The document discusses optimal treatment duration for venous thrombosis. It notes that while short-term anticoagulation for 2 weeks treats the acute issue, the risk of recurrence increases significantly after stopping treatment. Long-term anticoagulation for 3-6 months or more is often recommended to reduce subacute and chronic recurrence risks, though this must be weighed against bleeding risks. For unprovoked VTE specifically, recurrence risks can be up to 15% per year and identifying risk factors can help determine individualized treatment duration and alternatives to standard anticoagulants.
1) There is a considerable risk of recurrent venous thromboembolism (VTE) after stopping anticoagulation treatment, ranging from 3-15% per year depending on risk factors.
2) Cancer patients have a high risk of both recurrent VTE and bleeding during anticoagulation treatment.
3) Patients with a provoked VTE have a low recurrence risk of around 3% per year, while those with an unprovoked VTE have a risk up to 15% per year.
4) The risk of recurrence increases as soon as anticoagulation is stopped regardless of the previous duration of treatment.
1. Pregnancy increases the risk of venous thromboembolism (VTE) and it is a leading cause of maternal death. The risk is greatest in the first trimester and postpartum period following vaginal delivery.
2. All women should be assessed for VTE risk factors during early pregnancy and the risk reassessed if hospitalized or health issues arise. Women at high risk may benefit from pre-pregnancy counseling.
3. Women with prior VTE or inherited thrombophilia have an increased risk during pregnancy and postpartum and should receive thromboprophylaxis, typically with low molecular weight heparin (LMWH). The duration depends on their specific risk factors.
This document discusses thromboprophylaxis in obstetrics and gynecology. It notes that venous thromboembolism is prevalent in hospitalized patients but often clinically silent. Screening recommendations are provided for various conditions like prior VTE and thrombophilia. Guidelines are presented for thromboprophylaxis in pregnancy, postpartum, and for various high risk procedures and cancers. Risk factors for VTE with oral contraceptives and hormone replacement therapy are reviewed. Management of thrombophilia and antiphospholipid syndrome are also covered.
Il rischio tromboembolico nelle patologie arteriose e venose della donna 3Plinio Fabiani
This document discusses risk factors for thromboembolism in women, including reproductive factors and diseases that are more common in women. It provides statistics on the incidence of venous thromboembolism and notes that women are at higher risk during pregnancy and postpartum, as well as when using oral contraceptives or undergoing hormone replacement therapy. The document also examines differences in stroke risk factors and outcomes between men and women.
1) The patient requires careful management of anticoagulation for her mechanical heart valve during pregnancy and delivery. She should receive adjusted-dose low molecular weight heparin throughout pregnancy.
2) A regional anesthetic technique could be used for her planned c-section, but her coagulation status and platelet count must be checked closely both before and after the procedure due to her anticoagulation.
3) After delivery, she will need to resume anticoagulation while monitoring closely for any signs of spinal hematoma due to her recent regional block and anticoagulated state.
Anticoagulation in prosthatic valves with pregnancyShah Abbas
This document discusses anticoagulation management for pregnant women with prosthetic heart valves. It notes that less than 1% of pregnant women have prosthetic valves. Pregnancy causes physiological changes that increase cardiovascular demands. The risks of thrombosis are higher during pregnancy due to hypercoagulability. Options for anticoagulation include warfarin, unfractionated heparin, and low molecular weight heparin. Warfarin carries risks of fetal complications if used in the first trimester, so alternatives like heparin are preferred during that period. Careful anticoagulant management throughout pregnancy and the peripartum period can help reduce risks to both mother and fetus.
1) Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), affects around 900,000 people per year in the United States, causes around 100,000 deaths per year, and is a leading cause of preventable hospital death.
2) The document discusses guidelines for diagnosing and treating VTE, including which anticoagulants to use, how long to treat, considerations for cancer patients, and whether to use thrombolytics or inferior vena cava filters.
3) It also addresses frequently asked clinical questions like whether to treat incidental or distal PEs, the risks of recurrence for provoked versus unprov
1. A 38-year-old man with severe hemophilia A presented with right thigh pain and was diagnosed with a deep vein thrombosis (DVT) in his right femoral vein. He was treated with anticoagulation and factor VIII replacement.
2. During treatment, he developed a large iliacus muscle hemorrhage. His anticoagulation was held and factor replacement was continued. An IVC filter was placed to prevent further pulmonary embolism.
3. Over several weeks of intensive factor replacement and physical therapy, the patient's DVT and hemorrhage resolved without further complications. His case illustrates the complex management of both bleeding and thrombotic risks in patients with hemophilia.
1) There is a considerable risk of recurrent venous thromboembolism (VTE) after stopping anticoagulation treatment, ranging from 3-15% per year depending on risk factors.
2) Cancer patients have a high risk of both recurrent VTE and bleeding during anticoagulation treatment.
3) Patients with a provoked VTE have a low recurrence risk of around 3% per year, while those with an unprovoked VTE have a risk up to 15% per year.
4) The risk of recurrence increases as soon as anticoagulation is stopped regardless of the previous duration of treatment.
1. Pregnancy increases the risk of venous thromboembolism (VTE) and it is a leading cause of maternal death. The risk is greatest in the first trimester and postpartum period following vaginal delivery.
2. All women should be assessed for VTE risk factors during early pregnancy and the risk reassessed if hospitalized or health issues arise. Women at high risk may benefit from pre-pregnancy counseling.
3. Women with prior VTE or inherited thrombophilia have an increased risk during pregnancy and postpartum and should receive thromboprophylaxis, typically with low molecular weight heparin (LMWH). The duration depends on their specific risk factors.
This document discusses thromboprophylaxis in obstetrics and gynecology. It notes that venous thromboembolism is prevalent in hospitalized patients but often clinically silent. Screening recommendations are provided for various conditions like prior VTE and thrombophilia. Guidelines are presented for thromboprophylaxis in pregnancy, postpartum, and for various high risk procedures and cancers. Risk factors for VTE with oral contraceptives and hormone replacement therapy are reviewed. Management of thrombophilia and antiphospholipid syndrome are also covered.
Il rischio tromboembolico nelle patologie arteriose e venose della donna 3Plinio Fabiani
This document discusses risk factors for thromboembolism in women, including reproductive factors and diseases that are more common in women. It provides statistics on the incidence of venous thromboembolism and notes that women are at higher risk during pregnancy and postpartum, as well as when using oral contraceptives or undergoing hormone replacement therapy. The document also examines differences in stroke risk factors and outcomes between men and women.
1) The patient requires careful management of anticoagulation for her mechanical heart valve during pregnancy and delivery. She should receive adjusted-dose low molecular weight heparin throughout pregnancy.
2) A regional anesthetic technique could be used for her planned c-section, but her coagulation status and platelet count must be checked closely both before and after the procedure due to her anticoagulation.
3) After delivery, she will need to resume anticoagulation while monitoring closely for any signs of spinal hematoma due to her recent regional block and anticoagulated state.
Anticoagulation in prosthatic valves with pregnancyShah Abbas
This document discusses anticoagulation management for pregnant women with prosthetic heart valves. It notes that less than 1% of pregnant women have prosthetic valves. Pregnancy causes physiological changes that increase cardiovascular demands. The risks of thrombosis are higher during pregnancy due to hypercoagulability. Options for anticoagulation include warfarin, unfractionated heparin, and low molecular weight heparin. Warfarin carries risks of fetal complications if used in the first trimester, so alternatives like heparin are preferred during that period. Careful anticoagulant management throughout pregnancy and the peripartum period can help reduce risks to both mother and fetus.
1) Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), affects around 900,000 people per year in the United States, causes around 100,000 deaths per year, and is a leading cause of preventable hospital death.
2) The document discusses guidelines for diagnosing and treating VTE, including which anticoagulants to use, how long to treat, considerations for cancer patients, and whether to use thrombolytics or inferior vena cava filters.
3) It also addresses frequently asked clinical questions like whether to treat incidental or distal PEs, the risks of recurrence for provoked versus unprov
1. A 38-year-old man with severe hemophilia A presented with right thigh pain and was diagnosed with a deep vein thrombosis (DVT) in his right femoral vein. He was treated with anticoagulation and factor VIII replacement.
2. During treatment, he developed a large iliacus muscle hemorrhage. His anticoagulation was held and factor replacement was continued. An IVC filter was placed to prevent further pulmonary embolism.
3. Over several weeks of intensive factor replacement and physical therapy, the patient's DVT and hemorrhage resolved without further complications. His case illustrates the complex management of both bleeding and thrombotic risks in patients with hemophilia.
Deep Vein Pathophysiology: Reflux & ObstructionVein Global
By: Peter J. Pappas, M.D.
Visit VeinGlobal at http://www.veinglobal.com/ for more presentations and videos on this topic, or for more information on venous disease news, education and research.
This document discusses the treatment of pulmonary arterial hypertension (PAH), including:
- Approved PAH therapies such as endothelin receptor antagonists, phosphodiesterase-5 inhibitors, and prostanoids.
- The three main pathways involved in PAH pathogenesis.
- Treatment recommendations for PAH associated with congenital heart disease, including the use of PAH-specific therapies.
- Evidence that PAH-specific therapies can reduce mortality in patients with Eisenmenger syndrome.
- Lung transplantation is an option for patients with inadequate response to maximal PAH therapy.
04 b marino malattie cardiache congenite e sindromi genetiche PiccoloGrandeCuore
This document discusses congenital heart diseases and genetic syndromes. It provides an overview of epidemiological studies on non-cardiac malformations associated with congenital heart diseases. It also discusses the embryology of the heart. The document outlines new clinical roles for genetics, including reverse medicine using new diagnostic criteria, predictive medicine correlating genes to prognosis, and potential future applications of gene therapy and stem cell therapy. Specific genetic syndromes are examined in depth, including their cardiac defects, surgical outcomes, post-operative complications, and prognosis. These include Down syndrome, del22q11 syndrome, Noonan syndrome, and LEOPARD syndrome. The document emphasizes the importance of predictive medicine in correlating a patient's genetic syndrome to clinical prognosis
XIII Reunión anual de la sección de Insuficiencia Cardiaca de la SEC
OVIEDO, 16-18 JUNIO 2016 HOSPITAL UNIVERSITARIO CENTRAL DE ASTURIAS (HUCA)
http://secardiologia.es/insuficiencia/cientifico/ic-oviedo-2016
¿Qué se recomienda y qué es lo que hacemos?
VIERNES, 17 DE JUNIO 12.45-14.15 SALÓN DE ACTOS
En la prevención y seguimiento de los pacientes en riesgo de cardiotoxicidad
Xavier Bosch Genover, Barcelona
Mrs. S.A. is a 26-year old pregnant woman at 34 weeks of an IVF twin pregnancy who presented with left leg swelling and pain. She was diagnosed with left calf DVT. Despite anticoagulation therapy, she developed a recurrent massive left leg DVT. Given the increased risk of pulmonary embolism during delivery, doctors decided to place an IVC filter and perform a cesarean section. The procedures and pregnancy outcome were uncomplicated. Placement of an IVC filter can effectively reduce the risk of pulmonary embolism in high-risk pregnant patients with DVT.
This document discusses spontaneous bacterial peritonitis (SBP). It recommends that a diagnostic paracentesis be performed on all patients with ascites to test for SBP. SBP should be treated empirically if the ascitic fluid polymorphonuclear leukocyte count is ≥250 cells/mm3. Albumin therapy is recommended for SBP patients with renal dysfunction. The document differentiates between spontaneous and secondary SBP, noting that secondary SBP requires surgical management. It also provides guidance on SBP prophylaxis.
An 83-year-old woman with heart failure was admitted to the hospital for IV diuresis. Her expected 1-year mortality is 43.1% according to a study. For men of the same age, the expected 1-year mortality is 37.9%.
XIII Reunión anual de la sección de Insuficiencia Cardiaca de la SEC
OVIEDO, 16-18 JUNIO 2016 HOSPITAL UNIVERSITARIO CENTRAL DE ASTURIAS (HUCA)
http://secardiologia.es/insuficiencia/cientifico/ic-oviedo-2016
Utilidad de las técnicas de imagen de la insuficiencia cardiaca y trasplante ¿Qué técnica debemos utilizar y qué nos aporta en cada situación clínica?
VIERNES, 17 DE JUNIO 10:30-12:15 SALÓN DE ACTOS
Trasplante cardiaco. ¿Es posible la detección no invasiva del rechazo agudo?
José Antonio Vázquez de Prada, Santander
Thrombophilia are hereditary and/or acquired conditions that predispose patients to thrombosis.
The association between thrombophilia and recurrent pregnancy loss (RPL) has become an undisputed fact.
Women with heritable or acquired thrombophilic disorders have significantly increased risks of pregnancy loss
FOURIER: estudio de eventos cardiovasculares con evolocumab
30/03/2017 18:30h Casa del Corazón, Madrid
http://evolocumab.secardiologia.es
#evolocumab
Se abordarán los siguientes temas:
Presentación de resultados del estudio FOURIER
Interpretación de los datos en el contexto actual
Traslación clínica y aplicabilidad de los resultados
Coloquio y preguntas del público
The document analyzes antithrombin and protein C levels in 75 pediatric liver transplant patients to determine if low levels predict hepatic artery thrombosis (HAT). It found significantly lower levels of both proteins in patients who developed HAT compared to those who did not. Using cutoff levels, low antithrombin on the day of transplant was predictive of later HAT. Combined deficiencies in antithrombin and protein C may increase thrombosis risk more than individual deficiencies. Early supplementation with both proteins after transplant may help prevent HAT.
Approximately 10 to 30 percent of patients with proliferative lupus nephritis progress to end-stage renal disease (ESRD), depending upon the severity of the disease, ancestral and socioeconomic factors, noncompliance, and the response to initial treatment.
Overall prognosis has improved in recent decades, perhaps due to the use of combined immunosuppression .
The Western Norway B Vitamin Intervention Trial (Wenbi Tbhospital
This randomized controlled trial involved 3096 participants undergoing coronary angiography who were assigned to receive daily oral treatment with folic acid, vitamin B12, vitamin B6, or a placebo. The primary endpoint was a composite of death, heart attack, hospitalization for chest pain, and stroke. After a median follow-up of 38.4 months, there were no significant differences between the treatment groups for the primary endpoint or causes of death. While folic acid reduced homocysteine levels and slightly reduced hospitalizations for chest pain, no clinical benefits were found and the trial was stopped early due to safety concerns.
A 34-year-old Vietnamese woman presented with pulmonary thromboembolism following a cesarean delivery. She experienced cardiac arrest and was resuscitated, but later died from a pulmonary embolism. Pregnancy increases the risks of deep vein thrombosis and pulmonary embolism due to venous stasis, a hypercoagulable state, and vascular injury during delivery. Cesarean delivery further increases these risks compared to vaginal birth. While low molecular weight heparin can effectively prevent and treat thrombosis, early recognition and treatment are needed to reduce the high mortality rates associated with pulmonary embolism during pregnancy.
Ponencia presentada por el Dr. José Manuel García Pinilla en el directo online ‘Highlights del congreso HFA 2018: una mirada a Europa’, realizado el 15 de junio de 2018 en la XV Reunión Anual de la Sección de Insuficiencia Cardiaca de la SEC en Toledo.
CPG: Prevention and Treatment of Venous Thromboembolism (VTE)Khairunnisa Zamri
This document provides guidelines for the prevention and treatment of venous thromboembolism (VTE). It defines VTE as deep vein thrombosis and pulmonary embolism. It discusses the epidemiology, causes, risk factors, pathophysiology and various methods for prophylaxis and treatment of VTE, including pharmacological agents such as low molecular weight heparins, fondaparinux, vitamin K antagonists, and new oral anticoagulants. It also covers topics such as risk assessment, timing of prophylaxis, duration of treatment and switching between different anticoagulation agents.
An 83-year-old female patient presented with sudden onset dyspnea and was found to have a large pulmonary embolism and deep vein thromboses. Her hospital course was complicated by massive hemoptysis during a procedure for the PE. She required intubation, bronchoscopy, and remained on ventilatory support for several days. Testing later found she had an inherited hypercoagulable condition. On awakening, she displayed possible neurological deficits that prompted head imaging.
A 74-year-old African American female was admitted to the emergency department with signs of hypoglycemia, excessive anticoagulation, anemia, and infections. Laboratory tests found abnormal liver and kidney function along with hypothyroidism and rheumatoid arthritis. The patient received treatments including dextrose for hypoglycemia, antibiotics for infections, vitamin K to reverse anticoagulation, blood transfusions for anemia, and prognosis was poor due to multiple declining organ functions and infections.
This document discusses direct oral anticoagulants (DOACs) for treating and preventing blood clots. It summarizes clinical trials that found DOACs like dabigatran, rivaroxaban, apixaban, and edoxaban were as effective or more effective than warfarin for reducing strokes in atrial fibrillation while causing less bleeding. The document outlines the targets, dosing, monitoring requirements, and indications for each DOAC. It also notes advantages like fixed dosing and no monitoring required with DOACs, but potential disadvantages include lack of antidotes and methods to assess patient adherence.
This document discusses direct oral anticoagulants (DOACs) for treating and preventing blood clots. It summarizes clinical trials that found DOACs like dabigatran, rivaroxaban, apixaban, and edoxaban were as effective as warfarin for reducing strokes in atrial fibrillation with fewer bleeding risks. The document outlines the pharmacokinetics, dosing, indications and contraindications for each DOAC. It notes advantages of DOACs include rapid onset/offset, fixed dosing without monitoring, but notes disadvantages could include lack of antidotes and methods to assess patient adherence.
Deep Vein Pathophysiology: Reflux & ObstructionVein Global
By: Peter J. Pappas, M.D.
Visit VeinGlobal at http://www.veinglobal.com/ for more presentations and videos on this topic, or for more information on venous disease news, education and research.
This document discusses the treatment of pulmonary arterial hypertension (PAH), including:
- Approved PAH therapies such as endothelin receptor antagonists, phosphodiesterase-5 inhibitors, and prostanoids.
- The three main pathways involved in PAH pathogenesis.
- Treatment recommendations for PAH associated with congenital heart disease, including the use of PAH-specific therapies.
- Evidence that PAH-specific therapies can reduce mortality in patients with Eisenmenger syndrome.
- Lung transplantation is an option for patients with inadequate response to maximal PAH therapy.
04 b marino malattie cardiache congenite e sindromi genetiche PiccoloGrandeCuore
This document discusses congenital heart diseases and genetic syndromes. It provides an overview of epidemiological studies on non-cardiac malformations associated with congenital heart diseases. It also discusses the embryology of the heart. The document outlines new clinical roles for genetics, including reverse medicine using new diagnostic criteria, predictive medicine correlating genes to prognosis, and potential future applications of gene therapy and stem cell therapy. Specific genetic syndromes are examined in depth, including their cardiac defects, surgical outcomes, post-operative complications, and prognosis. These include Down syndrome, del22q11 syndrome, Noonan syndrome, and LEOPARD syndrome. The document emphasizes the importance of predictive medicine in correlating a patient's genetic syndrome to clinical prognosis
XIII Reunión anual de la sección de Insuficiencia Cardiaca de la SEC
OVIEDO, 16-18 JUNIO 2016 HOSPITAL UNIVERSITARIO CENTRAL DE ASTURIAS (HUCA)
http://secardiologia.es/insuficiencia/cientifico/ic-oviedo-2016
¿Qué se recomienda y qué es lo que hacemos?
VIERNES, 17 DE JUNIO 12.45-14.15 SALÓN DE ACTOS
En la prevención y seguimiento de los pacientes en riesgo de cardiotoxicidad
Xavier Bosch Genover, Barcelona
Mrs. S.A. is a 26-year old pregnant woman at 34 weeks of an IVF twin pregnancy who presented with left leg swelling and pain. She was diagnosed with left calf DVT. Despite anticoagulation therapy, she developed a recurrent massive left leg DVT. Given the increased risk of pulmonary embolism during delivery, doctors decided to place an IVC filter and perform a cesarean section. The procedures and pregnancy outcome were uncomplicated. Placement of an IVC filter can effectively reduce the risk of pulmonary embolism in high-risk pregnant patients with DVT.
This document discusses spontaneous bacterial peritonitis (SBP). It recommends that a diagnostic paracentesis be performed on all patients with ascites to test for SBP. SBP should be treated empirically if the ascitic fluid polymorphonuclear leukocyte count is ≥250 cells/mm3. Albumin therapy is recommended for SBP patients with renal dysfunction. The document differentiates between spontaneous and secondary SBP, noting that secondary SBP requires surgical management. It also provides guidance on SBP prophylaxis.
An 83-year-old woman with heart failure was admitted to the hospital for IV diuresis. Her expected 1-year mortality is 43.1% according to a study. For men of the same age, the expected 1-year mortality is 37.9%.
XIII Reunión anual de la sección de Insuficiencia Cardiaca de la SEC
OVIEDO, 16-18 JUNIO 2016 HOSPITAL UNIVERSITARIO CENTRAL DE ASTURIAS (HUCA)
http://secardiologia.es/insuficiencia/cientifico/ic-oviedo-2016
Utilidad de las técnicas de imagen de la insuficiencia cardiaca y trasplante ¿Qué técnica debemos utilizar y qué nos aporta en cada situación clínica?
VIERNES, 17 DE JUNIO 10:30-12:15 SALÓN DE ACTOS
Trasplante cardiaco. ¿Es posible la detección no invasiva del rechazo agudo?
José Antonio Vázquez de Prada, Santander
Thrombophilia are hereditary and/or acquired conditions that predispose patients to thrombosis.
The association between thrombophilia and recurrent pregnancy loss (RPL) has become an undisputed fact.
Women with heritable or acquired thrombophilic disorders have significantly increased risks of pregnancy loss
FOURIER: estudio de eventos cardiovasculares con evolocumab
30/03/2017 18:30h Casa del Corazón, Madrid
http://evolocumab.secardiologia.es
#evolocumab
Se abordarán los siguientes temas:
Presentación de resultados del estudio FOURIER
Interpretación de los datos en el contexto actual
Traslación clínica y aplicabilidad de los resultados
Coloquio y preguntas del público
The document analyzes antithrombin and protein C levels in 75 pediatric liver transplant patients to determine if low levels predict hepatic artery thrombosis (HAT). It found significantly lower levels of both proteins in patients who developed HAT compared to those who did not. Using cutoff levels, low antithrombin on the day of transplant was predictive of later HAT. Combined deficiencies in antithrombin and protein C may increase thrombosis risk more than individual deficiencies. Early supplementation with both proteins after transplant may help prevent HAT.
Approximately 10 to 30 percent of patients with proliferative lupus nephritis progress to end-stage renal disease (ESRD), depending upon the severity of the disease, ancestral and socioeconomic factors, noncompliance, and the response to initial treatment.
Overall prognosis has improved in recent decades, perhaps due to the use of combined immunosuppression .
The Western Norway B Vitamin Intervention Trial (Wenbi Tbhospital
This randomized controlled trial involved 3096 participants undergoing coronary angiography who were assigned to receive daily oral treatment with folic acid, vitamin B12, vitamin B6, or a placebo. The primary endpoint was a composite of death, heart attack, hospitalization for chest pain, and stroke. After a median follow-up of 38.4 months, there were no significant differences between the treatment groups for the primary endpoint or causes of death. While folic acid reduced homocysteine levels and slightly reduced hospitalizations for chest pain, no clinical benefits were found and the trial was stopped early due to safety concerns.
A 34-year-old Vietnamese woman presented with pulmonary thromboembolism following a cesarean delivery. She experienced cardiac arrest and was resuscitated, but later died from a pulmonary embolism. Pregnancy increases the risks of deep vein thrombosis and pulmonary embolism due to venous stasis, a hypercoagulable state, and vascular injury during delivery. Cesarean delivery further increases these risks compared to vaginal birth. While low molecular weight heparin can effectively prevent and treat thrombosis, early recognition and treatment are needed to reduce the high mortality rates associated with pulmonary embolism during pregnancy.
Ponencia presentada por el Dr. José Manuel García Pinilla en el directo online ‘Highlights del congreso HFA 2018: una mirada a Europa’, realizado el 15 de junio de 2018 en la XV Reunión Anual de la Sección de Insuficiencia Cardiaca de la SEC en Toledo.
CPG: Prevention and Treatment of Venous Thromboembolism (VTE)Khairunnisa Zamri
This document provides guidelines for the prevention and treatment of venous thromboembolism (VTE). It defines VTE as deep vein thrombosis and pulmonary embolism. It discusses the epidemiology, causes, risk factors, pathophysiology and various methods for prophylaxis and treatment of VTE, including pharmacological agents such as low molecular weight heparins, fondaparinux, vitamin K antagonists, and new oral anticoagulants. It also covers topics such as risk assessment, timing of prophylaxis, duration of treatment and switching between different anticoagulation agents.
An 83-year-old female patient presented with sudden onset dyspnea and was found to have a large pulmonary embolism and deep vein thromboses. Her hospital course was complicated by massive hemoptysis during a procedure for the PE. She required intubation, bronchoscopy, and remained on ventilatory support for several days. Testing later found she had an inherited hypercoagulable condition. On awakening, she displayed possible neurological deficits that prompted head imaging.
A 74-year-old African American female was admitted to the emergency department with signs of hypoglycemia, excessive anticoagulation, anemia, and infections. Laboratory tests found abnormal liver and kidney function along with hypothyroidism and rheumatoid arthritis. The patient received treatments including dextrose for hypoglycemia, antibiotics for infections, vitamin K to reverse anticoagulation, blood transfusions for anemia, and prognosis was poor due to multiple declining organ functions and infections.
This document discusses direct oral anticoagulants (DOACs) for treating and preventing blood clots. It summarizes clinical trials that found DOACs like dabigatran, rivaroxaban, apixaban, and edoxaban were as effective or more effective than warfarin for reducing strokes in atrial fibrillation while causing less bleeding. The document outlines the targets, dosing, monitoring requirements, and indications for each DOAC. It also notes advantages like fixed dosing and no monitoring required with DOACs, but potential disadvantages include lack of antidotes and methods to assess patient adherence.
This document discusses direct oral anticoagulants (DOACs) for treating and preventing blood clots. It summarizes clinical trials that found DOACs like dabigatran, rivaroxaban, apixaban, and edoxaban were as effective as warfarin for reducing strokes in atrial fibrillation with fewer bleeding risks. The document outlines the pharmacokinetics, dosing, indications and contraindications for each DOAC. It notes advantages of DOACs include rapid onset/offset, fixed dosing without monitoring, but notes disadvantages could include lack of antidotes and methods to assess patient adherence.
This document discusses risk thresholds for long-term anticoagulation after venous thromboembolism (VTE). It reports that annual VTE recurrence risks above 5% at 1 year and 15% at 5 years would discourage stopping anticoagulation for most physicians and patients. Recurrence risks are higher for unprovoked VTE compared to transiently provoked VTE. The risks of both recurrence and bleeding must be considered when determining duration of anticoagulation. A validated prediction model could help estimate individual patients' recurrence and bleeding risks to inform anticoagulation duration decisions.
This study updated the Vienna Prediction Model for predicting recurrent venous thromboembolism (VTE) risk by developing a "Dynamic Vienna Prediction Model" that uses serial D-dimer measurements over time. The study found that D-dimer levels did not substantially change after anticoagulation treatment. It also found that the effects of risk factors like sex and initial VTE location on recurrence risk may weaken over time. The new model integrates patient characteristics and serial D-dimer data to assess recurrence risk not just at 3 weeks but also at later time points, allowing for more flexible risk counseling and anticoagulation decisions.
dvt prophylaxis, in icu, deep venous thrombosis prophylaxis ,gagan brar
Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is extraordinarily common in hospitalized patients. Risk factors for VTE include immobilization, surgery, trauma, cancer, and thrombophilia. Prediction models can help assess patient risk, though require validation. Primary prophylaxis is preferred to prevent VTE and includes mechanical methods like intermittent pneumatic compression and graduated compression stockings, as well as pharmacologic agents like unfractionated heparin, low molecular weight heparins, and fondaparinux. These options aim to reduce the risk of VTE complications while minimizing bleeding risks.
1) Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), affects over 900,000 Americans each year and can be fatal. The risk of recurrence of VTE is 17-30% over time without continued anticoagulation treatment.
2) The risk of recurrent VTE depends on factors like whether the initial VTE was provoked by surgery or other transient risk factors, whether the patient has active cancer, and whether it is a first or subsequent episode of VTE. Hereditary thrombophilias alone do not strongly determine recurrence risk.
3) Treatment options for VTE include anticoagulants like warfar
Diagnosis and treatment of acute pulmonary embolism (VTE)Usama Ragab
By Dr. Usama Ragab, Zagazig Faculty of Medicine
PE may account for up to 15% of all post-operative deaths.
It is the commonest cause of death following elective surgery, and the commonest cause of maternal death.
Deep vein thrombosis (DVT) and Pulmonary embolism (PE)Aminul Haque
Deep vein thrombosis (DVT) and pulmonary embolism (PE), collectively referred to as venous thromboembolism (VTE), constitute a major global burden of disease.
This document discusses deep vein thrombosis (DVT) and pulmonary embolism (PE), collectively known as venous thromboembolism (VTE). It notes that VTE is a major global disease that is underdiagnosed and increasing in incidence. The document covers the etiology, risk factors, presentations, diagnosis, and management of VTE, including the use of anticoagulants like direct oral anticoagulants which have advantages over warfarin. It emphasizes the importance of appropriate diagnosis and treatment to prevent recurrence of VTE events and long-term complications.
This document discusses the diagnostic and treatment approaches to venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE). It provides details on evaluating patients using Wells criteria and D-dimer testing to determine pre-test probability and decide between imaging with CT pulmonary angiogram or VQ scan. For confirmed VTE, treatment options include warfarin, novel oral anticoagulants (NOACs), inferior vena cava filters or thrombolytics. The document reviews best practices for treating isolated distal DVT, catheter-related thrombosis, and selecting appropriate long-term anticoagulation therapy.
Co-Chairs, Alok A. Khorana, MD, FACP, FASCO, and Robert D. McBane, II, MD, along with Dana Angelini, MD, prepared useful Practice Aids pertaining to VTE for this CME/MOC/NCPD/CPE activity titled “Reducing the Global Burden of Cancer-Associated VTE: Applying Guideline-Concordant, Evidence-Based Care and Shared Decision-Making Strategies to Improve Patient Outcomes.” For the full presentation, downloadable Practice Aids, and complete CME/MOC/NCPD/CPE information, and to apply for credit, please visit us at https://bit.ly/3pxFR5t. CME/MOC/NCPD/CPE credit will be available until August 9, 2022.
The document discusses venous thromboembolism (VTE) risk assessment and prophylaxis for hospitalized medical patients. It provides recommendations from American Society of Hematology 2018 guidelines and Indonesian Thrombosis and Hemostasis Society 2018 national guidelines. The recommendations suggest using low molecular weight heparin or unfractionated heparin for VTE prophylaxis in acutely ill or critically ill medical patients based on their risk assessment scores. Mechanical prophylaxis alone or combined with pharmacological prophylaxis is conditionally recommended if patients cannot receive anticoagulants. Extended duration outpatient prophylaxis after hospital discharge is not routinely recommended.
1. Deep vein thrombosis (DVT) is caused by Virchow's triad of stasis, vessel damage, and hypercoagulability. Prolonged bed rest, major surgery, trauma, pregnancy, and cancer are common risk factors.
2. General anesthesia increases DVT risk compared to epidural anesthesia. Blood type A is also associated with higher risk.
3. DVT diagnosis involves tests like duplex ultrasound, MRI, and blood tests. Treatment includes anticoagulants like heparin and warfarin to prevent clots from worsening. Compression stockings and early mobilization are also used prophylactically.
1320 1340 Venothromboembolic Diseases AGupta FINAL (1).pptxOmarHussain55
This document provides an overview of venous thromboembolism (VTE) including deep vein thrombosis (DVT) and pulmonary embolism (PE). It discusses that VTE is a major cause of mortality and morbidity in the United States, killing over 200,000 people annually from PE alone. The document then reviews risk factors for VTE, treatment options including anticoagulation therapies and peripheral endovascular interventions, and indications for catheter-directed thrombolysis for acute massive PE.
Venous Thromboembolism (VTE): Recent Advances in Reducing the Disease BurdenNBCA
- Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is a major cause of morbidity and mortality worldwide. It is estimated that there are 900,000 cases of VTE per year in the US.
- Recent clinical trials have found that the direct oral anticoagulants rivaroxaban, apixaban, edoxaban and dabigatran are non-inferior to standard therapy for treating VTE and reduce the risk of recurrence, while having a similar or lower risk of bleeding.
- The EINSTEIN DVT and EINSTEIN PE trials found that rivaroxaban was non-infer
Acute coronary syndromes (ACS) include unstable angina and myocardial infarction, which are forms of coronary heart disease caused by reduced blood flow due to plaque rupture and clot formation in the coronary arteries. The document discusses the epidemiology, risk factors, pathophysiology, clinical presentation, diagnosis, and treatment of ACS. It provides details on evaluating patients using biomarkers, ECG, risk scores, restoring blood flow through procedures like PCI or fibrinolysis, and employing antiplatelet and anticoagulant medications in the early treatment of ACS.
This document provides a historical overview of the diagnosis and treatment of deep venous thrombosis (DVT) and pulmonary embolism (PE). It discusses key discoveries and studies that advanced the understanding and management of these conditions, such as Virchow identifying PE in 1846, studies in the 1960s establishing the use of heparin to prevent DVT and fatal PE after surgery, and randomized controlled trials in the 1990s comparing heparin/warfarin to heparin/warfarin plus inferior vena cava filters for DVT treatment. The document also reviews current diagnostic methods and medical and interventional treatment options for DVT and PE.
This document provides a historical overview of the diagnosis and treatment of deep venous thrombosis (DVT) and pulmonary embolism (PE). It discusses key discoveries and studies that advanced the understanding and management of these conditions, such as Virchow identifying PE in 1846, studies in the 1960s establishing the use of heparin to prevent DVT and fatal PE after surgery, and randomized controlled trials in the 1990s comparing heparin/warfarin to heparin/warfarin plus inferior vena cava filters for DVT treatment. The document also reviews current diagnostic methods and medical and interventional treatment options for DVT and PE.
This document provides definitions and background information about acute variceal hemorrhage. It defines acute variceal bleeding as hematemesis or melena within the last 48 hours in a known or suspected case of portal hypertension. Varices are the accepted source of bleeding if blood is seen arising from or clotted on top of an esophageal varix. Failure to control the bleeding is defined as rebleeding within 48 hours of treatment. The document discusses the anatomy of varices, risk factors for bleeding such as varix size, and complications associated with acute variceal hemorrhage such as high rebleeding and mortality rates.
Cancer-Associated Thrombosis.From LMWH to DOACsmagdy elmasry
This document summarizes a presentation on cancer-associated thrombosis (CAT). It discusses that up to 20% of cancer patients experience venous thromboembolism (VTE) and cancer patients have a 5 times higher risk of VTE than the general population. The presentation reviews risk factors for CAT, mechanisms of cancer-related VTE, treatment options including low molecular weight heparins (LMWH), vitamin K antagonists (VKA), and direct oral anticoagulants (DOACs). It summarizes evidence from clinical trials comparing these treatments and guidelines recommending LMWH for at least 6 months. Considerations for optimal use of each treatment class and avoiding certain options are also outlined.
1. Acute variceal hemorrhage refers to bleeding from enlarged veins (varices) in the esophagus or stomach that is caused by portal hypertension from liver cirrhosis. Variceal bleeding is a severe complication and is the cause of bleeding in 70% of upper GI bleeds in cirrhotic patients.
2. Varices develop due to increased pressure in the portal vein system from cirrhosis. Once varices form, there is a risk of 15% annual bleeding for large varices. Bleeding can often be controlled with medical and endoscopic therapy but there is a high risk (60%) of rebleeding without intervention.
3. Varices are classified based on location
This document discusses the challenges of managing anticoagulation in patients undergoing surgical procedures. It provides guidance on estimating thromboembolic and bleeding risk, deciding whether to interrupt anticoagulation, and timing interruptions. For patients at very high thromboembolic risk, the goal is to limit time off anticoagulation. Bleeding risk depends on procedure type and duration. Warfarin should be stopped 5 days before elective surgery to allow the INR to decrease safely.
This document discusses the management of gastrointestinal bleeding. It covers the clinical presentation and definitions of acute upper and lower GI bleeding. The core principles of GI bleeding management are outlined as assessing and stabilizing hemodynamic status, determining the source of bleeding, stopping active bleeding, treating any underlying abnormalities, and preventing recurrent bleeding. Specific causes, diagnostic evaluations, endoscopic and surgical treatments are described for various types of acute GI bleeding.
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by...Donc Test
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by Stamler, Verified Chapters 1 - 33, Complete Newest Version Community Health Nursing A Canadian Perspective, 5th Edition by Stamler, Verified Chapters 1 - 33, Complete Newest Version Community Health Nursing A Canadian Perspective, 5th Edition by Stamler Community Health Nursing A Canadian Perspective, 5th Edition TEST BANK by Stamler Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Pdf Chapters Download Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Pdf Download Stuvia Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Study Guide Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Ebook Download Stuvia Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Questions and Answers Quizlet Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Studocu Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Quizlet Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Pdf Chapters Download Community Health Nursing A Canadian Perspective, 5th Edition Pdf Download Course Hero Community Health Nursing A Canadian Perspective, 5th Edition Answers Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Ebook Download Course hero Community Health Nursing A Canadian Perspective, 5th Edition Questions and Answers Community Health Nursing A Canadian Perspective, 5th Edition Studocu Community Health Nursing A Canadian Perspective, 5th Edition Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Pdf Chapters Download Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Pdf Download Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Study Guide Questions and Answers Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Ebook Download Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Questions Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Studocu Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Stuvia
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Kat...rightmanforbloodline
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
10. Anticoagulation after VTE
Cancer patients
LMWH for 6 months
Complete remission +
no additional risk factors
Active cancer ±
additional risk factors
Chemotherapy
Interventions
Stop anticoagulation
Stable disease
Patient‘s preference
LMWH
Oral anticoagulants
11. Take home!
•
•
•
Considerable risk of recurrent VTE after stopping anticoagulation
Cancer patients are at high risk of recurrent VTE and bleeding
Provoked VTE low risk (~3%/yr)
13. Take home!
•
•
•
•
Considerable risk of recurrent VTE after stopping anticoagulation
Cancer patients are at high risk of recurrent VTE and bleeding
Provoked VTE low risk (~3%/yr)
Unprovoked VTE high risk (up to 15%/yr)
15. Bleeding during anticoagulation for VTE
Time period of AC
Initial 3 months
> 3 months
Major bleeding
(%, 95% CI)
2.06
2.74
(2.04-2.08)
(2.71-2.77)/yr
Intracranial bleeding
(%, 95% CI)
1.48
0.65
(1.40–1.56)
(0.63–0.68)/yr
Case fatality rate after 3 mo 9.1% (95% CI 2.5–21.7%)
Linkins, Ann Intern Med 2003
16. Take home!
•
•
•
•
•
•
Considerable risk of recurrent VTE after stopping anticoagulation
Cancer patients are at high risk of recurrent VTE and bleeding
Provoked VTE low risk (~3%/yr)
Unprovoked VTE high risk (up to 15%/yr)
Low recurrence risk during anticoagulation
Risk of bleeding
18. Recurrence risk after VTE
Duration of anticoagulation
6
12
18 months
Boutitie, BMJ 2011
19. Take home!
•
•
•
•
•
•
•
Considerable risk of recurrent VTE after stopping anticoagulation
Cancer patients are at high risk of recurrent VTE and bleeding
Provoked VTE low risk (~3%/yr)
Unprovoked VTE high risk (up to 15%/yr)
Low recurrence risk during anticoagulation
Risk of bleeding
Recurrence risk increases as soon as anticoagulation is stopped
regardless of previous duration
20. Take home!
•
•
•
•
•
•
•
•
•
Considerable risk of recurrent VTE after stopping anticoagulation
Cancer patients are at high risk of recurrent VTE and bleeding
Provoked VTE low risk (~3%/yr)
Unprovoked VTE high risk (up to 15%/yr)
Low recurrence risk during anticoagulation
Risk of bleeding
Recurrence risk increases as soon as anticoagulation is stopped
regardless of previous duration
The case/fatality rate of recurrence is low (<5%)
The case/fatality rate of severe bleeding while on anticoagulants is
high (~10%)
21. Management of patients with unprovoked VTE
• Identifying patients with low recurrence risk
– Thrombophilia screening
22. Risk factors of recurrence
HR
95% CI
Laboratory abnormality
Any vs. none
1.4
0.9 - 2.3
Men vs. women
2.7
1.8 - 4.2
Idiopathic vs. provoked
1.9
1.2 - 2.9
Christiansen, JAMA 2005
23. Risk factors (RF) in 158 pts with a second VTE
24%
35%
40%
no RF
1 RF
2 RF
3 RF
4 RF
factor V Leiden, factor II G20210A, HHC, high factor VIII or IX
Kyrle & Eichinger, Lancet 2010
24. Management of patients with unprovoked VTE
• Identifying patients with low recurrence risk
– Thrombophilia screening
– Residual vein thrombosis
25. Management of patients with unprovoked VTE
• Identifying patients with low recurrence risk
– Thrombophilia screening
– Residual vein thrombosis
– D-Dimer
– Prediction models
26. Nomogram to predict recurrence:
Eichinger, Circulation 2010
Vienna Prediction Model
27. Management of patients with unprovoked VTE
•
Identifying patients with low recurrence risk
•
Alternative antithrombotic concepts
28. Direct oral anticoagulants
EINSTEINext
AMPLIFYext
RESONATE
RE-MEDY
Einstein Inv.
NEJM 2010
Patients, n
Study drug
Control
Agnelli
NEJM 2012
1197
2486
1343
2856
Rivaroxaban
Apixaban
Dabigatran
Dabigatran
1 x 20 mg
2 x 5 mg
2 x 2.5 mg
2 x 150 mg
2 x 150 mg
Placebo
Placebo
Placebo
Warfarin
Schulman
NEJM 2013
Schulman
NEJM 2013
29. EINSTEINext - secondary prevention of VTE
Recurrent VTE and related death
EINSTEIN Investigators, N Engl J Med 2010
30. AMPLIFYext - secondary prevention of VTE
Recurrent VTE and related death
Agnelli, N Eng J Med 2013
31. RESONATE - secondary prevention of VTE
Recurrent VTE and related death
Schulman, N Eng J Med 2013
32. REMEDY - secondary prevention of VTE
Recurrent VTE and related death
Schulman, N Eng J Med 2013
35. Anticoagulation after venous thrombosis
stop: bleeding risk
recurrence risk
distal DVT
provoked* VTE
3 months
unprovoked VTE
long term
alternative: rivaroxaban
aspirin
* Surgery, trauma, immobilisation, pregnancy/puerperium, female hormone intake, long haul travel
9th
ACCP Consensus Conference on Antithrombotic Therapy; Kearon, Chest 2012
AWMF online, 6/2010
Editor's Notes
But is this 10% recurrence rate true for every patient? It is not and if we look closer we will see that the recurrence rates may be quite different between patients. I show you here rec. rates from our own study cohort, AUREC. There are patients with a very low rec. In grey and some with a high in orange. Who are these patients and how can we differentiate them.
But is this 10% recurrence rate true for every patient? It is not and if we look closer we will see that the recurrence rates may be quite different between patients. I show you here rec. rates from our own study cohort, AUREC. There are patients with a very low rec. In grey and some with a high in orange. Who are these patients and how can we differentiate them.
First, there is one simple approach by just looking at the location of the thrombotic event. Patients with isolated distal DVT have a low rec. Rate, whereas the risk is considerably higher among those with PE or prox. DVT and is about 25% after 5 years.
We also know that patients who had their VTE in association with a temporary risk factor have a low rec. risk which is around 3% per year in this meta analysis. Very consistent over the diff. studies.
Patients with cancer are of particular concern in case of venous thrombosis. They do have aa high risk of recurrence. Even when they are treated with VKA theire recurrence risk is 3-fold higher than in non cancer pat. With thrombosis. In addition, their bleeding risk during VKA doubles that of the non cancer population
This was the reason for interventional trials evluating the effect of LMWH heparin in cancer patients with VT. Based on lower recurrence rates at comparable safety LMWH is now recommended for 3-6 months in cancer pat with DVT or PE. No data from controlled trials on anticoagulation beyond 6 months are available. And this is now my personal approach.
In contrast patients with a first unprovoked VTE have a considerably higher risk of rec. Again data from our own study, which show that about 30% of the patients which means almost every third patient will have a recurrent event within 5 years after disc. Of anticoag.
The fate of patients who either stop or continue anticoagulation is nicely summarized in this illustration which I have taken from one of the large studies with the new direct anticoagulants. We can defer many aspects of VTE treatment just from this single graph and learn a lot just by looking at it. In this study all patients where treated with anticoagulants for about 6 months and were then randomized into one group who continued anticoagulation the dotted line and in another who stopped anticoagulation, the straight line. The Kaplan Meier plot shows the recurrent rates of VTE over time. Let‘s first concentrate on the dotted line. What we see here is that patients will start to have recurrent episodes of VTE as soon as anticoagulation ist stopped. The risk of recurrence is about 10% during the first year. This number is very consistent in all trials.
However, AC comes at a price and this is bleeding. Unfortunately, there are not many data on the bleeding risk during AC in VTE patients. Most data come from AFIB patients and cannot necessarily be extrapolated to VTE patients. If we look at recent data from trials with new direct AC we see that the risk of major bleeding in the compartor group who received LMWH followed by VKA ranges between 1.2 – 1.9%.
The fate of patients who either stop or continue anticoagulation is nicely summarized in this illustration which I have taken from one of the large studies with the new direct anticoagulants. We can defer many aspects of VTE treatment just from this single graph and learn a lot just by looking at it. In this study all patients where treated with anticoagulants for about 6 months and were then randomized into one group who continued anticoagulation the dotted line and in another who stopped anticoagulation, the straight line. The Kaplan Meier plot shows the recurrent rates of VTE over time. Let‘s first concentrate on the dotted line. What we see here is that patients will start to have recurrent episodes of VTE as soon as anticoagulation ist stopped. The risk of recurrence is about 10% during the first year. This number is very consistent in all trials.
This graph shows the recurrence rates after different durations of AC. If you shorten treatment duration the risk of rec. doubles during the first year as shown by the blue line and thus 3 months ins the minimum. However, if you extend AC to 3,6 or 12 months and longer rec. rates are similar after stopping. Thus, you have to decide between stopping after 3 months in patients with a low rec. risk or to cont. indefinitely in those at high risk.
There are 2 important consequences of recurrent venous thromboembolism.
One complication is the development of the post-thrombotic syndrome, or worsening of an preexisting PTS if venous thrombosis occurs in the same leg. The PTS is often associated with serious consequences for patient, such as life-style alterations, loss of work or frequent hospitalizations. It also results in a considerable increase in health costs.
Much more important, 5 to 10 percent of the patients with recurrent thrombosis die from pulmonary embolism. Therfore, prevention of recurrent VTE is of utmost clinical importance.
Because of the high rec. risk of patients with unprovoked VTE all these patients are candidates for long term AC. This is certainly a challenge for both patients and the health care system and attempts have are are been made to identify low risk patients with unprovoked VTE who may safely stop AC.
Screening for laboratory markers of thrombophilia such as FVL has widely been used for that purpose but has been meanwhile been abandoned. The predicitive value of these markers is either none, too weak or unknown to guide duration of AC
Res. Vein thrombosis is used by some to stratify pts according to their rec. Risk. This method is neither standardized nor validated and can thus not be recommended for routine care.
D-Dimer is predictive of rec. risk particularly when it is integrated with prediction models. At present 3 models which integrate clinical factors and D-Dimer have been published.
In serveral studies a posistive association between VTE and clinical outcomes such ascarotid plaques, AMI, death, etcand .has been described. In two studies no association between subclinical atherothrombosis and VTE was observed.
We also have to face the fact that we do not know everything. You see here the distribution of RF of recurrence in 158 patients from our cohort who all had two episodes of VTE. Many had one, or two or even more RF, but in more than a third of the patients no RF was detectable.
Because of the high rec. risk of patients with unprovoked VTE all these patients are candidates for long term AC. This is certainly a challenge for both patients and the health care system and attempts have are are been made to identify low risk patients with unprovoked VTE who may safely stop AC.
Screening for laboratory markers of thrombophilia such as FVL has widely been used for that purpose but has been meanwhile been abandoned. The predicitive value of these markers is either none, too weak or unknown to guide duration of AC
Res. Vein thrombosis is used by some to stratify pts according to their rec. Risk. This method is neither standardized nor validated and can thus not be recommended for routine care.
D-Dimer is predictive of rec. risk particularly when it is integrated with prediction models. At present 3 models which integrate clinical factors and D-Dimer have been published.
Because of the high rec. risk of patients with unprovoked VTE all these patients are candidates for long term AC. This is certainly a challenge for both patients and the health care system and attempts have are are been made to identify low risk patients with unprovoked VTE who may safely stop AC.
Screening for laboratory markers of thrombophilia such as FVL has widely been used for that purpose but has been meanwhile been abandoned. The predicitive value of these markers is either none, too weak or unknown to guide duration of AC
Res. Vein thrombosis is used by some to stratify pts according to their rec. Risk. This method is neither standardized nor validated and can thus not be recommended for routine care.
D-Dimer is predictive of rec. risk particularly when it is integrated with prediction models. At present 3 models which integrate clinical factors and D-Dimer have been published.
I show you our own model, the VPM, which integrates the pt. sex as the rec. risk is lower among women than in men, the location of VTE and the D-Dimer level measured 3 wks after disc. of AC. We provide a webbased calculator and you get an estimate of the rec. risk after 1 and 5 years. This lady for example has a very low rec risk. I have to point out that none of these models have been validated. We and another group from the Netherladns are currently performing a trial to validate the VPM. And once these data are confirmed this model can be used for routine care.
The limiting factor for indefinite ac is the bleeding risk. If we would have antithrombotic drug with no or a negligible bleeding risk. we could avoid much of this discussion.
With these considerations in the back of mind the new direct oral AC have been evaluated for long term AC after VTE regarding risk of rec. and bleeding. 4 studies have been published, 3 in comparison to placebo and one with warfarin.
The drugs are highly effective in preventing rec. As shown here
Similar efficacy is demonstrated with another xa inhib. apixaban
And also with dabigatran. You see now the graph I have enlarged for illustrative purposes.
In comparison to warfarin, dabigatran shows similar efficacy.
However, these drugs are very potnet and there is bleeding during ac treatment. If we look at major and CRNM rates are higher than in patients with placebo. It has to be kept in mind that the number of patients in these trials is too small to adequately assess the bleeding risk and that the observation time was limited to a maximum of two years. In comparison to warfarin, dabigatran showed lower risk of bleeding.
Just recently, also aspirin has been explored in this indication. In a pooled analysis of two trials aspirin reduces the risk of rec. by 32%. Importantly, aspirin also reduces the risk of other major vascular events including MI and CI. No significant increase in bleeding has been shown.