Venous thromboembolism: VTE

  1. Gastroepato
  2. Cardiology
  3. Deep vein thrombosis and studies
  4. Treatment of varicose veins
  5. Periphereal arterial disease
  6. Arteriopathy obliterant chronic obstructive
  7. Chronic obstructive arterial disease of the lower limbs
  8. Deep vein thrombosis
  9. Oral anticoagulant therapy
  10. The varices of the legs

notes by  dr Claudio Italiano 

 

vedi anche la profilassi della trombosi

 

Venous thromboembolism, ie the formation of thrombi, and therefore of blood coagulated within the veins, is a serious public health problem because it can cause hospital mortality between 5 and 10%, due to the risk of pulmonary embolism, that is they detach and become emboli that reach the pulmonary circle, causing a stop in a more or less important vessel of the lung. The prevalence of VTE is high in patients at risk, ie in:

Patients with prostate cancer
patients with AIDS
patients with breast cancer
patients with traffic accidents
enticed patients

For all these reasons a Congress of the International Society on Thrombosis and Haemostasis was held in Geneva in July 2007, reaching the following conclusions:

VTE is a global health problem
Prophylaxis can be implemented, ie to prevent the risk of embolism with adequate antithrombotic treatment, with low molecular weight heparins, in particular enoxaparin.

The Endorse study

The endorse study (epidemiologic) is a multinational, transversal (prevalence) observational study for the assessment of VTE risk in hospitalized patients and for the study of a adequate prophylaxis for venous thromboembolism among patients admitted to hospital, according to the ACCP guidelines, based on evidence. The ENDORSE study was conducted in 32 different countries and in 358 hospitals on approximately 68 thousand patients. With the help of the 2004 American College of Chest Physicians guidelines, the risk of venous thromboembolism of patients who participated in the study was calculated; the percentage of patients who actually underwent prophylaxis was also calculated. Of the patients admitted to the general and surgical wards, half are at risk of venous thromboembolism, but only one in two patients is prophylaxis to prevent the formation of thrombi. This is what emerged from the ENDORSE study, whose complete data have been published in the journal The Lancet. The numbers are significant:
64 percent of the patients in the surgical departments are at risk of venous thromboembolism and 46 percent of the patients in the internal medicine departments The results of the ENDORSE study clearly demonstrate that there should be greater awareness of the high prevalence of both surgical and doctors at risk of thromboembolism. Prolongation of prophylaxis with enoxaparin significantly reduces the risk of venous thromboembolism not only in surgical patients but also in those enticed with medical pathology.


This is demonstrated by the data collected by the EXCLAIM Study and presented at the Congress of the International Society of Thrombosis and Hemostasis underway in Geneva. "EXCLAIM is the first international study to have demonstrated the benefits of continuing with up to 30 days therapy with low molecular heparin in medical patients who have been immobilized following an admission," said Victor Tapson, director of the Center for Pulmonary Vascular Disease of Duke University and coordinator of the EXCLAIM study. "The evidence collected so far had shown the importance of ten-day prophylaxis in preventing venous thrombosis in this patient population for whom the risk of venous thromboembolism persists even after discontinuation of therapy, but no studies had investigated efficacy and safety. to extend the therapy for four weeks ".

The study involved 370 hospital centers in 20 different countries, including Italy, and enrolled more than 5,000 medical patients with reduced mobility for more than three days following hospital admission. All patients underwent standard therapy with subcutaneous enoxaparin sodium 40 mg for ten days, which was maintained for 28 days or replaced with placebo. Three months later, a 44 percent reduction in the relative risk of venous thromboembolism was observed in patients who had benefited from an extension of therapy. In particular, a 73 percent reduction in symptomatic events of deep vein thrombosis and 34 percent of asymptomatic ones was recorded. The risk of bleeding was greater in these patients, however the events were rare and there was no difference in mortality from all causes after six months. At the international congress, the authors emphasized that EXCLAIM adds new evidence on the importance of the extension of enoxaparin sodium administration not only in surgical patients, but also in those with reduced mobility following hospitalization for heart failure, respiratory failure , inflammatory or oncological disease. "Prophylaxis in deep vein thrombosis should not only affect the hospital doctor but also the general practitioner, who is responsible for the management of his patient in the delicate post-hospital period". Prophylaxis of venous thromboembolism with low molecular weight heparin or unfractionated heparin is recommended in acute ischemic stroke, but there is uncertainty about the regimen being able to provide optimal treatment. The PREVAIL study (Efficacy and Safety of Enoxaparin Versus Infractionated Heparin for the Prevention of Venous Thromboembolism After Acute Ischaemic Stroke) compared the efficacy and safety of Enoxaparin (Clexane, Lovenox) with that of unfractionated heparin in patients with stroke. The study involved 1762 patients with acute ischemic stroke. These patients were randomly assigned within 48 hours of the onset of symptoms to receive Enoxaparin 40 mg subcutaneously 1 time / day or 5000 IU unparased subcutaneous Heparin every 12 hours for 10 days (range 6-14) . Patients were stratified by the NIHSS score (severe stroke: greater than or equal to 14, less severe stroke: less than 14). The primary efficacy composite endpoint included symptomatic or asymptomatic deep vein thrombosis, symptomatic pulmonary embolism or fatal pulmonary embolism. Primary safety endpoints were: symptomatic intracranial haemorrhage, major extracranial hemorrhage, and all-cause mortality. Enoxaparin (n = 666) and fractionated heparin (n = 669) were administered on average for 10.5 days. Enoxaparin reduced the risk of venous thromboembolism by 43% versus 8% of unfractionated heparin. The combined frequency of major extracranial hemorrhage and symptomatic intracranial hemorrhage was small and similar between the two groups (Enoxaparin 1% versus 1% unfractionated heparin). No difference was observed regarding symptomatic intracranial hemorrhage between groups (1% versus 1%, respectively).

 The rate of major extracranial haemorrhage was higher in the Enoxaparin group than in the unfractionated Heparin group (1% versus 0%, p = 0.015). The results indicated that for patients with acute ischemic stroke, Enoxaparin is preferable to unfractionated Heparin for venous thromboembolism prophylaxis. (Xagena2007). Deep vein thrombosis prophylaxis of the patient of medical relevance: fondaparinux sodium, which is not a low molecular weight heparin, but a new molecule, a synthetic pentasaccharide that inhibits, binding to the antithrombin, the factor FXA (activated factor decino), is indicated at the dosage of 2.5 mg per day; for patients with renal impairment (where low molecular weight heparin should be monitored carefully) the dosage of fondaparinux is 1.5 mg / day (patients with a clearance between 20 and 50 ml / min). One of the main advantages of fondaparinux vs low molecular weight heparin is that it does not cause piastinopenia, because it does not bind to platelets and therefore the doctor is not obliged from a medico-legal point of view to dose the platelets. Furthermore, fondaparinux is indicated for the treatment of hemodynamically stable pulmonary embolism and of deep vein thrombosis at a dose of 7.5 mg subcutaneously once a day in patients weighing between 50 and 100 kg. In acute coronary syndrome, non-STEMI patients, see links on this site, and in the treatment of patients with unstable angina, fondaparinux reduced, compared to enoxaparin, mortality by 17% and reduced bleeding by more than 48% (OASIS-5 study , New England Journal of Medicine.The dosage used here is 2.5 mg / day.This study did change the ESC guidelines (European Society of Cardiology), recommendation grade 1A.


DOSAGE OF ENOXAPHARINE IN TROMBOEMBOLIC PROPHYLAXIS


In orthopedics: 4,000 U.I. aXa per day
In minor surgery: 2000
In major surgery: 4000
Internal medicine: 4000
hemodialysis: 100 / kg at the beginning of the session
DVT with or without pulmonary embolism: 100 U.I. aXa / kg every 12 hours
Unstable angina or IMA not Q: 100 U.I. aXa / kg every 12 hours


SCORE RISK
OBESE PATIENT: 1
HORMONE THERAPY: 1
MAJOR SURGERY: 2
NEOPLASTIC: 3
TEV PREGRITY: 3
HYPERCOAGULABILITY: 3
FOR VALUES> 3 HIGH RISK PATIENTS
of cardiology

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