE prevention using anticoagulant agents. However, interventional studies are needed to investigate the safety and efficacy of thromboprophylaxis in a high-risk cancer population.

Below-knee deep vein thrombosis: an opportunity to prevent pulmonary embolism?

The prevention of venous thromboembolic disease following trauma is a priority. In contrast to above-knee deep vein thrombosis (AKDVT), the management of below-knee deep vein thrombosis (BKDVT) is controversial because the risk of pulmonary embolism (PE) has not been firmly established. We hypothesized that BKDVT and AKDVT have an equivalent risk for PE in trauma patients. We identified patients from July 2006 to December 2011 with BKDVT and/or AKDVT diagnosed by lower extremity duplex ultrasound (LEDU) and patients with PE diagnosed by computed tomography angiogram. Time of DVT onset, progression or regression, and time of PE were assessed. The BKDVT and AKDVT patient groups were defined by the location of DVT on initial LEDU. The use of therapeutic anticoagulation and inferior vena cava filter (IVCF) were compared between the BKDVT and AKDVT groups. Of 11,330 patients evaluated during the study period, 2,881 (25.4%) underwent surveillance LEDU, and 251 (8.7%) of these patients had DVT alone or associated with PE. BKDVT progressed to AKDVT and/or PE in 21 patients (12.9%). PE rates were 6.1% and 1.1% in the BKDVT and AKDVT groups, respectively (p = 0.1). There was a higher rate of therapeutic anticoagulation and/or IVCF in the AKDVT group than in the BKDVT group (86% vs. 24%, p < 0.0001). In our study population, BKDVT was associated with a higher rate of PE compared with AKDVT, which was likely secondary to the treatment of AKDVT. Because BKDVT progressed to AKDVT or PE in 1 of 8 patients, BKDVT should not be ignored in trauma patients. Aggressive chemical prophylaxis and perhaps therapeutic anticoagulation or IVCF should be considered in patients with BKDVT. Further investigation is warranted to confirm these conclusions. Therapeutic study, level IV.

Prevention of venous thromboembolic disease in the critical patient: An assessment of clinical practice in the Community of Madrid

ObjectiveTo analyze measures referred to venous thromboembolic prophylaxis in critically ill patients. DesignAn epidemiological, cross-sectional (prevalence cut), multicenter study was performed using an electronic survey. Comparison of results with quality indexes of the Spanish Society of Intensive Care Medicine, the American College of Chest Physician guidelines and international studies. SettingIntensive Care Units (ICUs) in the Community of Madrid (Spain). PatientsAll patients admitted to the ICU on the day of the survey. Variables of interestGeneral aspects of venous thromboembolic prophylaxis and protocols used (risk stratification and ultrasound screening). A descriptive analysis was performed, continuous data being expressed as the mean or median, and categorical data as percentages. ResultsA total of 234 patients in 18 ICUs were included. Eighteen percent (42/234) received no prophylaxis, and 55% had no contraindication to pharmacological prophylaxis. Of the 192 patients receiving prophylaxis, 84% received pharmacological prophylaxis, 14% mechanical prophylaxis and 2% combined prophylaxis. Low molecular weight heparin was the only pharmacological prophylaxis used, with a majority use of enoxaparin (17 of 18 ICUs). In patients with mechanical prophylaxis (31/192), antiembolic stockings were the most commonly used option (58%). Pharmacological prophylaxis contraindications were reported in 20% of the patients (46/234), the most frequent cause being thrombocytopenia (28% of the cases). Fifty percent of the ICUs used no specific venous thromboembolic prophylaxis protocol. ConclusionsPharmacological prophylaxis with low molecular weight heparin was the most frequently used venous thromboembolic prophylactic measure. In patients with contraindications to pharmacological prophylaxis, mechanical measures were little used. The use of combined prophylaxis was anecdotal. Many of our ICUs lack specific prophylaxis protocols.

¿Qué aportan los nuevos anticoagulantes en la prevención del tromboembolismo venoso y arterial?

Over the last decades, the only available oral anticoagulants were antivitamin K (AVK). The efficacy of the AVKs has been demonstrated, although they entail many disadvantages which require periodic monitoring of their anticoagulation action to adjust the doses. The new oral anticoagulants (NOACs) have pharmacokinetic and pharmacodynamic advantages because they can be administered orally at fixed doses without requiring monitorization. In the prevention of venous thromboembolic disease (VTD) after orthopedic surgery, NOACs have been shown to have a superior or similar efficacy to enoxaparin and similar safety. However, in the treatment and prevention of recurrences of VTD and in the prevention of stroke and systemic arterial embolisms in patients with nonvalvular auricular fibrillation, the NOACs have shown similar or greater efficacy as AVK and a superior safety profile with a very significant reduction in the rate of intracranial hemorrhages.