Therapeutic anticoagulation

2020 ◽  
pp. 3729-3734
Author(s):  
David Keeling
Keyword(s):  
Atrial Fibrillation ◽  
Pulmonary Embolism ◽  
Deep Vein Thrombosis ◽  
Venous Thromboembolism ◽  
Heart Valves ◽  
Factor Xa ◽  
Vein Thrombosis ◽  
Therapeutic Anticoagulation ◽  
Acute Venous Thromboembolism ◽  
Deep Vein

The main indications for therapeutic anticoagulation are venous thromboembolism, deep vein thrombosis, and pulmonary embolism, and the prevention of stroke in patients with atrial fibrillation or mechanical heart valves. Low-molecular-weight heparins have largely replaced unfractionated heparin in its treatment. Their much more predictable anticoagulant response combined with high bioavailability after subcutaneous injection means that the dose can be calculated by body weight and given subcutaneously without any monitoring or dose adjustment. Their widespread use resulted in most patients with deep vein thrombosis being managed as outpatients, and this is also increasingly the case for uncomplicated pulmonary embolism. Oral direct inhibitors of anticoagulation that specifically target thrombin or factor Xa are increasingly used to treat acute venous thromboembolism and for stroke prevention in atrial fibrillation.

Incidence of venous thromboembolism among patients receiving neoadjuvant chemotherapy for advanced epithelial ovarian cancer

2020 ◽  
Vol 30 (4) ◽  
pp. 491-497 ◽  
Author(s):  
Julia Rose Salinaro ◽  
Kourtnie McQuillen ◽  
Megan Stemple ◽  
Robert Boccaccio ◽  
Jessie Ehrisman ◽  
...  
Keyword(s):  
Ovarian Cancer ◽  
Pulmonary Embolism ◽  
Deep Vein Thrombosis ◽  
Venous Thromboembolism ◽  
Adjuvant Chemotherapy ◽  
Neoadjuvant Chemotherapy ◽  
Epithelial Ovarian Cancer ◽  
Primary Outcome ◽  
Vein Thrombosis ◽  
Deep Vein

ObjectivesNeoadjuvant chemotherapy may be considered for women with epithelial ovarian cancer who have poor performance status or a disease burden not amenable to primary cytoreductive surgery. Overlap exists between indications for neoadjuvant chemotherapy and known risk factors for venous thromboembolism, including impaired mobility, increasing age, and advanced malignancy. The objective of this study was to determine the rate of venous thromboembolism among women receiving neoadjuvant chemotherapy for epithelial ovarian cancer.MethodsA multi-institutional, observational study of patients receiving neoadjuvant chemotherapy for primary epithelial ovarian, fallopian tube, or peritoneal cancer was conducted. Primary outcome was rate of venous thromboembolism during neoadjuvant chemotherapy. Secondary outcomes included rates of venous thromboembolism at other stages of treatment (diagnosis, following interval debulking surgery, during adjuvant chemotherapy, or during treatment for recurrence) and associations between occurrence of venous thromboembolism during neoadjuvant chemotherapy, subject characteristics, and interval debulking outcomes. Venous thromboembolism was defined as deep vein thrombosis in the upper or lower extremities or in association with peripherally inserted central catheters or ports, pulmonary embolism, or concurrent deep vein thrombosis and pulmonary embolism. Both symptomatic and asymptomatic venous thromboembolism were reported.ResultsA total of 230 patients receiving neoadjuvant chemotherapy were included; 63 (27%) patients overall experienced a venous thromboembolism. The primary outcome of venous thromboembolism during neoadjuvant chemotherapy occurred in 16 (7.7%) patients. Of the remaining venous thromboembolism events, 22 were at diagnosis (9.6%), six post-operatively (3%), five during adjuvant chemotherapy (3%), and 14 during treatment for recurrence (12%). Patients experiencing a venous thromboembolism during neoadjuvant chemotherapy had a longer mean time to interval debulking and were less likely to undergo optimal cytoreduction (50% vs 80.2%, p=0.02).ConclusionsPatients with advanced ovarian cancer are at high risk for venous thromboembolism while receiving neoadjuvant chemotherapy. Consideration of thromboprophylaxis may be warranted.

Venous Thromboembolism

2017 ◽  
Author(s):  
Guillermo A. Escobar ◽  
Peter K. Henke ◽  
Thomas W. Wakefield
Keyword(s):  
Pulmonary Embolism ◽  
Deep Vein Thrombosis ◽  
Venous Thromboembolism ◽  
Lower Extremity ◽  
The United States ◽  
Laboratory Evaluation ◽  
Individual Risk ◽  
Vein Thrombosis ◽  
Clinical Scenarios ◽  
Deep Vein

Deep vein thrombosis (DVT) and pulmonary embolism (PE) comprise venous thromboembolism (VTE). Together, they comprise a serious health problem as there are over 275,000 new VTE cases per year in the United States, resulting in a prevalence of one to two per 1,000 individuals, with some studies suggesting that the incidence may even be double that. This review covers assessment of a VTE event, initial evaluation of a patient suspected of having VTE, medical history, clinical presentation of VTE, physical examination, laboratory evaluation, imaging, prophylaxis against perioperative VTE, indications for immediate intervention (threat to life or limb), indications for urgent intervention, and management of nonemergent VTE. Figures show a modified Caprini score questionnaire used at the University of Michigan to determine individual risk of VTE and the indicated prophylaxis regimen; Wells criteria for DVT and PE; phlegmasia cerulea dolens secondary to acute left iliofemoral DVT after thigh trauma; compression duplex ultrasonography of lower extremity veins; computed tomographic angiogram of the chest demonstrating a thrombus in the pulmonary artery, with extension into the right main pulmonary; management of PE according to Wells criteria findings; management of PE with right heart strain in cases of massive or submassive PE; treatment of DVT according to clinical scenario; a lower extremity venogram of a patient with May-Thurner syndrome and its subsequent endovascular treatment; and various examples of retrievable vena cava filters (not drawn to scale). Tables list initial clinical assessment for VTE, clinical scenarios possibly benefiting from prolonged anticoagulation after VTE, indications for laboratory investigation of secondary thrombophilia, venous thromboembolic risk accorded to hypercoagulable states, and Pulmonary Embolism Rule-out Criteria Score to avoid the need for D-dimer in patients suspected of having PE.   This review contains 11 highly rendered figures, 5 tables, and 167 references. Key words: anticoagulation; deep vein thrombosis; postthrombotic syndrome; pulmonary embolism; recurrent venous thromboembolism; thrombophilia; venous thromboembolism; PE; VTE; DVT 

scholarly journals Anticoagulant therapies for acute venous thromboembolism: a comparison between those discharged directly from the emergency department versus hospital in two Canadian cities

BMJ Open ◽  
2018 ◽  
Vol 8 (10) ◽  
pp. e022063 ◽  
Author(s):  
Tammy J Bungard ◽  
Bruce Ritchie ◽  
Jennifer Bolt ◽  
William M Semchuk
Keyword(s):  
Emergency Department ◽  
Pulmonary Embolism ◽  
Venous Thromboembolism ◽  
Severity Index ◽  
Vein Thrombosis ◽  
Risk Patients ◽  
Acute Venous Thromboembolism ◽  
Record Review ◽  
Deep Vein

ObjectiveTo compare the characteristics/management of acute venous thromboembolism (VTE) for patients either discharged directly from the emergency department (ED) or hospitalised throughout a year within two urban cities in Canada.DesignRetrospective medical record review.SettingHospitals in Edmonton, Alberta (n=4) and Regina, Saskatchewan (n=2) from April 2014 to March 2015.ParticipantsAll patients discharged from the ED or hospital with acute deep vein thrombosis or pulmonary embolism (PE). Those having another indication for anticoagulant therapy, pregnant/breast feeding or anticipated lifespan <3 months were excluded.Primary and secondary outcomesPrimarily, to compare proportion of patients receiving traditional therapy (parenteral anticoagulant±warfarin) relative to a direct oral anticoagulant (DOAC) between the two cohorts. Secondarily, to assess differences with therapy selected based on clot burden and follow-up plans postdischarge.Results387 (25.2%) and 665 (72.5%) patients from the ED and hospital cohorts, respectively, were included. Compared with the ED cohort, those hospitalised were older (57.3 and 64.5 years; p<0.0001), more likely to have PE (35.7% vs 83.8%) with a simplified Pulmonary Embolism Severity Index (sPESI) ≥1 (31.2% vs 65.2%), cancer (14.7% and 22.3%; p=0.003) and pulmonary disease (10.1% and 20.6%; p<0.0001). For the ED and hospital cohorts, similar proportions of patients were prescribed traditional therapies (72.6% and 71.1%) and a DOAC (25.8% and 27.4%, respectively). For the ED cohort, DOAC use was similar between those with a sPESI score of 0 and ≥1 (35.1% and 34.9%, p=0.98) whereas for those hospitalised lower risk patients were more likely to receive a DOAC (31.4% and 23.8%, p<0.055). Follow-up was most common with family physicians for those hospitalised (51.5%), while specialists/VTE clinic was most common for those directly discharged from the ED (50.6%).ConclusionsTraditional and DOAC therapies were proportionately similar between the ED and hospitalised cohorts, despite clear differences in patient populations and follow-up patterns in the community.

scholarly journals Apixaban Anti-Xa Level Monitoring in Treatment of Provoked Acute Upper Extremity Deep Vein Thrombosis for Patient on Dialysis: A Case Report

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 14-14
Author(s):  
Guillaume Roberge ◽  
Philip S. Wells
Keyword(s):  
Deep Vein Thrombosis ◽  
Venous Thromboembolism ◽  
Upper Extremity ◽  
Conflicts Of Interest ◽  
Subcutaneous Fat ◽  
Chronic Hemodialysis ◽  
Vein Thrombosis ◽  
Acute Venous Thromboembolism ◽  
Deep Vein ◽  
Trough Levels

Background. Patients with end stage renal disease on dialysis are at higher risk of major bleeding and recurrent thrombosis and as such, treatment of acute venous thromboembolism (VTE) is challenging. Ideally, treatment would avoid inpatient admission as for most other patients with acute VTE. DOACs represent the easiest option but there are concerns over bioaccumulation increasing bleeding risk. Despite the absence of a standardized therapeutic range, anti-Xa trough level is measured to monitor potential DOACs bioaccumulation and thus, used for safety surveillance. Methods. We describe a case of a 51 yo female, 36 kg, on chronic hemodialysis with a provoked acute upper extremity deep vein thrombosis. Due to a lack of subcutaneous fat and calciphylaxis we were reluctant to use low molecular weight heparin and warfarin. She was treated with apixaban 2,5 mg twice daily for 6 weeks. Over 4 weeks, the apixaban anti-Xa trough levels were measured on dialysis days 12 hours after the morning dose. Results. The anti-Xa trough levels ranged from 58 to 84 ng/mL, similar to what is expected in patients with normal kidney function. There were no adverse events in the 3 months after anticoagulation initiation. Conclusion. We saw no evidence of bioaccumulation. This indicates a potential role for apixaban low doses in acute venous thromboembolism for patients on dialysis. Disclosures No relevant conflicts of interest to declare. OffLabel Disclosure: The use of Apixaban for treatment of acute venous thromboembolism in patient on dialysis has not been approved.

scholarly journals Venous Thromboembolism in Denmark: Seasonality in Occurrence and Mortality

TH Open ◽  
2019 ◽  
Vol 03 (02) ◽  
pp. e171-e179 ◽  
Author(s):  
Nils Skajaa ◽  
Erzsébet Horváth-Puhó ◽  
Kasper Adelborg ◽  
Paolo Prandoni ◽  
Kenneth J. Rothman ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Deep Vein Thrombosis ◽  
Venous Thromboembolism ◽  
Seasonal Pattern ◽  
Cerebral Vein ◽  
Cerebral Vein Thrombosis ◽  
Splanchnic Vein Thrombosis ◽  
Vein Thrombosis ◽  
Winter Peak ◽  
Deep Vein

Background Many cardiovascular conditions exhibit seasonality in occurrence and mortality, but little is known about the seasonality of venous thromboembolism. Methods Using Danish registries, we identified all patients with deep vein thrombosis, pulmonary embolism, splanchnic vein thrombosis, cerebral vein thrombosis, and retinal vein thrombosis during 1977–2016. We tallied monthly deaths occurring within 90 days of the venous thromboembolism diagnosis. We estimated peak-to-trough ratios and timing of the peak of both diagnoses and deaths summed over all years of the study period. The departure from 1.0 of the peak-to-trough ratio measures the intensity of any seasonal pattern. Results We estimated a peak-to-trough ratio of 1.09 (95% confidence interval: 1.07–1.11) for deep vein thrombosis and 1.22 (1.19–1.24) for pulmonary embolism occurrence. The peak-to-trough ratios for splanchnic vein thrombosis, cerebral vein thrombosis, and retinal vein thrombosis occurrence were 1.10 (1.01–1.20), 1.19 (1.00–1.40), and 1.12 (1.07–1.17), respectively. The occurrence of all conditions peaked during winter or fall. In time trend analyses, the peak-to-trough ratio increased considerably for splanchnic vein thrombosis, cerebral vein thrombosis, and retinal vein thrombosis occurrence. In associated mortality, the peak-to-trough ratio for deep vein thrombosis was larger (1.15, 1.07–1.23) than that for pulmonary embolism (1.04, 1.01–1.08). Discussion Excess winter risks were modest, but more marked for pulmonary embolism occurrence than for deep vein thrombosis occurrence. The seasonal pattern intensified throughout the study period for splanchnic vein thrombosis, cerebral vein thrombosis, and retinal vein thrombosis. The winter peak in mortality following pulmonary embolism was smaller than that for deep vein thrombosis.

Risk of recurrent venous thromboembolism among deep vein thrombosis and pulmonary embolism patients treated with warfarin

2014 ◽  
Vol 31 (3) ◽  
pp. 439-447 ◽  
Author(s):  
Beth L. Nordstrom ◽  
Michael A. Evans ◽  
Brian R. Murphy ◽  
Edith A. Nutescu ◽  
Jeff R. Schein ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Deep Vein Thrombosis ◽  
Venous Thromboembolism ◽  
Vein Thrombosis ◽  
Recurrent Venous Thromboembolism ◽  
Deep Vein

More than one in two venous thromboembolism treated in French hospitals occurs during the hospital stays

2015 ◽  
Vol 31 (6) ◽  
pp. 390-396 ◽  
Author(s):  
Francois-André Allaert ◽  
Eric Benzenine ◽  
Catherine Quantin
Keyword(s):  
Pulmonary Embolism ◽  
Deep Vein Thrombosis ◽  
Venous Thromboembolism ◽  
Hospital Stay ◽  
Principal Diagnosis ◽  
Vein Thrombosis ◽  
Icd 10 ◽  
Hospital Stays ◽  
Deep Vein

Objective The objective was to describe the prevalence of venous thromboembolism, pulmonary embolism, and deep vein thrombosis among hospitalized patients and the percentages of those occurring during the hospital stays. Methods French DRG gave now the opportunity to investigate the frequency of venous thromboembolism occurring during the hospital stay. Statistics are issued from the national PMSI MCO databases encoded using the CIM10. Since 2010–2011 it is possible to differentiate the reason for hospital admission from the pathologies which secondly occurred. Any stay with the ICD-10 codes selected was considered as a hospital-occurred thrombosis unless it was the principal diagnosis of the first medical unit summary. To eliminate outpatient consultations or in day care, stays of <48 h were excluded. Results The results pertain to the 78,838,983 hospitalizations in France from 2005 to 2011 and on the 18,683,603 hospital stays in 2010–2011. The incidence of hospital stays came to 860,343 (1.09%) for venous thromboembolism, with 428,261 (0.543%) for deep vein thrombosis without pulmonary embolism and 432,082 (0.548%) for pulmonary embolism. It corresponds to an incidence of 189 per 100,000 inhabitants. Out of 100 hospital stays involving venous thromboembolism, for 40.3% venous thromboembolism was the cause of hospitalization whereas 59.7% can be considered to have occurred during hospital stay. These distributions are of 25.6 and 74.4% for deep vein thrombosis, respectively, 53.8 and 46.2% for pulmonary embolism. Conclusion The high proportion of hospital-occurred venous thromboembolism is an alarming situation that should question the quality of prevention and/or its effectiveness.

Late consequences of venous thromboembolism: Measuring quality of life after deep vein thrombosis and pulmonary embolism

2018 ◽  
Vol 164 ◽  
pp. 170-176 ◽  
Author(s):  
Waleed Ghanima ◽  
Hilde Skuterud Wik ◽  
Mazdak Tavoly ◽  
Tone Enden ◽  
Lars-Petter Jelsness-Jørgensen
Keyword(s):  
Quality Of Life ◽  
Pulmonary Embolism ◽  
Deep Vein Thrombosis ◽  
Venous Thromboembolism ◽  
Vein Thrombosis ◽  
Deep Vein

Comparison of clinical probability-adjusted D-dimer and age-adjusted D-dimer interpretation to exclude venous thromboembolism

2017 ◽  
Vol 117 (10) ◽  
pp. 1937-1943 ◽  
Author(s):  
Jim Julian ◽  
Lori-Ann Linkins ◽  
Shannon Bates ◽  
Clive Kearon ◽  
Sarah Takach Lapner
Keyword(s):  
Pulmonary Embolism ◽  
Deep Vein Thrombosis ◽  
Venous Thromboembolism ◽  
Diagnostic Accuracy ◽  
Blood Samples ◽  
Vein Thrombosis ◽  
Clinical Probability ◽  
Deep Vein ◽  
New Strategies ◽  
D Dimer

SummaryTwo new strategies for interpreting D-dimer results have been proposed: i) using a progressively higher D-dimer threshold with increasing age (age-adjusted strategy) and ii) using a D-dimer threshold in patients with low clinical probability that is twice the threshold used in patients with moderate clinical probability (clinical probability-adjusted strategy). Our objective was to compare the diagnostic accuracy of age-adjusted and clinical probability-adjusted D-dimer interpretation in patients with a low or moderate clinical probability of venous thromboembolism (VTE). We performed a retrospective analysis of clinical data and blood samples from two prospective studies. We compared the negative predictive value (NPV) for VTE, and the proportion of patients with a negative D-dimer result, using two D-dimer interpretation strategies: the age-adjusted strategy, which uses a progressively higher D-dimer threshold with increasing age over 50 years (age in years × 10 µg/L FEU); and the clinical probability-adjusted strategy which uses a D-dimer threshold of 1000 µg/L FEU in patients with low clinical probability and 500 µg/L FEU in patients with moderate clinical probability. A total of 1649 outpatients with low or moderate clinical probability for a first suspected deep vein thrombosis or pulmonary embolism were included. The NPV of both the clinical probability-adjusted strategy (99.7%) and the age-adjusted strategy (99.6%) were similar. However, the proportion of patients with a negative result was greater with the clinical probability-adjusted strategy (56.1% vs, 50.9%; difference 5.2%; 95% CI 3.5% to 6.8%). These findings suggest that clinical probability-adjusted D-dimer interpretation is a better way of interpreting D-dimer results compared to age-adjusted interpretation.

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