Thromboembolism medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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]:

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]

Randomized controlled trials of aspirin after discontinuation of anticoagulants.[6][7]
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)

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,[8] 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.[9] 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.[10] The number needed to treat is quite potent at 4 to 5 patients need to prevent one case of post-phlebitic syndrome.[11]

Pulmonary Embolism

Emergency treatment at a hospital is necessary to treat pulmonary embolism.

Contraindications to Medical Therapy

References

  1. 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.
  2. 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. 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.
  4. 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.
  5. 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. 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. 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.
  8. Watson L, Armon M. "Thrombolysis for acute deep vein thrombosis". Cochrane Database Syst Rev: CD002783. PMID 15495034.
  9. 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.
  10. 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.
  11. 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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