Abstract Venous thromboembolism (VTE) is a major therapeutic issue in cancer patients. Advances in this field and heterogeneities in clinical practices prompted us to establish guidelines in the ...management of VTE in cancer patients according to the SOR (Standards, Options and Recommendations) methodology. A literature review of the studies published on this topic between 1999 and 2007 was performed. The guidelines were developed from the analysis of 38 out of 418 publications selected. They were peer-reviewed by 65 independent experts. The treatment of VTE in patients with cancer, including those with intracranial malignancies, should be based on low-molecular-weight heparins administered at therapeutic doses for at least 3 months. In the event of recurrent VTE, pulmonary embolism with hemodynamic failure or contra-indication to anticoagulant treatment, the indications and usages of vena cava filters and thrombolytic drugs should be the same as in non-cancer patients.
Patients hospitalized with COVID-19 often exhibit markers of a hypercoagulable state and have an increased incidence of VTE. In response, CHEST issued rapid clinical guidance regarding prevention of ...VTE. Over the past 18 months the quality of the evidence has improved. We thus sought to incorporate this evidence and update our recommendations as necessary.
This update focuses on the optimal approach to thromboprophylaxis in hospitalized patients. The original questions were used to guide the search, using MEDLINE via PubMed. Eight randomized controlled trials and one observational study were included. Meta-analysis, using a random effects model, was performed. The panel created summaries using the GRADE Evidence-to-Decision framework. Updated guidance statements were drafted, and a modified Delphi approach was used to obtain consensus.
We provide separate guidance statements for VTE prevention for hospitalized patients with acute (moderate) illness and critically ill patients in the ICU. However, we divided each original question and resulting recommendation into two questions: standard prophylaxis vs therapeutic (or escalated dose) prophylaxis and standard prophylaxis vs intermediate dose prophylaxis. This led to a change in one recommendation, and an upgrading of three additional recommendations based upon higher quality evidence.
Advances in care for patients with COVID-19 have improved overall outcomes. Despite this, rates of VTE in these patients remain elevated. Critically ill patients should receive standard thromboprophylaxis for VTE, and moderately ill patients with a low bleeding risk might benefit from therapeutic heparin. We see no role for intermediate dose thromboprophylaxis in either setting.
Abstract Introduction Several studies have suggested that statins may lower the risk of venous thromboembolism (VTE), whereas fibrates may increase this risk. However, no studies have evaluated ...whether lipid-lowering drugs (LLD) use was associated with the risk of VTE recurrence. Materials and methods In a prospective cohort study, we followed-up all patients who had been treated for a first unprovoked VTE event in our centre. The association between LLD exposure and risk of recurrence of VTE after discontinuation of anticoagulation was analyzed with Cox proportional hazards model with adjustment for age, sex, body mass index, site of thrombosis, antiplatelets use, and duration of anticoagulation before inclusion in the study. Results 432 patients (median age 65.5 years interquartile range 45.0-75.0, 174 men) were followed up for a median of 29.5 months after discontinuation of anticoagulation. Sixty patients (13.9%) had recurrent VTE. During follow-up, 48 patients (11.1%) received statins, 36 patients (8.3%) received fibrates. In multivariate analysis, the risk of recurrent VTE associated with statin exposure was 1.02 (95% confidence interval 0.36-2.91) and 2.15 (95% confidence interval 1.01-4.61) for fibrate exposure. Conclusion Our results suggest an association between fibrate intake and an increased risk of recurrent VTE, whereas statin intake was not associated with recurrent VTE. Larger studies are needed to validate these results.
Perioperative management of patients treated with the non-vitamin K antagonist oral anticoagulants is an ongoing challenge. Due to the lack of good clinical studies involving adequate monitoring and ...reversal therapies, management requires knowledge and understanding of pharmacokinetics, renal function, drug interactions, and evaluation of the surgical bleeding risk. Consideration of the benefit of reversal of anticoagulation is important and, for some low risk bleeding procedures, it may be in the patient's interest to continue anticoagulation. In case of major intra-operative bleeding in patients likely to have therapeutic or supra-therapeutic levels of anticoagulation, specific reversal agents/antidotes would be of value but are currently lacking. As a consequence, a multimodal approach should be taken which includes the administration of 25 to 50 U/kg 4-factor prothrombin complex concentrates or 30 to 50 U/kg activated prothrombin complex concentrate (FEIBA®) in some life-threatening situations. Finally, further studies are needed to clarify the ideal therapeutic intervention.
Background: Cancer patients undergoing surgical resection of their tumour are hypercoagulable beyond the period of hospitalization. Preclinical studies demonstrate that the postoperative ...hypercoagulable state promotes metastases, an effect that is abrogated by administration of perioperative low-molecular-weight heparin (LMWH). Methods: We conducted a randomized open-label clinical trial (Funded by Canadian Institute of Health Research and Leo Pharma; ClinicalTrials.gov NCT 01455831) to determine if extended duration thromboprophylaxis using subcutaneous LMWH (tinzaparin 4500 IU daily), beginning at decision to operate and continuing for 56 days postoperatively, compared with inpatient postoperative thromboprophylaxis only, increased the 3-year disease-free survival (DSF) in patients undergoing resection for colorectal cancer. Secondary outcomes included 5-year overall survival (OS), postoperative bleeding and venous thromboembolism (VTE). Results: Trial recruitment was stopped prematurely after 614 of the planned 1075 patients were registered, following a predefined interim analysis for futility. The intention-to-treat analysis included 602 patients. The 3-year DFS was 78.9% (63 of 299 recurrences) in the tinzaparin group and 80.5% (59 of 303 recurrences) in the control group (hazard ratio HR 1.09, 95% confidence interval CI 0.91-1.31, p = 0.3). The 5-year OS was 91.3% in the tinzaparin group and 92.4% in the control group (HR 1.08, 95% CI 0.66-1.79, p = 0.1). The incidence of postoperative VTE was 1.7% and 1.3% in the tinzaparin and control groups, respectively (HR 1.3, 95% CI 0.30-5.69, p = 0.7). The incidence of major bleeding in the first postoperative week was 0.3% and 2% in the tinzaparin and control groups, respectively (HR 0.16, 95% CI 0.02-1.15, p = 0.07). Conclusion: Extended-duration perioperative anticoagulation with tinzaparin did not improve DFS or OS in colorectal cancer patients undergoing surgical resection. The incidences of postoperative bleeding and VTE were low.
Abstract Prior meta-analysis and observational studies have suggested that the bleeding risks associated with anticoagulation using vitamin K antagonists (VKA) or aspirin (ASA) are similar. Objective ...The aim of this systematic review was to provide the odds ratios (ORs) of major bleeding, intracranial bleeding or major extra-cranial bleeding of anticoagulation with VKA compared to low doses of ASA. Methods We conducted a systematic review of Ovid MEDLINE, Embase and the Cochrane Central Register of Controlled Trials (RCT). Randomized controlled trials reporting bleeding rates in adult patients randomized to a VKA (INR 2–3) or to ASA alone (< 325 mg daily). Random effects OR were calculated. Results Fifteen trials reporting the outcome of 2511 participants treated with VKA alone and 2471 treated with ASA alone were included; most common conditions evaluated were non-valvular atrial fibrillation (five trials) and heart failure (three trials). Overall, the use of VKA was associated with an increased risk of major bleeding (OR 1.76 (95% CI 1.33–2.33) when compared to ASA. The OR associated with VKA use for intracranial bleeding and extra-cranial bleeding were 1.74 (95% CI 0.83–3.62) and 1.66 (95% CI 0.94–2.92), respectively. In trials achieving good control of anticoagulation time in therapeutic range (TTR) > 65%, the risk of bleeding with VKA was similar to that of ASA OR 1.16 (95% CI 0.79–1.71). Conclusion Contrary to prior reports our results suggest that the risk of major bleeding with the use VKA is higher compared to those of patients treated with ASA alone. However, in patients achieving a good TTR, the risk of major bleeding with VKA or ASA is similar.
Au cours des dernières décennies, les thérapies intensives se sont révélées efficaces pour améliorer la fonction motrice chez les enfants atteints de paralysie cérébrale (PC) en âge scolaire. Les ...évidences de l’efficacité de ces thérapies chez les jeunes enfants sont rares. Cette étude vise à déterminer si une intervention intensive axée sur les objectifs fonctionnels telle que la thérapie HABIT-ILE est efficace chez les enfants d’âge préscolaire (1 à 4 ans) atteints de PC unilatérale.
Cinquante enfants ont participé à cinq heures de thérapie HABIT-ILE par jour pendant dix jours. Les enfants ont été randomisés dans un groupe témoin (n=25) ou un groupe de traitement (n=25). Le groupe de traitement a été évalué au départ (T0), après le traitement (T1) et à 3 mois (T2). Le groupe témoin a été évalué aux mêmes moments recevant HABIT-ILE après T2. La mesure principale de l’étude est le changement dans l’Assisting Hand Assessment (AHA) entre T0 et T2. La fonction unimanuelle a également été évaluée à l’aide du Melbourne-2 (MA2), tandis que la fonction motrice globale a été testée à l’aide de l’évaluation de la fonction motrice globale-66 (GMFM-66). La performance quotidienne a été évaluée avec le Pediatric Évaluation of Disability Inventory (PEDI-CAT) et les objectifs fonctionnels avec la Canadian Occupational Performance Measure (COPM).
Des ANCOVA ont évalué les différences d’amélioration entre les groupes, mettant en évidence des différences hautement significatives dans les mesures principales et secondaires comparant T0 - T2 et T0 - T1, avec des changements beaucoup plus importants dans le groupe traitement.
HABIT-ILE est efficace chez les jeunes enfants atteints de PC unilatérale, induisant des améliorations importantes des capacités manuelles, de la motricité globale et des activités de la vie quotidienne.
Safety of outpatient treatment in acute pulmonary embolism ERKENS, P. M. G.; GANDARA, E.; WELLS, P. ...
Journal of thrombosis and haemostasis,
November 2010, 2010-Nov, 2010-11-00, 20101101, 2010-11, Letnik:
8, Številka:
11
Journal Article
Recenzirano
Odprti dostop
See also Baglin T. Fifty per cent of patients with pulmonary embolism can be treated as outpatients. This issue, pp 2404–5; Kovacs MJ, Hawel JD, Rekman JF, Lazo‐Langner A. Ambulatory management of ...pulmonary embolism: a pragmatic evaluation. This issue, pp 2406–11.
Summary. Introduction: Data regarding outpatient treatment of pulmonary embolism (PE) is scarce. This study evaluates the safety of outpatient management of acute PE. Methods: This is a retrospective cohort study of consecutive patients presenting at the Ottawa Hospital with acute PE diagnosed between 1 January 2007 and 31 December 2008. PE was defined as an arterial filling defect on CTPA or a high probability V/Q scan. Patients were managed as outpatients if they were hemodynamically stable, did not require supplemental oxygenation and did not have contraindications to low‐molecular‐weight heparin therapy. Results: In this cohort of 473 patients with acute PE, 260 (55.0%) were treated as outpatients and 213 (45.0%) were admitted to the hospital. The majority of the patients were admitted because of severe comorbidities (45.5%) or hypoxia (22.1%). No outpatient died of fatal PE during the 3‐month follow‐up period. At the end of follow‐up, the overall mortality was 5.0% (95% CI, 2.7–8.4%). The rates of recurrent venous thromboembolism (VTE) in outpatients were 0.4% (95% CI, 0.0–2.1%) and 3.8% (95% CI, 1.9–7.0%) within 14 days and 3 months, respectively. The rates of major bleeding episodes were 0% (95% CI, 0–1.4%) and 1.5% (95% CI, 0.4–3.9%) within 14 days and 3 months, respectively. Four (1.5%) outpatients were admitted to the hospital within 14 days. Conclusions: A majority of patients with acute PE can be managed as outpatients with a low risk of mortality, recurrent VTE and major bleeding episodes.
PDF
