scholarly journals Venous Thromboembolism: Role of the Clinical Laboratory in Diagnosis and Management

2019 ◽  
Vol 3 (5) ◽  
pp. 870-882 ◽  
Author(s):  
Rugvedita S Parakh ◽  
Daniel E Sabath
Keyword(s):  
Venous Thromboembolism ◽  
Clinical Laboratory ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Outpatient Basis ◽  
Risk Patients ◽  
Cardiovascular Illness ◽  
Newer Anticoagulants

Abstract Background Venous thromboembolism (VTE) is the third most common cause of cardiovascular illness and is projected to double in incidence by 2050. It is a spectrum of disease that includes deep venous thrombosis (DVT) and pulmonary embolism (PE). In February 2016, the American College of Chest Physicians provided updated management guidelines for DVT and PE to address some of the unresolved questions from the previous version and to provide recommendations related to newer anticoagulants. Content Here we review current concepts for screening, diagnosis, thromboprophylaxis, and management of DVT and PE. We also describe the management of VTE in acute, long-term, and extended phases of treatment. Thrombophilia testing is rarely necessary and should be used judiciously; the laboratory can serve an important role in preventing unnecessary testing. The direct oral anticoagulants are as effective as conventional treatment and are preferred agents except in the case of cancer. The initial management of PE should be based on risk stratification including the use of D-dimer testing. Thrombolysis is used in cases of hemodynamically unstable PE and not for low-risk patients who can be treated on an outpatient basis. Summary This review is intended to provide readers with updated guidelines for screening, testing, prophylaxis, and management from various organizations.

scholarly journals Direct Oral Anticoagulants or Standard Anticoagulant Therapy in Fragile Patients with Venous Thromboembolism

TH Open ◽  
2019 ◽  
Vol 03 (01) ◽  
pp. e67-e76 ◽  
Author(s):  
Juan López-Núñez ◽  
Ricard Pérez-Andrés ◽  
Pierpaolo Di Micco ◽  
Sebastian Schellong ◽  
Covadonga Gómez-Cuervo ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
Anticoagulant Therapy ◽  
Major Bleeding ◽  
Lower Risk ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Term Therapy ◽  
Composite Outcome ◽  
Long Term Therapy

Background The efficacy and safety of the direct oral anticoagulants (DOACs) in fragile patients (age ≥ 75 years and/or creatinine clearance levels ≤ 50 mL/min and/or body weight ≤ 50kg) with venous thromboembolism (VTE) has not been evaluated. Methods We used the RIETE database to compare the rates of the composite of VTE recurrences or major bleeding during anticoagulation in fragile patients with VTE, according to the use of DOACs or standard anticoagulant therapy. Results From January 2013 to April 2018, 24,701 patients were recruited. Of these, 10,054 (41%) were fragile. Initially, 473 fragile patients (4.7%) received DOACs and 8,577 (85%) low-molecular-weight heparin (LMWH). For long-term therapy, 1,298 patients (13%) received DOACs and 5,038 (50%) vitamin K antagonists (VKAs). Overall, 95 patients developed VTE recurrences and 262 had major bleeding. Patients initially receiving DOACs had a lower rate of the composite outcome (hazard ratio [HR]: 0.32; 95% confidence interval [CI]: 0.08–0.88) than those on LMWH. Patients receiving DOACs for long-term therapy had a nonsignificantly lower rate of the composite outcome (HR: 0.70; 95% CI: 0.46–1.03) than those on VKAs. On multivariable analysis, patients initially receiving DOACs had a nonsignificantly lower risk for the composite outcome (HR: 0.36; 95% CI: 0.11–1.15) than those on LMWH, while those receiving DOACs for long-term therapy had a significantly lower risk (HR: 0.61; 95% CI: 0.41–0.92) than those on VKAs. Conclusions Our data suggest that the use of DOACs may be more effective and safe than standard therapy in fragile patients with VTE, a subgroup of patients where the risk for bleeding is particularly high.

scholarly journals Przewlekłe leczenie przeciwkrzepliwe

2018 ◽  
Vol 49 (2) ◽  
pp. 47-49 ◽  
Author(s):  
Krystyna Zawilska
Keyword(s):  
Pulmonary Embolism ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Compression Therapy ◽  
Good Choice ◽  
Anticoagulant Treatment ◽  
Efficacy And Safety ◽  
Risk Of Bleeding

AbstractUnprovoked venous thromboembolism (VTE) - proximal venous thrombosis or pulmonary embolism - should be treated either 3 months or indefinitely if the risk of bleeding is low. This article summarizes the efficacy and safety of extended therapy of VTE with direct oral anticoagulants (DOAC) in comparison with warfarin, as well as the role of of acetylsalicylic acid (ASA) for the long-term prevention of recurrent VTE. As the Survet study showed, for some patients who have already completed at least 6 months of anticoagulant treatment for their index VTE event, an oral glycosaminoglycan - sulodexide associated with compression therapy is a good choice, because it decreases the incidence of recurrences of VTE without detectable risks for the patients’ safety.

scholarly journals Stroke and thromboembolism prevention in atrial fibrillation

Heart ◽  
2019 ◽  
Vol 106 (1) ◽  
pp. 10-17 ◽  
Author(s):  
Sina Jame ◽  
Geoffrey Barnes
Keyword(s):  
Atrial Fibrillation ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Alternative Therapy ◽  
Anticoagulation Management ◽  
Risk Assessment Models ◽  
Risk Stratification Tool ◽  
Risk Patients

Prevention of stroke and systemic thromboembolism remains the cornerstone for management of atrial fibrillation (AF) and flutter. Multiple risk assessment models for stroke and systemic thromboembolism are currently available. The score, with its known limitations, remains as the recommended risk stratification tool in most major guidelines. Once at-risk patients are identified, vitamin K antagonists (VKAs) and, more recently, direct oral anticoagulants (DOACs) are the primary medical therapy for stroke prevention. In those with contraindication for long-term anticoagulation, left atrial appendage occluding devices are developing as a possible alternative therapy. Some controversy exists regarding anticoagulation management for cardioversion of acute AF (<48 hours); however, systemic anticoagulation precardioversion and postcardioversion is recommended for those with longer duration of AF. Anticoagulation management peri-AF ablation is also evolving. Uninterrupted VKA and DOAC therapy has been shown to reduce perioperative thromboembolic risk with no significant escalation in major bleeding. Currently, under investigation is a minimally interrupted approach to anticoagulation with DOACs periablation. Questions remain, especially regarding the delivery of anticoagulation care and integration of wearable rhythm monitors in AF management.

Real-life treatment of venous thromboembolism with direct oral anticoagulants: The influence of recommended dosing and regimens

2017 ◽  
Vol 117 (02) ◽  
pp. 382-389 ◽  
Author(s):  
Javier Trujillo-Santos ◽  
Pierpaolo Di Micco ◽  
Francesco Dentali ◽  
James Douketis ◽  
José Antonio Díaz-Peromingo ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
Major Bleeding ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Real Life ◽  
Initial Therapy ◽  
Term Therapy ◽  
Long Term Therapy ◽  
Recommended Therapy

SummaryIn patients with venous thromboembolism (VTE), the influence on outcome of using direct oral anticoagulants (DOACs) at non-recommended doses or regimens (once vs twice daily) has not been investigated yet. We used the RIETE (Registro Informatizado Enfermedad TromboEmbólica) registry to compare the outcomes in patients with VTE receiving DOACs according to the recommendations of the product label versus in those receiving non-recommended doses and/or regimens. The major outcomes were the rate of VTE recurrences, major bleeding and death during the course of therapy. As of March 2016, 1635 VTE patients had received DOACs for initial therapy and 1725 for long-term therapy. For initial therapy, 287 of 1591 patients (18 %) on rivaroxaban and 22 of 44 (50 %) on apixaban did not receive the recommended therapy. For long-term therapy, 217 of 1611 patients (14 %) on rivaroxaban, 29 of 81 (36 %) on apixaban and 15 of 33 (46 %) on dabigatran did not receive the recommended therapy. During the course of therapy with DOACs, eight patients developed VTE recurrences, 14 had major bleeding and 13 died. Patients receiving DOACs at non-recommended doses and/or regimens experienced a higher rate of VTE recurrences (adjusted HR: 10.5; 95 %CI: 1.28–85.9) and a similar rate of major bleeding (adjusted HR: 1.04; 95 %CI: 0.36–3.03) or death (adjusted HR: 1.41; 95 %CI: 0.46–4.29) than those receiving the recommended doses and regimens. In our cohort, a non-negligible proportion of VTE patients received non-recommended doses and/or regimens of DOACs. This use may be associated with worse outcomes.

scholarly journals Individualised Risk Assessments for Recurrent Venous Thromboembolism: New Frontiers in the Era of Direct Oral Anticoagulants

Hemato ◽  
2021 ◽  
Vol 2 (1) ◽  
pp. 64-78
Author(s):  
Julie Wang ◽  
Hui Yin Lim ◽  
Prahlad Ho
Keyword(s):  
Risk Assessment ◽  
Venous Thromboembolism ◽  
Prediction Models ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Laboratory Data ◽  
Ease Of Use ◽  
Recurrence Rates ◽  
Coagulation Assays

Venous thromboembolism (VTE) is a leading cause of morbidity and mortality and is associated with high recurrence rates. The introduction of direct oral anticoagulants (DOACs) in the 2010s has changed the landscape of VTE management. DOACs have become the preferred anticoagulant therapy for their ease of use, predictable pharmacokinetics, and improved safety profile. Increasingly, guidelines have recommended long term anticoagulation for some indications such as following first unprovoked major VTE, although an objective individualised risk assessment for VTE recurrence remains elusive. The balance of preventing VTE recurrence needs to be weighed against the not insignificant bleeding risk, which is cumulative with prolonged use. Hence, there is a need for an individualised, targeted approach for assessing the risk of VTE recurrence, especially in those patients in whom the balance between benefit and risk of long-term anticoagulation is not clear. Clinical factors alone do not provide the level of discrimination required on an individual level. Laboratory data from global coagulation assays and biomarkers may provide enhanced risk assessment ability and are an active area of research. A review of the prediction models and biomarkers for assessing VTE recurrence risk is provided, with an emphasis on contemporary developments in the era of DOACs and global coagulation assays.

scholarly journals Use of direct oral anticoagulants for postoperative venous thromboembolism prophylaxis after surgery for gynecologic malignancies

2022 ◽  
pp. ijgc-2021-003006
Author(s):  
Marilyn Boo ◽  
Peter Sykes ◽  
Bryony Simcock
Keyword(s):  
Venous Thromboembolism ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Postoperative Mortality ◽  
Standard Of Care ◽  
Pelvic Surgery ◽  
Gynecologic Malignancies ◽  
Current Standard ◽  
Thromboembolism Prophylaxis

Venous thromboembolism is a preventable cause of postoperative mortality in patients undergoing surgery for malignancy. Current standard of care based on international guideline recommends 28 days of extended thromboprophylaxis after major abdominal and pelvic surgery for malignancies with unfractionated heparin or low molecular weight heparin. Direct oral anticoagulants have been approved for the treatment of venous thromboembolism in the general population. This regimen has a significant advantage over other types of anticoagulation regimens, particularly being administered by non-parenteral routes and without the need for laboratory monitoring. In this review, we evaluate the role of direct anticoagulation and provide an update on completed and ongoing clinical trials.

scholarly journals The role of direct oral anticoagulants in the treatment of cancer associated venous thromboembolism

Oncoreview ◽  
2018 ◽  
Vol 8 (3) ◽  
pp. 70-75
Author(s):  
Elizaveta Panchenko ◽  
Julia Fedotkina ◽  
Anatoly Dobrovolsky
Keyword(s):  
Venous Thromboembolism ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants

scholarly journals Clinical pearls: Laboratory assessments of direct oral anticoagulants (DOACS)

2017 ◽  
Vol 37 (04) ◽  
pp. 295-301 ◽  
Author(s):  
Jonathan Douxfils ◽  
Dorothy Adcock ◽  
Robert Gosselin
Keyword(s):  
Atrial Fibrillation ◽  
Venous Thromboembolism ◽  
Stroke Prevention ◽  
Clinical Laboratory ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Factor Xa ◽  
Coagulation Testing ◽  
Testing Plan

SummaryDirect oral anticoagulants (DOACS) are being used for stroke prevention in patients with atrial fibrillation as well as for prophylaxis and treatment of venous thromboembolism. Clinicians who treat, or may encounter, patients with DOAC exposure, should be aware of the limitations of coagulation testing in this setting, and seek counsel from their laboratory to understand the effects of DOACS on coagulation results. Generally, assays that employ clot based principles, or methods that require thrombin or Factor Xa activation or substrates may be affected by the presence of DOACS. The clinical laboratory should have an algorithmic testing plan for adequately assessing the presence of all DOACS and readily provide this information to clinicians. We describe Clinical Pearls for DOAC assessment using common and esoteric coagulation testing.

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