Treatment of Venous Thrombosis with Intravenous Unfractionated Heparin Administered in the Hospital as Compared with Subcutaneous Low-Molecular-Weight Heparin Administered at Home. The Tasman Study Group

Academic Medical Center, Amsterdam, The Netherlands.
New England Journal of Medicine (Impact Factor: 55.87). 03/1996; 334(11):682-687. DOI: 10.1056/NEJM199603143341102


An intravenous course of standard (unfractionated) heparin with the dose adjusted to prolong the activated partial-thromboplastin time to a desired length is the standard initial in-hospital treatment for patients with deep-vein thrombosis, but fixed-dose subcutaneous low-molecular-weight heparin appears to be as effective and safe. Because the latter treatment can be given on an outpatient basis, we compared the two treatments in symptomatic outpatients with proximal-vein thrombosis but no signs of pulmonary embolism.
We randomly assigned patients to adjusted-dose intravenous standard heparin administered in the hospital (198 patients) or fixed-dose subcutaneous low-molecular-weight heparin administered at home, when feasible (202 patients). We compared the treatments with respect to recurrent venous thromboembolism, major bleeding, quality of life, and costs.
Seventeen of the 198 patients who received standard heparin (8.6 percent) and 14 of the 202 patients who received low-molecular-weight heparin (6.9 percent) had recurrent thromboembolism (difference, 1.7 percentage points; 95 percent confidence interval, -3.6 to 6.9). Major bleeding occurred in four patients assigned to standard heparin (2.0 percent) and one patient assigned to low-molecular-weight heparin (0.5 percent; difference, 1.5 percentage points; 95 percent confidence interval, -0.7 to 2.7). Quality of life improved in both groups. Physical activity and social functioning were better in the patients assigned to low-molecular-weight heparin. Among the patients in that group, 35 percent were never admitted to the hospital at all, and 40 percent were discharged early. This treatment was associated with a mean reduction in hospital days of 67 percent, ranging from 29 percent to 86 percent in the various study centers.
In patients with proximal-vein thrombosis, treatment with low-molecular-weight heparin at home is feasible, effective, and safe.

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    • "In addition, both the effect of therapy on the patients' well-being and the cost of therapy are factors to be weighed in determining the optimal treatment. It is current practice to treat acute venous thrombosis with intravenous standard (unfractionated) heparin for at least five days in a dose adjusted to lengthen the activated partial-thromboplastin time into a desired range (Koopman M, et al, 1996). LMWHs are effective and indicated for the prevention of venous thromboembolism, for the treatment of venous thrombosis, for the treatment of patients with unstable angina ( Jack H, et al, 2001), LMWH do not cross the placenta (Dimitrakakis C, et al, 2000)(Omri A, et al, 1989)(Robin F, et al 1999) and have several clinical advantages over un-fractionated heparin. "

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    • "The use of low molecular weight heparins (LMWHs) was investigated and implemented in DVT patients before it became standard practice in PE patients [6–8]. Likewise, whereas the ambulatory treatment of patients with DVT has been widespread for over a decade [9, 10], outpatient treatment of patients with PE at low risk of an adverse outcome has only been validated in the past years [11]. Due to these differences in outcome and nuances in therapeutic approach, efficacy and safety outcomes may not be readily translatable from one group of VTE patients to another. "
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    • "A study on technological innovations in surgery showed that as more patients were treated on an outpatient basis, fewer hospital beds were needed, and traditional operating rooms had to adapt to a greater turnover of patients. In addition, postoperative care is carried out in the community rather than in hospitals [2,4]. Also reduction of costs is mentioned as a result of substituting day care for clinical care [2-8]. "
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