New treatments are available for treatment of venous thromboembolism.
To review the evidence on the efficacy of interventions for treatment of deep venous thrombosis (DVT) and pulmonary embolism.
MEDLINE, MICROMEDEX, the Cochrane Controlled Trials Register, and Cochrane Database of Systematic Reviews from the 1950s through June 2006.
Randomized, controlled trials; systematic reviews of trials; and observational studies; all restricted to English-language articles.
Paired reviewers assessed study quality and abstracted data. The authors pooled results about optimal duration of anticoagulation.
This review includes 101 articles. Low-molecular-weight heparin (LMWH) is modestly superior to unfractionated heparin at preventing recurrent DVT and is at least as effective as unfractionated heparin for treatment of pulmonary embolism. Outpatient treatment of venous thromboembolism is likely to be effective and safe in carefully chosen patients, with appropriate services available. Inpatient or outpatient use of LMWH is cost-saving or cost-effective compared with unfractionated heparin. In observational studies, catheter-directed thrombolysis safely restored vein patency in select patients. Moderately strong evidence supports early use of compression stockings to reduce postthrombotic syndrome. Limited evidence suggests that vena cava filters are only modestly efficacious for prevention of pulmonary embolism. Conventional-intensity oral anticoagulation beyond 12 months may be optimal for patients with unprovoked venous thromboembolism, although patients with transient risk factors benefit little from more than 3 months of therapy. High-quality trials support use of LMWH in place of oral anticoagulation, particularly in patients with cancer. Little evidence is available to guide treatment of venous thromboembolism during pregnancy.
The authors could not address all management questions, and excluded non-English-language literature.
The strength of evidence varies across the study questions but generally is strong.
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"These practices include the administration of parenteral anticoagulation for 5 days and the achievement of an international normalized ratio (INR) 2.0 for 24 hours before stopping parenteral anticoagulation, an early start with oral vitamin K antagonists (VKA), and the initial treatment with subcutaneous low-molecular-weight heparin (LMWH) rather than with intravenous unfractionated heparin. These practices were shown to reduce the incidence of medical complications, such as death, recurrent VTE, major bleeding, thrombocytopenia and infusion phlebitis, and to decrease the LOS2345. However, although elderly patients have a higher incidence of VTE and VTE-related complications than younger patients, elderly patients are underrepresented in prospective studies of VTE treatment678. "
[Show abstract][Hide abstract]ABSTRACT: Whether anticoagulation management practices are associated with improved outcomes in elderly patients with acute venous thromboembolism (VTE) is uncertain. Thus, we aimed to examine whether practices recommended by the American College of Chest Physicians guidelines are associated with outcomes in elderly patients with VTE. We studied 991 patients aged ≥65 years with acute VTE in a Swiss prospective multicenter cohort study and assessed the adherence to four management practices: parenteral anticoagulation ≥5 days, INR ≥2.0 for ≥24 hours before stopping parenteral anticoagulation, early start with vitamin K antagonists (VKA) ≤24 hours of VTE diagnosis, and the use of low-molecular-weight heparin (LMWH) or fondaparinux. The outcomes were all-cause mortality, VTE recurrence, and major bleeding at 6 months, and the length of hospital stay (LOS). We used Cox regression and lognormal survival models, adjusting for patient characteristics. Overall, 9% of patients died, 3% had VTE recurrence, and 7% major bleeding. Early start with VKA was associated with a lower risk of major bleeding (adjusted hazard ratio 0.37, 95% CI 0.20–0.71). Early start with VKA (adjusted time ratio [TR] 0.77, 95% CI 0.69–0.86) and use of LMWH/fondaparinux (adjusted TR 0.87, 95% CI 0.78–0.97) were associated with a shorter LOS. An INR ≥2.0 for ≥24 hours before stopping parenteral anticoagulants was associated with a longer LOS (adjusted TR 1.2, 95% CI 1.08–1.33). In elderly patients with VTE, the adherence to recommended anticoagulation management practices showed mixed results. In conclusion, only early start with VKA and use of parenteral LMWH/fondaparinux were associated with better outcomes.
"About 10 to 30% of patients with DVT develop overt PTS (C4,5) at one year post-DVT. DVT has a recurrence rate of about 20% to 30% after 5 years, but the rate varies depending on the presence of risk factors and prolonged anticoagulation if indicated7879808182. PTS is a chronic condition that affects the deep venous system, may extend to the superficial venous system of the legs in patients with a documented history of deep vein thrombosis and has been discussed in our review on DVT, DVT and PTS: bridging the gap [83,84]. "