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DOI: 10.1055/s-0032-1311797
Medical Therapy in Venous Thromboembolism
Publikationsverlauf
Publikationsdatum:
30. Mai 2012 (online)
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Abstract
Immediate intense anticoagulation with parenteral anticoagulants (heparin or fondaparinux) followed by vitamin K antagonists is the current standard therapy for deep vein thrombosis (DVT) or nonmassive pulmonary embolism. In the future, new oral anticoagulants may replace not only vitamin K antagonists but also initial parenteral anticoagulation. Duration of anticoagulation should be at least 3 months because shorter courses double the recurrence rates. More prolonged anticoagulation therapy may be warranted in the presence of specific clinical risk factors. Global markers of coagulation, particularly D-dimer, may discriminate low- and high-risk patients. Models that combine clinical characteristics and laboratory markers further improve prediction of the recurrence risk in individual patients, but these models await validation before they can be applied in routine care.
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References
- 1 Imberti D, Maraldi C, Gallerani M. Interventional approaches in VTE treatment (vena cava filters, catheter-guided thrombolysis, thrombosuction). Semin Respir Crit Care Med 2012; 33 (2) 176-185
- 2 Bauersachs R, Berkowitz SD, Brenner B , et al; EINSTEIN Investigators. Oral rivaroxaban for symptomatic venous thromboembolism. N Engl J Med 2010; 363 (26) 2499-2510
- 3 Kearon C, Kahn SR, Agnelli G, Goldhaber S, Raskob GE, Comerota AJ. ; American College of Chest Physicians. Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th edition). Chest 2008; 133 (6, Suppl) 454S-545S
- 4 Schulman S, Kearon C, Kakkar AK , et al; RE-COVER Study Group. Dabigatran versus warfarin in the treatment of acute venous thromboembolism. N Engl J Med 2009; 361 (24) 2342-2352
- 5 Erkens PM, Prins MH. Fixed dose subcutaneous low molecular weight heparins versus adjusted dose unfractionated heparin for venous thromboembolism. Cochrane Database Syst Rev 2010; 8 (9) CD001100
- 6 Martel N, Lee J, Wells PS. Risk for heparin-induced thrombocytopenia with unfractionated and low-molecular-weight heparin thromboprophylaxis: a meta-analysis. Blood 2005; 106 (8) 2710-2715
- 7 Monreal M, Lafoz E, Olive A, del Rio L, Vedia C. Comparison of subcutaneous unfractionated heparin with a low molecular weight heparin (Fragmin) in patients with venous thromboembolism and contraindications to coumarin. Thromb Haemost 1994; 71 (1) 7-11
- 8 Boccalon H, Elias A, Chalé JJ, Cadène A, Gabriel S. Clinical outcome and cost of hospital vs home treatment of proximal deep vein thrombosis with a low-molecular-weight heparin: the Vascular Midi-Pyrenees study. Arch Intern Med 2000; 160 (12) 1769-1773
- 9 Squizzato A, Galli M, Dentali F, Ageno W. Outpatient treatment and early discharge of symptomatic pulmonary embolism: a systematic review. Eur Respir J 2009; 33 (5) 1148-1155
- 10 Aujesky D, Roy PM, Verschuren F , et al. Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, non-inferiority trial. Lancet 2011; 378 (9785) 41-48
- 11 Büller HR, Davidson BL, Decousus H , et al; Matisse Investigators. Fondaparinux or enoxaparin for the initial treatment of symptomatic deep venous thrombosis: a randomized trial. Ann Intern Med 2004; 140 (11) 867-873
- 12 Büller HR, Davidson BL, Decousus H , et al; Matisse Investigators. Subcutaneous fondaparinux versus intravenous unfractionated heparin in the initial treatment of pulmonary embolism. N Engl J Med 2003; 349 (18) 1695-1702
- 13 Prandoni P, Lensing AW, Piccioli A , et al. Recurrent venous thromboembolism and bleeding complications during anticoagulant treatment in patients with cancer and venous thrombosis. Blood 2002; 100 (10) 3484-3488
- 14 Lee AY, Levine MN, Baker RI , et al; Randomized Comparison of Low-Molecular-Weight Heparin versus Oral Anticoagulant Therapy for the Prevention of Recurrent Venous Thromboembolism in Patients with Cancer (CLOT) Investigators. Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in patients with cancer. N Engl J Med 2003; 349 (2) 146-153
- 15 Arya R. How I manage venous thromboembolism in pregnancy. Br J Haematol 2011; 153 (6) 698-708
- 16 Kearon C, Ginsberg JS, Anderson DR , et al; SOFAST Investigators. Comparison of 1. month with 3 months of anticoagulation for a first episode of venous thromboembolism associated with a transient risk factor. J Thromb Haemost 2004; 2 (5) 743-749
- 17 Carrier M, Le Gal G, Wells PS, Rodger MA. Systematic review: case-fatality rates of recurrent venous thromboembolism and major bleeding events among patients treated for venous thromboembolism. Ann Intern Med 2010; 152 (9) 578-589
- 18 Iorio A, Guercini F, Pini M. Low-molecular-weight heparin for the long-term treatment of symptomatic venous thromboembolism: meta-analysis of the randomized comparisons with oral anticoagulants. J Thromb Haemost 2003; 1 (9) 1906-1913
- 19 van der Heijden JF, Hutten BA, Büller HR, Prins MH. Vitamin K antagonists or low-molecular-weight heparin for the long term treatment of symptomatic venous thromboembolism. Cochrane Database Syst Rev 2002; (1) CD002001
- 20 Agnelli G, Prandoni P, Becattini C , et al; Warfarin Optimal Duration Italian Trial Investigators. Extended oral anticoagulant therapy after a first episode of pulmonary embolism. Ann Intern Med 2003; 139 (1) 19-25
- 21 Agnelli G, Prandoni P, Santamaria MG , et al; Warfarin Optimal Duration Italian Trial Investigators. Three months versus one year of oral anticoagulant therapy for idiopathic deep venous thrombosis. N Engl J Med 2001; 345 (3) 165-169
- 22 Campbell IA, Bentley DP, Prescott RJ, Routledge PA, Shetty HG, Williamson IJ. Anticoagulation for three versus six months in patients with deep vein thrombosis or pulmonary embolism, or both: randomised trial. BMJ 2007; 334 (7595) 674-680
- 23 Schulman S, Rhedin AS, Lindmarker P , et al; Duration of Anticoagulation Trial Study Group. A comparison of six weeks with six months of oral anticoagulant therapy after a first episode of venous thromboembolism. N Engl J Med 1995; 332 (25) 1661-1665
- 24 Kearon C, Gent M, Hirsh J , et al. A comparison of three months of anticoagulation with extended anticoagulation for a first episode of idiopathic venous thromboembolism. N Engl J Med 1999; 340 (12) 901-907
- 25 Pinede L, Ninet J, Duhaut P , et al; Investigators of the “Durée Optimale du Traitement AntiVitamines K” (DOTAVK) Study. Comparison of 3 and 6 months of oral anticoagulant therapy after a first episode of proximal deep vein thrombosis or pulmonary embolism and comparison of 6 and 12 weeks of therapy after isolated calf deep vein thrombosis. Circulation 2001; 103 (20) 2453-2460
- 26 Ridker PM, Goldhaber SZ, Danielson E , et al; PREVENT Investigators. Long-term, low-intensity warfarin therapy for the prevention of recurrent venous thromboembolism. N Engl J Med 2003; 348 (15) 1425-1434
- 27 Schulman S, Granqvist S, Holmström M , et al; The Duration of Anticoagulation Trial Study Group. The duration of oral anticoagulant therapy after a second episode of venous thromboembolism. N Engl J Med 1997; 336 (6) 393-398
- 28 Boutitie F, Pinede L, Schulman S , et al. Influence of preceding length of anticoagulant treatment and initial presentation of venous thromboembolism on risk of recurrence after stopping treatment: analysis of individual participants' data from seven trials. BMJ 2011; 342: d3036
- 29 Fanikos J, Grasso-Correnti N, Shah R, Kucher N, Goldhaber SZ. Major bleeding complications in a specialized anticoagulation service. Am J Cardiol 2005; 96 (4) 595-598
- 30 Linkins LA, Choi PT, Douketis JD. Clinical impact of bleeding in patients taking oral anticoagulant therapy for venous thromboembolism: a meta-analysis. Ann Intern Med 2003; 139 (11) 893-900
- 31 Baglin T, Luddington R, Brown K, Baglin C. Incidence of recurrent venous thromboembolism in relation to clinical and thrombophilic risk factors: prospective cohort study. Lancet 2003; 362 (9383) 523-526
- 32 Rodger MA, Kahn SR, Wells PS , et al. Identifying unprovoked thromboembolism patients at low risk for recurrence who can discontinue anticoagulant therapy. CMAJ 2008; 179 (5) 417-426
- 33 Christiansen SC, Cannegieter SC, Koster T, Vandenbroucke JP, Rosendaal FR. Thrombophilia, clinical factors, and recurrent venous thrombotic events. JAMA 2005; 293 (19) 2352-2361
- 34 Le Gal G, Kovacs MJ, Carrier M , et al. Risk of recurrent venous thromboembolism after a first oestrogen-associated episode. Data from the REVERSE cohort study. Thromb Haemost 2010; 104 (3) 498-503
- 35 Kyrle PA, Rosendaal FR, Eichinger S. Risk assessment for recurrent venous thrombosis. Lancet 2010; 376 (9757) 2032-2039
- 36 Siragusa S, Malato A, Anastasio R , et al. Residual vein thrombosis to establish duration of anticoagulation after a first episode of deep vein thrombosis: the Duration of Anticoagulation based on Compression UltraSonography (DACUS) study. Blood 2008; 112 (3) 511-515
- 37 Prandoni P, Prins MH, Lensing AW , et al; AESOPUS Investigators. Residual thrombosis on ultrasonography to guide the duration of anticoagulation in patients with deep venous thrombosis: a randomized trial. Ann Intern Med 2009; 150 (9) 577-585
- 38 Carrier M, Rodger MA, Wells PS, Righini M, LE Gal G. Residual vein obstruction to predict the risk of recurrent venous thromboembolism in patients with deep vein thrombosis: a systematic review and meta-analysis. J Thromb Haemost 2011; 9 (6) 1119-1125
- 39 Hron G, Eichinger S, Weltermann A, Quehenberger P, Halbmayer WM, Kyrle PA. Prediction of recurrent venous thromboembolism by the activated partial thromboplastin time. J Thromb Haemost 2006; 4 (4) 752-756
- 40 Eichinger S, Hron G, Hirschl M , et al. Prediction of recurrent venous thromboembolism by measuring ProC Global. Thromb Haemost 2007; 98 (6) 1232-1236
- 41 Hron G, Kollars M, Binder BR, Eichinger S, Kyrle PA. Identification of patients at low risk for recurrent venous thromboembolism by measuring thrombin generation. JAMA 2006; 296 (4) 397-402
- 42 Eichinger S, Hron G, Kollars M, Kyrle PA. Prediction of recurrent venous thromboembolism by endogenous thrombin potential and D-dimer. Clin Chem 2008; 54 (12) 2042-2048
- 43 Tripodi A, Legnani C, Chantarangkul V, Cosmi B, Palareti G, Mannucci PM. High thrombin generation measured in the presence of thrombomodulin is associated with an increased risk of recurrent venous thromboembolism. J Thromb Haemost 2008; 6 (8) 1327-1333
- 44 Besser M, Baglin C, Luddington R, van Hylckama Vlieg A, Baglin T. High rate of unprovoked recurrent venous thrombosis is associated with high thrombin-generating potential in a prospective cohort study. J Thromb Haemost 2008; 6 (10) 1720-1725
- 45 Palareti G, Legnani C, Cosmi B , et al. Predictive value of D-dimer test for recurrent venous thromboembolism after anticoagulation withdrawal in subjects with a previous idiopathic event and in carriers of congenital thrombophilia. Circulation 2003; 108 (3) 313-318
- 46 Eichinger S, Minar E, Bialonczyk C , et al. D-dimer levels and risk of recurrent venous thromboembolism. JAMA 2003; 290 (8) 1071-1074
- 47 Verhovsek M, Douketis JD, Yi Q , et al. Systematic review: D-dimer to predict recurrent disease after stopping anticoagulant therapy for unprovoked venous thromboembolism. Ann Intern Med 2008; 149 (7) 481-490 , W94
- 48 Bruinstroop E, Klok FA, Van De Ree MA, Oosterwijk FL, Huisman MV. Elevated D-dimer levels predict recurrence in patients with idiopathic venous thromboembolism: a meta-analysis. J Thromb Haemost 2009; 7 (4) 611-618
- 49 Douketis J, Tosetto A, Marcucci M , et al. Patient-level meta-analysis: effect of measurement timing, threshold, and patient age on ability of D-dimer testing to assess recurrence risk after unprovoked venous thromboembolism. Ann Intern Med 2010; 153 (8) 523-531
- 50 Palareti G, Cosmi B, Legnani C , et al; PROLONG Investigators. D-dimer testing to determine the duration of anticoagulation therapy. N Engl J Med 2006; 355 (17) 1780-1789
- 51 Cosmi B, Legnani C, Tosetto A , et al; PROLONG Investigators (on behalf of Italian Federation of Anticoagulation Clinics). Usefulness of repeated D-dimer testing after stopping anticoagulation for a first episode of unprovoked venous thromboembolism: the PROLONG II prospective study. Blood 2010; 115 (3) 481-488
- 52 Eichinger S, Heinze G, Jandeck LM, Kyrle PA. Risk assessment of recurrence in patients with unprovoked deep vein thrombosis or pulmonary embolism: the Vienna prediction model. Circulation 2010; 121 (14) 1630-1636