Thromboembolism medical therapy
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Medical Therapy
Medical Therapy
Deep Venous Thrombosis
Hospitalization
Treatment at home is an option according to a meta-analysis by the Cochrane Collaboration.[1]
Hospitalization should be considered in patients with more than two of the following risk factors as these patients may have more risk of complications during treatment[2]:
- Bilateral deep venous thrombosis
- Renal insufficiency
- Body weight <70 kg
- Recent prolonged immobility
- Chronic heart failure
- Cancer
Anticoagulation
Anticoagulation is the usual treatment for DVT. In general, patients are initiated on a brief course (i.e., less than a week) of heparin treatment while they start on a 3- to 6-month course of warfarin (or related vitamin K inhibitors). Low molecular weight heparin (LMWH) is preferred,[3] though unfractionated heparin is given in patients who have a contraindication to LMWH (e.g., renal failure or imminent need for invasive procedure). In patients who have had recurrent DVTs (two or more), anticoagulation is generally “life-long.” The Cochrane Collaboration has meta-analyzed the risk and benefits of prolonged anti-coagulation.[4]
An abnormal D-dimer level at the end of treatment might signal the need for continued treatment among patients with a first unprovoked proximal deep-vein thrombosis.[5]
| Trial | Patients | Intervention | Comparison | Outcome | Results | Comment | |
|---|---|---|---|---|---|---|---|
| Intervention | Control | ||||||
| ASPIRE, 2012[6] | 822 patients • first-ever, unprovoked venous thromboembolism • completed initial anticoagulant |
Aspirin 100 mg/day | Placebo | venous thromboembolism at 37 months | 4.8% | 6.5% | relative risk ratio = 0.74 (95% CI: 0.52 to 1.05; P=0.09) |
| WARFASA, 2012[7] | 502 patients • first-ever, unprovoked venous thromboembolism • completed initial anticoagulant |
Aspirin 100 mg/day | Placebo | venous thromboembolism at 24 months | 6.6% | 11.2% |
0.58 (95% CI: 0.36 to 0.93) |
Cancer associated thrombolism (CAT)
Clinical practice guidelines from the American Society of Clinical Oncology (ASCO) state[8]:
- “initial anticoagulation may include LMWH, UFH, fondaparinux, or rivaroxaban”
More recently, direct oral anticoagulants (DOACs) lower the risk of current VTE compared to treatment with LMWH[9][10].
Thrombolysis
Thrombolysis is generally reserved for extensive clot, e.g. an iliofemoral thrombosis. Although a meta-analysis of randomized controlled trials by the Cochrane Collaboration shows improved outcomes with thrombolysis,[11] there may be an increase in serious bleeding complications.
Compression Stockings
Elastic compression stockings should be routinely applied “beginning within 1 month of diagnosis of proximal DVT and continuing for a minimum of 1 year after diagnosis”.[3] Starting within one week may be more effective.[12] The stockings in almost all trials were stronger than routine anti-embolism stockings and created either 20-30 mm Hg or 30-40 mm Hg. Most trials used knee-high stockings. A meta-analysis of randomized controlled trials by the Cochrane Collaboration showed reduced incidence of post-phlebitic syndrome.[13] The number needed to treat is quite potent at 4 to 5 patients need to prevent one case of post-phlebitic syndrome.[14]
Pulmonary Embolism
Emergency treatment at a hospital is necessary to treat pulmonary embolism.
Contraindications to Medical Therapy
- Warfarin is contraindicated during pregnancy. It crosses the placenta and increases the risk of miscarriage, stillbirth, embryopathy (nasal hypoplasia or stippled epiphyses), central nervous system abnormalities, maternal hemorrhage and fetal hemorrhage. It is safe to use it in postpartum period and is compatible with breastfeeding.
- Low-molecular-weight heparin has largely replaced unfractionated heparin for prophylaxis and treatment.
References
References
- ↑ Othieno R, Abu Affan M, Okpo E (2007). “Home versus in-patient treatment for deep vein thrombosis”. Cochrane database of systematic reviews (Online) (3): CD003076. doi:10.1002/14651858.CD003076.pub2. PMID 17636714.
- ↑ Trujillo-Santos J, Herrera S, Page MA; et al. (2006). “Predicting adverse outcome in outpatients with acute deep vein thrombosis. findings from the RIETE Registry”. J. Vasc. Surg. 44 (4): 789–93. doi:10.1016/j.jvs.2006.06.032. PMID 16926081.
- ↑ 3.0 3.1 Snow V, Qaseem A, Barry P; et al. (2007). “Management of venous thromboembolism: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians”. Ann. Intern. Med. 146 (3): 204–10. PMID 17261857.
- ↑ Hutten BA, Prins MH (2006). “Duration of treatment with vitamin K antagonists in symptomatic venous thromboembolism”. Cochrane database of systematic reviews (Online) (1): CD001367. doi:10.1002/14651858.CD001367.pub2. PMID 16437432.
- ↑ Palareti G, Cosmi B, Legnani C; et al. (2006). “D-dimer testing to determine the duration of anticoagulation therapy”. N. Engl. J. Med. 355 (17): 1780–9. doi:10.1056/NEJMoa054444. PMID 17065639.
- ↑ 6.0 6.1 Brighton, Timothy A. “Low-Dose Aspirin for Preventing Recurrent Venous Thromboembolism”. New England Journal of Medicine. doi:10.1056/NEJMoa1210384. ISSN 0028-4793. Retrieved 2012-11-05. Unknown parameter
|coauthors=ignored (help) - ↑ 7.0 7.1 Becattini C, Agnelli G, Schenone A, Eichinger S, Bucherini E, Silingardi M; et al. (2012). “Aspirin for preventing the recurrence of venous thromboembolism”. N Engl J Med. 366 (21): 1959–67. doi:10.1056/NEJMoa1114238. PMID 22621626.
- ↑ Key NS, Khorana AA, Kuderer NM, Bohlke K, Lee AYY, Arcelus JI; et al. (2020). “Venous Thromboembolism Prophylaxis and Treatment in Patients With Cancer: ASCO Clinical Practice Guideline Update”. J Clin Oncol. 38 (5): 496–520. doi:10.1200/JCO.19.01461. PMID 31381464. Review in: Ann Intern Med. 2020 Jan 21;172(2):JC2
- ↑ Fuentes HE, McBane RD, Wysokinski WE, Tafur AJ, Loprinzi CL, Murad MH; et al. (2019). “Direct Oral Factor Xa Inhibitors for the Treatment of Acute Cancer-Associated Venous Thromboembolism: A Systematic Review and Network Meta-analysis”. Mayo Clin Proc. 94 (12): 2444–2454. doi:10.1016/j.mayocp.2019.05.035. PMID 31685262.
- ↑ Agnelli G, Becattini C, Meyer G, Muñoz A, Huisman MV, Connors JM; et al. (2020). “Apixaban for the Treatment of Venous Thromboembolism Associated with Cancer”. N Engl J Med. 382 (17): 1599–1607. doi:10.1056/NEJMoa1915103. PMID 32223112 Check
|pmid=value (help). - ↑ Watson L, Armon M. “Thrombolysis for acute deep vein thrombosis”. Cochrane Database Syst Rev: CD002783. PMID 15495034.
- ↑ Prandoni P, Lensing AW, Prins MH; et al. (2004). “Below-knee elastic compression stockings to prevent the post-thrombotic syndrome: a randomized, controlled trial”. Ann. Intern. Med. 141 (4): 249–56. PMID 15313740.
- ↑ Kolbach D, Sandbrink M, Hamulyak K, Neumann H, Prins M. “Non-pharmaceutical measures for prevention of post-thrombotic syndrome”. Cochrane Database Syst Rev: CD004174. doi:10.1002/14651858.CD004174.pub2. PMID 14974060.
- ↑ Kakkos S, Daskalopoulou S, Daskalopoulos M, Nicolaides A, Geroulakos G (2006). “Review on the value of graduated elastic compression stockings after deep vein thrombosis”. Thromb Haemost. 96 (4): 441–5. PMID 17003920.
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