Embolism and thrombosis: Difference between revisions

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==Treatment==
==Treatment==
{{main|anticoagulant}}
 
Embolism and thrombosis may be prevented by [[anticoagulation]] with [[anticoagulant]]s.
Embolism and thrombosis may be prevented by [[anticoagulation]] with [[anticoagulant]]s.
===Duration of treatment===
{| class="wikitable"
|+ Randomized controlled trials since 1995 of the duration of anticoagulation
! &nbsp; !! Patients !! Duration of<br>short course !! Duration of<br>long course !! findings
|-
| Campbell, 2007<ref name="pmid17289685">{{cite journal |author=Campbell IA, Bentley DP, Prescott RJ, Routledge PA, Shetty HG, Williamson IJ |title=Anticoagulation for three versus six months in patients with deep vein thrombosis or pulmonary embolism, or both: randomised trial |journal=BMJ |volume=334 |issue=7595 |pages=674 |year=2007 |month=March |pmid=17289685 |pmc=1839169 |doi=10.1136/bmj.39098.583356.55 |url=http://bmj.com/cgi/pmidlookup?view=long&pmid=17289685 |issn=}}</ref> || DVT or PE without prior episode within 3 years || 3 mos|| 6 mos|| Prolonged tended to do slightly better
|-
| Schulman, 2003<ref name="pmid14585939">{{cite journal |author=Schulman S, Wåhlander K, Lundström T, Clason SB, Eriksson H |title=Secondary prevention of venous thromboembolism with the oral direct thrombin inhibitor ximelagatran |journal=N. Engl. J. Med. |volume=349 |issue=18 |pages=1713–21 |year=2003 |month=October |pmid=14585939 |doi=10.1056/NEJMoa030104 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=14585939&promo=ONFLNS19 |issn=}}</ref> || DVT or PE. 13% had prior VTE. || 6 mos|| 24 mos|| Prolonged did better
|-
| Kearon, 2004<ref name="pmid15099280">{{cite journal |author=Kearon C, Ginsberg JS, Anderson DR, ''et al'' |title=Comparison of 1 month with 3 months of anticoagulation for a first episode of venous thromboembolism associated with a transient risk factor |journal=J. Thromb. Haemost. |volume=2 |issue=5 |pages=743–9 |year=2004 |month=May |pmid=15099280 |doi=10.1046/j.1538-7836.2004.00698.x |url=http://dx.doi.org/10.1046/j.1538-7836.2004.00698.x |issn=}}</ref> || First episode of VTE due to transient risk factor || 1 mo || 3 mos || Prolonged did better
|-
| Ridker, 2003<ref name="pmid12601075">{{cite journal |author=Ridker PM, Goldhaber SZ, Danielson E, ''et al'' |title=Long-term, low-intensity warfarin therapy for the prevention of recurrent venous thromboembolism |journal=N. Engl. J. Med. |volume=348 |issue=15 |pages=1425–34 |year=2003 |month=April |pmid=12601075 |doi=10.1056/NEJMoa035029 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=12601075&promo=ONFLNS19 |issn=}}</ref> || Idiopathic VTE. 30% had prior VTE || 6 mos || 2.1 yrs || Prolonged did better
|-
| Agnelli, 2001<ref name="pmid11463010">{{cite journal |author=Agnelli G, Prandoni P, Santamaria MG, ''et al'' |title=Three months versus one year of oral anticoagulant therapy for idiopathic deep venous thrombosis. Warfarin Optimal Duration Italian Trial Investigators |journal=N. Engl. J. Med. |volume=345 |issue=3 |pages=165–9 |year=2001 |month=July |pmid=11463010 |doi= |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=11463010&promo=ONFLNS19 |issn=}}</ref> || First episode of idiopathic DVT || 3 mos || 1 yr || Prolonged did better
|-
| Kearon, 1999<ref name="pmid10089183">{{cite journal |author=Kearon C, Gent M, Hirsh J, ''et al'' |title=A comparison of three months of anticoagulation with extended anticoagulation for a first episode of idiopathic venous thromboembolism |journal=N. Engl. J. Med. |volume=340 |issue=12 |pages=901–7 |year=1999 |month=March |pmid=10089183 |doi= |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=10089183&promo=ONFLNS19 |issn=}}</ref> || First episode of idiopathic VTE. || 3 mos || 2 yrs || Prolonged did better
|-
| Pinede, 2001<ref name="pmid11369685">{{cite journal |author=Pinede L, Ninet J, Duhaut P, ''et al'' |title=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 |journal=Circulation |volume=103 |issue=20 |pages=2453–60 |year=2001 |month=May |pmid=11369685 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=11369685 |issn=}}</ref> || DVT or PE without prior episode within 3 years || 6 wks for distal DVT;<br>3 mos for proximal or [[pulmonary embolism|PE]]|| 12 wks for distal DVT;<br>6 mos for proximal or [[pulmonary embolism|PE]]|| Prolonged tended to do slightly better
|-
| Levine, 1995<ref name="pmid8584992">{{cite journal |author=Levine MN, Hirsh J, Gent M, ''et al'' |title=Optimal duration of oral anticoagulant therapy: a randomized trial comparing four weeks with three months of warfarin in patients with proximal deep vein thrombosis |journal=Thromb. Haemost. |volume=74 |issue=2 |pages=606–11 |year=1995 |month=August |pmid=8584992 |doi= |url= |issn=}}</ref> || Acute DVT with normal normal impedance plethysmogram (IPG) after 4 weeks || 1 mo || 3 mos || Prolonged tended to do better
|}
[[Clinical practice guideline]]s by the [[American College of Chest Physicians]] address the duration of anticoagulation for [[deep venous thrombosis]] and [[pulmonary embolism]].<ref name="pmid18574272">{{cite journal |author=Kearon C, Kahn SR, Agnelli G, Goldhaber S, Raskob GE, Comerota AJ |title=Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) |journal=Chest |volume=133 |issue=6 Suppl |pages=454S–545S |year=2008 |month=June |pmid=18574272 |doi=10.1378/chest.08-0658 |url=http://www.chestjournal.org/cgi/pmidlookup?view=long&pmid=18574272 |issn=}}</ref> Although initial trials suggested lack of benefit from prolonged anticoaguation<ref name="pmid16091573">{{cite journal |author=Ost D, Tepper J, Mihara H, Lander O, Heinzer R, Fein A |title=Duration of anticoagulation following venous thromboembolism: a meta-analysis |journal=JAMA |volume=294 |issue=6 |pages=706–15 |year=2005 |month=August |pmid=16091573 |doi=10.1001/jama.294.6.706 |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=16091573 |issn=}}</ref>, trials since 1995 favor longer anticoagulation. In patients who have had ''recurrent DVTs'' (two or more), anticoagulation is generally "life-long."  The [[Cochrane Collaboration]] and others have meta-analyzed the risk and benefits of prolonged anti-coagulation.<ref name="pmid16437432">{{cite journal |author=Hutten BA, Prins MH |title=Duration of treatment with vitamin K antagonists in symptomatic venous thromboembolism |journal=Cochrane database of systematic reviews (Online) |volume= |issue=1 |pages=CD001367 |year=2006 |pmid=16437432 |doi=10.1002/14651858.CD001367.pub2}}</ref><ref name="pmid16091573"/>An abnormal [[D-dimer]] level at the end of treatment might signal the need for continued treatment among patients with a first unprovoked pulmonary embolus.<ref name="pmid17065639">{{cite journal |author=Palareti G, Cosmi B, Legnani C, ''et al'' |title=D-dimer testing to determine the duration of anticoagulation therapy |journal=N. Engl. J. Med. |volume=355 |issue=17 |pages=1780-9 |year=2006 |pmid=17065639 |doi=10.1056/NEJMoa054444}}</ref>
{| class="wikitable"
|+ Recommendations by the American College of Chest Physicians for the Duration of Therapy<ref name="pmid18574272">{{cite journal |author=Kearon C, Kahn SR, Agnelli G, Goldhaber S, Raskob GE, Comerota AJ |title=Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) |journal=Chest |volume=133 |issue=6 Suppl |pages=454S–545S |year=2008 |month=June |pmid=18574272 |doi=10.1378/chest.08-0658 |url=http://www.chestjournal.org/cgi/pmidlookup?view=long&pmid=18574272 |issn=}}</ref>
! Setting
! Recommended duration
|-
| Single DVT due to transient risk factor
| 3 months
|-
| Single unprovoked DVT
| at least 3 months (longer if favorable risks for anticoagulation
|-
| Second episode of unprovoked VTE
| long-term treatment
|-
| DVT in patients with cancer
|  LMWH for the first 3 to 6 months of long-term anticoagulant therapy
|}


==Prevention==
==Prevention==

Revision as of 07:40, 7 August 2008

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Embolism and thrombosis is "a collective term for pathological conditions which are caused by the formation of a blood clot (thrombus) in a blood vessel, or by blocking of a blood vessel with an embolus, undissolved materials in the blood stream."[1]

Classification

Treatment

Embolism and thrombosis may be prevented by anticoagulation with anticoagulants.

Duration of treatment

Randomized controlled trials since 1995 of the duration of anticoagulation
  Patients Duration of
short course		 Duration of
long course		 findings
Campbell, 2007[2] DVT or PE without prior episode within 3 years 3 mos 6 mos Prolonged tended to do slightly better
Schulman, 2003[3] DVT or PE. 13% had prior VTE. 6 mos 24 mos Prolonged did better
Kearon, 2004[4] First episode of VTE due to transient risk factor 1 mo 3 mos Prolonged did better
Ridker, 2003[5] Idiopathic VTE. 30% had prior VTE 6 mos 2.1 yrs Prolonged did better
Agnelli, 2001[6] First episode of idiopathic DVT 3 mos 1 yr Prolonged did better
Kearon, 1999[7] First episode of idiopathic VTE. 3 mos 2 yrs Prolonged did better
Pinede, 2001[8] DVT or PE without prior episode within 3 years 6 wks for distal DVT;
3 mos for proximal or PE		 12 wks for distal DVT;
6 mos for proximal or PE		 Prolonged tended to do slightly better
Levine, 1995[9] Acute DVT with normal normal impedance plethysmogram (IPG) after 4 weeks 1 mo 3 mos Prolonged tended to do better

Clinical practice guidelines by the American College of Chest Physicians address the duration of anticoagulation for deep venous thrombosis and pulmonary embolism.[10] Although initial trials suggested lack of benefit from prolonged anticoaguation[11], trials since 1995 favor longer anticoagulation. In patients who have had recurrent DVTs (two or more), anticoagulation is generally "life-long." The Cochrane Collaboration and others have meta-analyzed the risk and benefits of prolonged anti-coagulation.[12][11]An abnormal D-dimer level at the end of treatment might signal the need for continued treatment among patients with a first unprovoked pulmonary embolus.[13]

Recommendations by the American College of Chest Physicians for the Duration of Therapy[10]
Setting Recommended duration
Single DVT due to transient risk factor 3 months
Single unprovoked DVT at least 3 months (longer if favorable risks for anticoagulation
Second episode of unprovoked VTE long-term treatment
DVT in patients with cancer LMWH for the first 3 to 6 months of long-term anticoagulant therapy

Prevention

Among patients with cancer, anticoagulation does not help in the primary prevention of embolism and thrombosis.[14]

References

  1. ↑ Anonymous (2024), Embolism and thrombosis (English). Medical Subject Headings. U.S. National Library of Medicine.
  2. ↑ Campbell IA, Bentley DP, Prescott RJ, Routledge PA, Shetty HG, Williamson IJ (March 2007). "Anticoagulation for three versus six months in patients with deep vein thrombosis or pulmonary embolism, or both: randomised trial". BMJ 334 (7595): 674. DOI:10.1136/bmj.39098.583356.55. PMID 17289685. PMC 1839169. Research Blogging.
  3. ↑ Schulman S, Wåhlander K, Lundström T, Clason SB, Eriksson H (October 2003). "Secondary prevention of venous thromboembolism with the oral direct thrombin inhibitor ximelagatran". N. Engl. J. Med. 349 (18): 1713–21. DOI:10.1056/NEJMoa030104. PMID 14585939. Research Blogging.
  4. ↑ Kearon C, Ginsberg JS, Anderson DR, et al (May 2004). "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. 2 (5): 743–9. DOI:10.1046/j.1538-7836.2004.00698.x. PMID 15099280. Research Blogging.
  5. ↑ Ridker PM, Goldhaber SZ, Danielson E, et al (April 2003). "Long-term, low-intensity warfarin therapy for the prevention of recurrent venous thromboembolism". N. Engl. J. Med. 348 (15): 1425–34. DOI:10.1056/NEJMoa035029. PMID 12601075. Research Blogging.
  6. ↑ Agnelli G, Prandoni P, Santamaria MG, et al (July 2001). "Three months versus one year of oral anticoagulant therapy for idiopathic deep venous thrombosis. Warfarin Optimal Duration Italian Trial Investigators". N. Engl. J. Med. 345 (3): 165–9. PMID 11463010. [e]
  7. ↑ Kearon C, Gent M, Hirsh J, et al (March 1999). "A comparison of three months of anticoagulation with extended anticoagulation for a first episode of idiopathic venous thromboembolism". N. Engl. J. Med. 340 (12): 901–7. PMID 10089183. [e]
  8. ↑ Pinede L, Ninet J, Duhaut P, et al (May 2001). "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 103 (20): 2453–60. PMID 11369685. [e]
  9. ↑ Levine MN, Hirsh J, Gent M, et al (August 1995). "Optimal duration of oral anticoagulant therapy: a randomized trial comparing four weeks with three months of warfarin in patients with proximal deep vein thrombosis". Thromb. Haemost. 74 (2): 606–11. PMID 8584992. [e]
  10. ↑ 10.0 10.1 Kearon C, Kahn SR, Agnelli G, Goldhaber S, Raskob GE, Comerota AJ (June 2008). "Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)". Chest 133 (6 Suppl): 454S–545S. DOI:10.1378/chest.08-0658. PMID 18574272. Research Blogging.
  11. ↑ 11.0 11.1 Ost D, Tepper J, Mihara H, Lander O, Heinzer R, Fein A (August 2005). "Duration of anticoagulation following venous thromboembolism: a meta-analysis". JAMA 294 (6): 706–15. DOI:10.1001/jama.294.6.706. PMID 16091573. Research Blogging.
  12. ↑ Hutten BA, Prins MH (2006). "Duration of treatment with vitamin K antagonists in symptomatic venous thromboembolism". Cochrane database of systematic reviews (Online) (1): CD001367. DOI:10.1002/14651858.CD001367.pub2. PMID 16437432. Research Blogging.
  13. ↑ Palareti G, Cosmi B, Legnani C, et al (2006). "D-dimer testing to determine the duration of anticoagulation therapy". N. Engl. J. Med. 355 (17): 1780-9. DOI:10.1056/NEJMoa054444. PMID 17065639. Research Blogging.
  14. ↑ Wells PS (May 2008). "Review: evidence for the effectiveness of anticoagulation therapy or prophylaxis for VTE in cancer is limited". ACP J. Club 148 (3): 7. PMID 18489070. [e]
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