Chapter 111. Venous Thrombosis (Part 6)

Table 111-3 Long-Term Treatment with Vitamin K Antagonists for Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE)Patient CategoriesDuration, monthsCommentsFirst episode of DVT or PE secondary to a transient (reversible) risk factor3Recommendation applies to both proximal and calf vein thrombosisFirstepisodeof6–12Continuationofidiopathic DVT or PEanticoagulant therapy after 6–12 months may be consideredFirst episode of DVT6–12Continuationofor PE with a documented thrombophilic abnormalityanticoagulant therapy after 6–12 months may be consideredFirst episode of DVT or PE with documented12Continuationofanticoagulant therapy after 12 months may be consideredantiphospholipid or two or more abnormalities thrombophilicThe preferred intensity of VKA treatment for DVT is an INR between 2 and 3....
Nội dung trích xuất từ tài liệu:
Chapter 111. Venous Thrombosis (Part 6) Chapter 111. Venous Thrombosis (Part 6) Table 111-3 Long-Term Treatment with Vitamin K Antagonists forDeep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) Patient Categories Duration, Comments months First episode of DVT 3 Recommendation appliesor PE secondary to a transient to both proximal and calf vein(reversible) risk factor thrombosis First episode of 6–12 Continuation ofidiopathic DVT or PE anticoagulant therapy after 6–12 months may be considered First episode of DVT 6–12 Continuation ofor PE with a documented anticoagulant therapy after 6–12thrombophilic abnormality months may be considered First episode of DVT 12 Continuation ofor PE with documented anticoagulant therapy after 12antiphospholipid or two or months may be consideredmore thrombophilicabnormalities The preferred intensity of VKA treatment for DVT is an INR between 2and 3. Higher intensities are not more effective, whereas lower intensities are lesseffective with a similar bleeding risk. Although VKAs are generally used for long-term treatment, LMWH is preferred in patients with DVT and concomitant cancer.This treatment is associated with a lower risk of recurrent thrombosis than VKAand a similar risk of bleeding. The role of thrombolytic therapy as well as surgical removal of thethrombus in the initial treatment of DVT is controversial; the currentrecommendations are to refrain from their use with the single exception of patientswith massive, recent ileofemoral DVT at risk of limb gangrene. Patients with DVT are at risk of developing the postthrombotic syndromein the first years after the initial episode. This syndrome can range from mild, withsome swelling and pain at the end of the day, to severe, with massive swelling andskin ulceration. Graduated elastic compression stockings to the knee with an anklepressure of 30–40 mmHg fitted in the first weeks after the initial thrombosis andworn for 2 years reduce the risk of the postthrombotic syndrome by ~50%. As a result of the introduction of LMWH for the initial treatment of DVT,most patients with DVT can be treated at home either entirely or after a shorthospital stay. The LMWH can be self-injected or given by family members orvisiting nurses. Pulmonary Embolism The initial treatment with LMWH followed by a VKA for patients with PEis identical to that for patients with DVT. The intensity and duration of VKAtreatment is also no different (Table 111-3). An alternative for LMWH isunfractionated heparin, which is still often used. The main disadvantage ofunfractionated heparin is the need for continuous IV infusion and the requirementof frequent laboratory monitoring and dose adjustments. In contrast, LMWH canbe given in fixed doses adjusted only for body weight. Another alternative for theinitial LMWH therapy is fondaparinux, which can be given as a 2.5-mg once-a-day SC injection, without laboratory monitoring. The treatment with LWMH or fondaparinux followed by VKA is indicatedfor PE patients who are hemodynamically stable—the great majority of patients.However, for those patients with PE who are hemodynamically unstable (usuallydefined as a systolic blood pressure be considered only for patients with a contraindication for anticoagulant therapy,as well as in those with recurrent PE despite adequate treatment. Further Readings Colman RW et al (eds): Hemostasis and Thrombosis: Basic Principles andClinical Practice, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006 Prandoni P: Links between arterial and venous disease. J Intern Med262:341, 2007 [PMID: 17697155] Rosendaal FR: Venous thrombosis, a multicausal disease. Lancet 353:1167,1999 [PMID: 10209995] The Seventh ACCP Conference on Antithrombotic and ThrombolyticTherapy. Chest 126(3 Suppl):167S, 2004