Long-Term Anticoagulant Therapy of Patients with Venous Thromboembolism. What Are the Practices?

Current guidelines of antithrombotic therapy suggest early initiation of vitamin K antagonists (VKA) in non-cancer patients with venous thromboembolism (VTE), and long-term therapy with low-molecular weight heparin (LMWH) for those with cancer. We used data from RIETE (international registry of patients with VTE) to report the use of long-term anticoagulant therapy over time and to identify predictors of anticoagulant choice (regarding international guidelines) in patients with- and without cancer. Among 35,280 patients without cancer, 82% received long-term VKA (but 17% started after the first week). Among 4,378 patients with cancer, 66% received long term LMWH as monotherapy. In patients without cancer, recent bleeding (odds ratio [OR] 2.70, 95% CI 2.26-3.23), age >70 years (OR 1.15, 95% CI 1.06-1.24), immobility (OR 2.06, 95% CI 1.93-2.19), renal insufficiency (OR 2.42, 95% CI 2.15-2.71) and anemia (OR 1.75, 95% CI 1.65-1.87) predicted poor adherence to guidelines. In those with cancer, anemia (OR 1.83, 95% CI 1.64-2.06), immobility (OR 1.51, 95% CI 1.30-1.76) and metastases (OR 3.22, 95% CI 2.87-3.61) predicted long-term LMWH therapy. In conclusion, we report practices of VTE therapy in real life and found that a significant proportion of patients did not receive the recommended treatment. The perceived increased risk for bleeding has an impact on anticoagulant treatment decision

Comparison of seven prognostic tools to identify low-risk pulmonary embolism in patients aged <50 years

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Influència dels filtres de vena cava inferior sobre la pràctica clínica en la malaltia tromboembòlica venosa

Introducció: Tot i que les guies de pràctica clínica recomanen l'ús d'un filtre de vena cava inferior (FVCI) en pacients amb un episodi agut de malaltia tromboembòlica venosa (MTEV) i contraindicacions per al tractament anticoagulant o un episodi de sagnat major durant els primers tres mesos de tractament anticoagulant, no existeixen assajos clínics ni estudis aleatoritzats que avaluïn l'eficàcia i seguretat dels filtres de vena cava inferior (FVCI) en les anomenades 'indicacions absolutes'. Objectius: Avaluar l'eficàcia d'un FVCI en pacients que desenvolupen un episodi de MTEV recurrent malgrat un correcte tractament anticoagulant i en pacients amb MTEV aguda que presenten un episodi de sagnat major durant el tractament anticoagulant. Material i mètodes: A partir de la cohort RIETE (Registro Informatizado de la Enfermedad Tromboembólica) s'ha realitzat un estudi de casos i controls on, mitjançant l'anàlisi per aparellament per propensity score, s'ha valorat l'associació entre 1) la inserció d'un FVCI per una MTEV recurrent i la mortalitat global, mortalitat per tromboembòlia pulmonar (TEP), nous episodis de MTEV i episodis de sagnat major a 30 dies després de l'episodi de recidiva, 2) la inserció d'un FVCI en pacients amb un episodi de sagnat major durant els primers tres mesos de tractament anticoagulant per MTEV i la mortalitat global, mortalitat per sagnat, nous episodis de sagnat o de MTEV. Resultats: Els pacients que van presentar un episodi recurrent de MTEV malgrat un correcte tractament anticoagulant es varen analitzar en funció del tipus de recidiva: trombosi venosa profunda (TVP) o TEP. Dels pacients que van recidivar en forma de TVP, 17 pacients portadors d'un FVCI van ser aparellats amb 49 pacients tractats sense FVCI; l'anàlisi per aparellament no va mostrar diferències pel que fa a mortalitat global entre pacients portadors de FVCI respecte no portadors de FVCI (17.7% vs 12.2%). Dels pacients que van recidivar en forma de TEP, 48 pacients tractats amb un FVCI van ser aparellats amb 91 pacients sense FVCI; l'anàlisi va mostrar una disminució significativa de la mortalitat global en els pacients portadors de FVCI (2.1% vs 25.3%; p=0.002) i una disminució no significativa de la mortalitat per TEP. Entre els pacients que van presentar un episodi de sagnat major durant els primers tres mesos de tractament anticoagulant i van ser tractats amb la inserció d'un FVCI, 122 pacients tractats amb la inserció d'un FVCI van ser aparellats amb 429 pacients sense FVCI; la inserció d'un FVCI es va associar a una disminució significativa de la mortalitat global (HR 0.49; IC 95% 0.31-0.77) i del sagnat fatal (HR 0.16; IC 95% 0.07-0.49), amb un risc similar de nous episodis de sagnat i de TEP recurrent. Conclusions: 1. L'ús d'un FVCI en pacients amb un episodi de TEP recurrent malgrat un correcte tractament anticoagulant s'associa a una disminució de la mortalitat global, sense observar-se aquest efecte en pacients que presenten una recidiva en forma de TVP. 2. En pacients que presenten un episodi de sagnat major durant els primers 3 mesos de tractament anticoagulant per MTEV, l'ús d'un FVCI s'associa a una disminució de la mortalitat global i de la mortalitat per sagnat.Introducción: Aunque las guías de práctica clínica recomiendan el uso de un filtro de vena cava inferior (FVCI) en pacientes con un episodio agudo de enfermedad tromboembólica venosa (ETEV) y contraindicaciones para el tratamiento anticoagulante o un episodio de sangrado mayor, no existen ensayos clínicos ni estudios randomizados que evalúen la eficacia y seguridad de los FVCI en las llamadas "indicaciones absolutas". Objetivos: Evaluar la eficacia de un FVCI en pacientes con un episodio recurrente de ETEV a pesar de un correcto tratamiento anticoagulante y en pacientes con ETEV aguda que presentan un episodio de sangrado mayor durante el tratamiento anticoagulante. Material y métodos: A partir de la cohorte RIETE (Registro Informatizado de la Enfermedad Tromboembólica) se ha realizado un estudio de casos y controles donde, mediante el análisis por propensity score matching, se ha evaluado la asociación entre 1) la inserción de un FVCI por ETEV recurrente y la mortalidad global, mortalidad por tromboembolismo pulmonar (TEP), nuevos episodios de ETEV y episodios de sangrado mayor a 30 días tras el episodio de recidiva y 2) la inserción de un FVCI en pacientes con un episodio de sangrado mayor durante los primeros tres meses de tratamiento anticoagulante por ETEV aguda y la mortalidad global, mortalidad por sangrado, nuevos episodios de sangrado o de ETEV. Resultados Los pacientes que presentaron un episodio de ETEV recurrente a pesar de un correcto tratamiento anticoagulante se analizaron en función del tipo de recidiva: trombosis venosa profunda (TVP) o TEP. De los pacientes que recidivaron en forma de TVP, 17 pacientes portadores de un FVCI se aparearon con 49 pacientes tratados sin FVC; el análisis por apareamiento no mostró diferencias en la mortalidad global entre los pacientes portadores de FVCI respecto a los no portadores de FVCI (17.7% vs 12.2%). De los pacientes que recidivaron en forma de TEP, 48 pacientes tratados con un FVCI se aparearon con 91 pacientes sin FVCI; el análisis mostró una disminución significativa de la mortalidad global en los pacientes portadores de un FVCI (2.1% vs 25.3%; p=0.002) y una disminución no significativa de la mortalidad por TEP. Entre los pacientes que presentaron un episodio de sangrado mayor durante los primeros tres meses de tratamiento anticoagulante y fueron tratados con la inserción de un FVCI, 122 pacientes tratados con la inserción de un FVCI fueron apareados con 429 pacientes sin FVCI; la inserción de un FVCI se asoció a una disminución significativa de la mortalidad global (HR 0.49; IC 95% 0.31-0.77) y del sangrado fatal (HR 0.16; IC 95% 0.07-0.49), con un riesgo similar de nuevos episodios de sangrado mayor y TEP recurrente. Conclusiones: 1. El uso de un FVCI en pacientes con TEP recurrente a pesar de un correcto tratamiento anticoagulante se asocia a una disminución de la mortalidad global, sin observarse este efecto en pacientes que presentan una recidiva en forma de TVP. 2. En pacientes que presentan un episodio de sangrado mayor durante los primeros tres meses de tratamiento anticoagulante por ETEV, el uso de un FVCI se asocia a una disminución de la mortalidad global y la mortalidad por sangrado.Introduction Even though guidelines recommend the use of inferior vena cava filters (IVCF) in patients with acute venous thromboembolism (VTE) and a contraindication for anticoagulant treatment or a recurrent VTE despite adequate anticoagulant treatment, there are no randomized trials or cohort studies testing the influence of an IVCF in such indications. Objectives To assess the influence of an IVCF insertion in VTE patients with 1) an episode of recurrent venous thromboembolism (VTE) despite adequate anticoagulant treatment, or 2) a major bleeding event during the first 3 months of anticoagulant treatment. Material and methods Among a cohort of VTE patients recruited in the RIETE (Registro Informatizado de la Enfermedad Tromboembólica), registry, we performed a case-control study (propensity score matching) to assess the association between IVCF insertion in patients with a recurrent VTE episode and all-cause mortality, fatal pulmonary embolism (PE), recurrent VTE and major bleeding. Additionally we analyzed the effect of an IVCF insertion on all-cause mortality, fatal bleeding, re-bleeding or recurrent VTE in patients who developed major bleeding during the first 3 months of anticoagulant therapy. Results: Patients with recurrent VTE were divided according to type of recurrence: deep venous thrombosis (DVT) or PE. Among patients with a recurrent DVT, 17 patients with an IVCF were matched with 49 patients without filter; the insertion of an IVCF did not reduce all-cause mortality rates (17.7% vs 12.2%). Among patients with a recurrent PE, 48 patients with an IVCF inserted were matched with 91 patients without filter; the insertion of an IVFC was associated with a significant decrease in all-cause mortality rate (2.1% vs 25.3%; p=0.002) and a non-significant lower rate of fatal PE (2.1% vs 17.6%). Among VTE patients with a major bleeding event during the first 3 months of anticoagulant treatment, 122 patients with an IVCF inserted were matched with 429 patients without filtre. The insertion of an IVCF was associated with a lower all-cause mortality (HR 0.49; 95% CI 0.31-0.77) and fatal bleeding (HR 0.16; 95% CI 0.07-0.49) risk, with a similar re-bleeding and recurrent PE rates. Conclusions: Among patients with a VTE recurrence during the first 3 months of anticoagulant therapy insertion of an IVCF was not associated with a survival benefit in patients with recurrent DVT, but reduced the risk of all-cause mortality in patients with recurrent PE. The insertion of an IVCF in patients with a major bleeding event during the first 3 months of anticoagulant therapy for a VTE was associated with a lower risk of all-cause mortality and fatal bleeding

Persistent cutaneous abdominal ulcerations secondary to diffuse dermal angiomatosis: an underestimated sign for severe atherosclerosis: A case report.

BACKGROUND: Diffuse dermal angiomatosis (DDA) is a rare, acquired, reactive vascular proliferation, clinically characterized by livedoid erythematous-violaceous plaques, which frequently evolve to ulceration and necrosis. Histopathologically, it is manifested by a diffuse proliferation of endothelial cells within the full thickness of the dermis. DDA has been mainly associated with severe peripheral atherosclerosis. METHODS: We report a 63-year-old woman who presented with multiple erythematous-violaceous plaques with central deep skin ulcers on thighs, lower abdomen, and perianal area, associated with intermittent claudication, low-grade fever, and weight loss. Initially, the clinical picture along with positive cultures for Klebsiella pneumoniae suggested a multifocal ecthyma gangrenosum; nevertheless, a skin biopsy showed a diffuse dermal proliferation of endothelial cells interstitially arranged between collagen bundles. A computed tomography scan revealed severe aortic atheromatosis with complete luminal occlusion of the infrarenal aorta and common iliac arteries. RESULTS: The diagnosis of DDA secondary to severe atherosclerosis was established. The patient underwent a left axillofemoral bypass surgery with a rapidly healing of the ulcers in the next weeks./nCONCLUSIONS: DDA should be considered in the differential diagnosis of livedoid ischemic lesions. Recognition of DDA as a cutaneous sign of severe peripheral vascular disease is important for both dermatologists and internists. Recognition of risk factors and their management with an early intervention to correct tissue ischemia can be curative

Long-Term Anticoagulant Therapy of Patients with Venous Thromboembolism. What Are the Practices?

Current guidelines of antithrombotic therapy suggest early initiation of vitamin K antagonists (VKA) in non-cancer patients with venous thromboembolism (VTE), and long-term therapy with low-molecular weight heparin (LMWH) for those with cancer. We used data from RIETE (international registry of patients with VTE) to report the use of long-term anticoagulant therapy over time and to identify predictors of anticoagulant choice (regarding international guidelines) in patients with- and without cancer. Among 35,280 patients without cancer, 82% received long-term VKA (but 17% started after the first week). Among 4,378 patients with cancer, 66% received long term LMWH as monotherapy. In patients without cancer, recent bleeding (odds ratio [OR] 2.70, 95% CI 2.26-3.23), age >70 years (OR 1.15, 95% CI 1.06-1.24), immobility (OR 2.06, 95% CI 1.93-2.19), renal insufficiency (OR 2.42, 95% CI 2.15-2.71) and anemia (OR 1.75, 95% CI 1.65-1.87) predicted poor adherence to guidelines. In those with cancer, anemia (OR 1.83, 95% CI 1.64-2.06), immobility (OR 1.51, 95% CI 1.30-1.76) and metastases (OR 3.22, 95% CI 2.87-3.61) predicted long-term LMWH therapy. In conclusion, we report practices of VTE therapy in real life and found that a significant proportion of patients did not receive the recommended treatment. The perceived increased risk for bleeding has an impact on anticoagulant treatment decision.This Registry is supported by unrestricted educational grants from Sanofi Spain and Bayer Pharma AG. The funding source had no role in the design, protocol development, or conduct of the study; data collection, management, or analysis; interpretation, preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication. The RIETE Registry was supported with an unrestricted educational grant from Sanofi Spain and Bayer Pharma AG. Bayer Pharma AG’s support was limited to the part of RIETE outside Spain, which accounts for a 20.05% of the total patients included in the RIETE Registry. The authors have nothing to disclose. The authors have declared that no competing interests exist

Long-term anticoagulant therapy of patients with venous thromboembolism. What are the practices?

Current guidelines of antithrombotic therapy suggest early initiation of vitamin K antagonists (VKA) in non-cancer patients with venous thromboembolism (VTE), and long-term therapy with low-molecular weight heparin (LMWH) for those with cancer. We used data from RIETE (international registry of patients with VTE) to report the use of long-term anticoagulant therapy over time and to identify predictors of anticoagulant choice (regarding international guidelines) in patients with- and without cancer. Among 35,280 patients without cancer, 82% received long-term VKA (but 17% started after the first week). Among 4,378 patients with cancer, 66% received long term LMWH as monotherapy. In patients without cancer, recent bleeding (odds ratio [OR] 2.70, 95% CI 2.26-3.23), age >70 years (OR 1.15, 95% CI 1.06-1.24), immobility (OR 2.06, 95% CI 1.93-2.19), renal insufficiency (OR 2.42, 95% CI 2.15-2.71) and anemia (OR 1.75, 95% CI 1.65-1.87) predicted poor adherence to guidelines. In those with cancer, anemia (OR 1.83, 95% CI 1.64-2.06), immobility (OR 1.51, 95% CI 1.30-1.76) and metastases (OR 3.22, 95% CI 2.87-3.61) predicted long-term LMWH therapy. In conclusion, we report practices of VTE therapy in real life and found that a significant proportion of patients did not receive the recommended treatment. The perceived increased risk for bleeding has an impact on anticoagulant treatment decision

Patients without cancer: Clinical characteristics according to long-term anticoagulant therapy.

<p><b><i>Abbreviations</i>:</b> VKA, vitamin K antagonists; LMWH, low-molecular-weight heparin; SD, standard deviation; CrCl, creatinine clearance; VTE, venous thromboembolism; DVT, deep vein thrombosis. Differences between patients starting VKA within the first week and the other groups</p><p>* p <0.05</p><p>^‡p <0.001.</p><p>Patients without cancer: Clinical characteristics according to long-term anticoagulant therapy.</p

Prescription of long-term therapy within the first 90 days in non-cancer patients.

<p>Prescription of long-term therapy within the first 90 days in non-cancer patients.</p

Prescription of long-term therapy within the first 90 days in patients with cancer.

<p>Prescription of long-term therapy within the first 90 days in patients with cancer.</p