Prophylactic Treatment For Venous Thromboembolism Research Articles

Rosuvastatin use reduces thrombin generation potential in patients with venous thromboembolism: a randomized controlled trial

Essentials The role of statins in hemostasis and venous thromboembolism (VTE) prophylaxis is not clear.This trial assessed whether rosuvastatin use affects thrombin generation in patients with VTE.Endogenous thrombin potential and peak were decreased by 10% and 5% with rosuvastatin therapy.These results provide basis for trials on the efficacy of statins in reducing recurrent VTE risk. SummaryBackgroundStatin therapy could form an alternative prophylactic treatment for venous thromboembolism (VTE) if statins are proven to downregulate hemostasis and prevent recurrent VTE, without increasing bleeding risk.ObjectivesThe STAtins Reduce Thrombophilia (START) trial investigated whether statin affects coagulation in patients with prior VTE.Patients/methodsAfter anticoagulation withdrawal, patients were randomized to rosuvastatin 20 mg day−1 for 4 weeks or no intervention. Plasma samples taken at baseline and at the end of the study were analyzed employing thrombin generation assay.Results and conclusionsThe study comprised 126 rosuvastatin users and 119 non‐users. Mean age was 58 years, 61% were men, 49% had unprovoked VTE and 75% had cardiovascular (CV) risk factors. Endogenous thrombin potential (ETP) increased from baseline to end of study in non‐statin users (mean 97.22 nm*min; 95% CI, 40.92–153.53) and decreased in rosuvastatin users (mean −24.94 nm*min; 95% CI, −71.81 to 21.93). The mean difference in ETP change between treatments was −120.24 nm*min (95% CI, −192.97 to −47.51), yielding a 10.4% ETP reduction by rosuvastatin. The thrombin peak increased in both non‐statin (mean 20.69 nm; 95% CI, 9.80–31.58) and rosuvastatin users (mean 8.41 nm; 95% CI −0.86 to 17.69). The mean difference in peak change between treatments was −11.88 nm (95% CI, −26.11 to 2.35), yielding a 5% peak reduction by rosuvastatin. Other thrombin generation parameters did not change substantially. The reduction in ETP and peak by rosuvastatin was more pronounced in the subgroups of participants with CV risk factors and with unprovoked VTE. We conclude that rosuvastatin reduces thrombin generation potential in patients who had VTE.

Clozapine-Associated Pulmonary Embolism: A High-Mortality, Dose-Independent and Early-Onset Adverse Effect.

Recent epidemiological studies have identified an excess of pulmonary embolism (PE) cases in patients treated with antipsychotic drugs. The findings are particularly relevant for patients treated with clozapine, which has many potentially life-threatening adverse drug effects. Among these adverse drug effects are myocarditis and agranulocytosis that have early onset and are dose independent, but also seizures and myocardial repolarization delay, which are dose dependent and may occur at any time. Together with death rates, these variables have important implications for clinical practice. Study Question: What are the time of onset, dose relationship, and mortality of clozapine-associated PE? The published case reports of clozapine-associated PE were identified in a MEDLINE search. Cases occurring within 6 months of starting clozapine were considered to have early onset. Dosages of clozapine at the time of PE were defined as low (200 mg/d or less) or high (300 mg/d or greater). Patient outcome was divided into survival of the PE event and death. The search identified 23 cases of clozapine-associated PE. The PE had early onset (6.4 ± 7.0 weeks) in 20 patients (87%, 95% confidence interval 67.9%-95.5%). PE occurred in 9 patients treated with low doses (152.8 ± 50.7 mg/d) and in 11 patients on high doses (372.7 ± 127.2 mg/d) of clozapine. Six patients (26.1%, 95% confidence interval 12.6%-46.5%) died. A systematic review of the published case reports of clozapine-associated PE indicates that this adverse effect is highly lethal, has early onset and is dose independent. The findings should prompt careful monitoring and consideration of prophylactic treatment for venous thromboembolism for 6 months after starting treatment with clozapine.

Post-Hospital Discharge Venous Thromboembolism in Colorectal Surgery.

There are limited data regarding the criteria for prophylactic treatment of venous thromboembolism (VTE) after hospital discharge. We sought to identify risk factors of post-hospital discharge VTE events following colorectal surgery. The NSQIP database was utilized to examine patients developed VTE after hospital discharge following colorectal surgery during 2005-2013. Multivariate analysis using logistic regression was performed to quantify risk factors of VTE after discharge. We evaluated a total of 219,477 patients underwent colorectal resections. The overall incidence of VTE was 2.1 % (4556). 33.8 % (1541) of all VTE events occurred after hospital discharge. The length of postoperative hospitalization had a strong association with post-discharge VTE, with the highest risk in patients who were hospitalized for more than 1 week after operation (AOR 9.08, P < 0.01). Other factors associated with post-discharge VTE included chronic steroid use (AOR 1.81, P < 0.01), stage 4 colorectal cancer (AOR 1.40, P = 0.03), obesity (AOR 1.37, P < 0.01), age >70 (AOR 1.21, P = 0.04), and open surgery (AOR 1.36, P < 0.01). Patients who were hospitalized for more than 1 week after an open colorectal resections had a 12 times higher risk of post-discharge VTE event compared to patients hospitalized less than 4 days after a laparoscopic resection (AOR 12.34, P < 0.01). VTE is uncommon following colorectal resections; however, a significant proportion occurs after patients are discharged from the hospital (33.8 %). The length of postoperative hospitalization appears to have a strong association with post-discharge VTE. High-risk patients may benefit from continued VTE prophylaxis after discharge.

A Nationwide Analysis of Postoperative Deep Vein Thrombosis and Pulmonary Embolism in Colon and Rectal Surgery

There are limited data regarding predictive factors of postoperative venous thromboembolism (VTE) in patients undergoing colorectal resection. We sought to identify associations between patient comorbidities and postoperative VTE in colorectal resection. The National Surgical Quality Improvement Program (NSQIP) database was used to examine clinical data of patients experiencing postoperative VTE after colorectal resection from 2005 to 2011. Multivariate analysis using logistic regression was performed to quantify risk factors of VTE. We sampled 116,029 patients undergoing colorectal resection. The rate of VTE was 2 % (2,278) with 0.2 % (182) having deep vein thrombosis (DVT) and pulmonary embolism (PE). The first week after operation was the most common time for postoperative VTE. A significant number of patients suffering DVT and PE were diagnosed after index hospital discharge (PE 34.6 %, DVT 29.3 %). The most important risk factors identified for DVT include (P < 0.05) ASA score >2 (adjusted odds ratio (AOR) 1.77) and hypoalbuminemia (serum albumin level <3.5 mg/dl) (AOR 1.69). The most important factors had associations with PE include (P < 0.05) DVT (AOR 14.60) and disseminated cancer (AOR 1.70). Ulcerative colitis (AOR 1.48, P = 0.01) and stage 4 cancer (AOR 1.29, P = 0.02) have associations with DVT. Open colorectal procedures have higher risk of DVT compared to laparoscopic procedures (AOR 1.33, P < 0.01). Postoperative VTE occurs in 2 % of colorectal resections. Thirty percent of VTE events were diagnosed after discharge. Prophylactic treatment of VTE after discharge may have benefits in high-risk patients. Thirteen and eleven perioperative risk factors have associations with DVT and PE, respectively. Emergent admission, open procedures, ulcerative colitis, and stage 4 cancer patients have increased risk of DVT.

A Software for the Prescription of Prophylactic Treatment of Venous Thromboembolism (VTE) in Hospitalized Patients. Evaluation of the Prescriptive Mode

AbstractAbstract 4371 Background/Aim:Using of a software for venous thromboprophylaxis prescription in hospitalized patients. Evaluation of the prescriptive mode in relation to the risk profile of the patient. Materials and Methods:Has been developed a software, which guides the physician to the choice of prophylaxis of VTE on the basis of a thromboembolic risk score (The Padua Prediction Score), renal function and the type of admission. We analyzed data derived from prescriptions over a period of 14 consecutive months. Results:3125 patients were included. 68% of the patients were “high-risk (HR)” and 32% at “low risk (LR)”. Were treated with drug therapy, 89% of HR patients and 40% of LR. 11% of HR patients were not treated for severe renal failure or high risk of bleeding. Conclusion:All HR patients were considered for thromboprophilaxis. 89 % of HR patients and 40% of LR were treated. In our initial experience the software is an effective tool to identify patients at high risk and more effective prophylactic strategy. Furthermore, the evaluation of creatinine clearance allows to assess the bleeding risk associated with prophylactic treatment. [Display omitted] Disclosures:No relevant conflicts of interest to declare.

Additional Information Needed

The article recommended patterns of movement that should be avoided postoperatively. To give some more detail: Basically it is the case that most patients—in spite of information provided—perform their usual customary movements without experiencing a dislocation. Actual dislocations usually happen for other reasons—for example, because of particular force or violence, unsatisfactory implantation techniques, or other special circumstances. Controlled movement patterns are not problematic, they usually do not result in luxation (including medical movement check-ups and physiotherapy). Irrational fears may result in an omission of necessary examinations and treatments—continued provision of rational information to the patient is therefore required. For forensic reasons, the guidelines from the Association of the Scientific Medical Societies (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF) are more likely to be relevant for the prophylaxis of thrombosis, because often, the customary 11–14 day course of prophylactic treatment for venous thromboembolism is not given in the context of endoprosthesis of the knee. The article does not explain geriatric aftercare in any factual detail. The primary indication is for orthopedic-traumatologic rehabilitation. Mostly, inpatient rehabilitation is relevant; because outpatient treatment is often not a realistic option in view of multiple comorbidities, age, and other pathologies that require inpatient treatment. Afterwards, geriatric rehabilitation may be indicated. As a rule, it is recommended that one should proceed as follows in such cases: even while the patient is having surgery, immediate postoperative rehabilitation follow-up treatment (subsequent curative treatment) should be organized. Often, additional outpatient treatment is required; this is also the time to decide whether of the basis of a specific medical indication, short term or subsequent geriatric rehabilitation measures are indicated. All this requires careful medical advice and information for the patient.

Enoxaparin Versus Unfractionated Heparin in the Prevention of Venous Thromboembolism After Acute Ischemic Stroke: Rationale, Design, and Methods of an Open-Label, Randomized, Parallel-Group Multicenter Trial

Small sample size and methodologic limitations make it difficult to interpret and compare trials of low molecular-weight heparin (for example, enoxaparin) versus unfractionated heparin as prophylactic treatment for venous thromboembolism (VTE), that is, deep vein thrombosis and/or pulmonary embolism, in patients with acute ischemic stroke. This prospective, open-label, randomized, parallel-group, multicenter trial is designed to evaluate the efficacy and safety of enoxaparin versus unfractionated heparin for the prevention of VTE after acute ischemic stroke. Approximately 1760 patients with the diagnosis of acute ischemic stroke accompanied by leg paralysis will be randomly assigned (1:1) within 48 hours of stroke symptoms to receive enoxaparin (40 mg subcutaneously) once daily or unfractionated heparin (5000 U subcutaneously) every 12 hours for 10 +/- 4 days. Contrast venography will be used to evaluate asymptomatic patients after treatment for deep vein thrombosis. In addition, diagnostic algorithms will be used to objectively confirm or rule out VTE events for patients in whom upper- or lower-extremity deep vein thrombosis/pulmonary embolism is suggested. The primary efficacy end point measure will be the cumulative occurrence of documented VTE during the initial treatment period. Secondary end points are VTE incidence; neurologic outcome at days 30, 60, and 90; safety; and health care resource use during initial hospitalization and during the 30- and 90-day follow-up periods. This study will provide clinical and health economic data regarding the use of enoxaparin as primary prophylactic treatment of VTE in patients who have had an acute ischemic stroke.

Assessment of the Risk and Prophylactic Treatment of Venous Thromboembolism in the Elderly

Numerous large randomized controlled trials have assessed the benefit of prophylactic anticoagulation for venous thromboembolism in selected patients. However, few trials were conducted in elderly patients, as this issue was not addressed in this specific population,or as elderly patients were excluded of these studies. Therefore, as the risk of a first episode of venous thromboembolism (in surgical and in medical setting) and the risk of a major anticoagulant-related bleeding are both increased in elderly subjects, the results of the main available studies can not be extrapolated to this population. Consequently, in practice, the balance between expected benefit and risk of prophylactic anticoagulation should be carefully assessed for each individual elderly patient taking in account the specific risk of venous thromboembolism in elderly in the absence of anticoagulation, the risk of anticoagulant related bleeding according to the type of anticoagulant treatment and the intrinsic risk of bleeding of elderly subjects and, lastly, the available guideline recommendations. In order to improve such evaluation, it is anticipated that further prophylactic studies are needed in elderly patients. In addition, the development of anticoagulation clinics and new oral anticoagulants should help to reduce anticoagulant related bleeding for an equivalent, or an increased, benefit.

Venous thromboembolism in acute stroke. Prognostic importance of hypercoagulability.

To assess the incidence, risk factors, and clinical importance of deep vein thrombosis in acute stroke, we studied 70 consecutive patients who underwent hemostasis screening at the time of entry into the study and followed up these patients with serial venous Doppler examinations and the iodine 125-labeled fibrinogen uptake test. Mortality was significantly higher among the 20 patients who developed a deep vein thrombosis, and eight of them had necropsy evidence of pulmonary embolism. Severity of leg paresis and a shortened activated partial thromboplastin time were significantly associated with subsequent deep vein thrombosis with multivariate analysis. Significantly higher levels of fibrinopeptide A were found in patients with postmortem evidence of pulmonary embolism. Deep vein thrombosis is a frequent complication of acute stroke and may influence the prognosis by inducing pulmonary embolism. Our findings allow rapid identification of high-risk patients who may benefit maximally from prophylactic treatment of venous thromboembolism.