Sex and anticoagulation in patients with idiopathic venous thromboembolism.
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Anticoagulants↗
Biomedical subjects
Paolo Prandoni
Publications and source records attributed to Paolo Prandoni.
Cancer and venous thromboembolism.
The evidence of the important two-way clinical correlation between cancer and venous thromboembolism (VTE) dates back to Trousseau's time. Over time it has been established that cancer patients not only exhibit a higher risk of developing VTE when compared with noncancer patients, but also that VTE, especially in its idiopathic presentation, sometimes acts as an epiphenomenon of a hidden cancer, offering possible chances for anticipated diagnosis of the pathology. Research has contributed greatly to the progression of this field through the identification of VTE risk factors in this setting, and through the assessment of the most adequate thromboprophylaxis and treatment modalities as well as secondary prophylaxis management. Anticoagulant drugs appear to be an attractive strategy in cancer treatment because there is growing evidence for their possible benefits in terms of cancer prognosis and patient survival.
Anticoagulants↗
Inherited thrombophilia and venous thromboembolism.
The term thrombophilia includes any inherited and acquired disorders associated with an increased tendency to venous thromboembolism (VTE). Inherited thrombophilia is one of the main determinants of VTE, and the presence of inherited thrombophilic defects exposed carriers to increased risks for VTE compared with noncarriers. There is no clear relationship between clinical manifestations and the type of underlying thrombophilic defect. Thus, the diagnosis of inherited thrombophilia has to be established on a laboratory basis. Carriers of thrombophilic defects may experience thrombosis at a younger age than noncarriers. However, a first thrombotic manifestation that occurs late in life may also be an expression of thrombophilia and this remains in many cases the only etiopathogenetic explanation for the event. Screening of family members of symptomatic probands has the potential to identify still asymptomatic carriers who may benefit from more appropriate thromboprophylaxis during high-risk situations for VTE. Women of fertile age who belong to these thrombophilic families might receive the greatest advantage from screening. Many inherited thrombophilic disorders can be considered risk factors for recurrent VTE, especially if more than one defect is present in the same patient. More intensive or prolonged duration of VTE treatment might be requested for the prevention of recurrent VTE in the most severe thrombophilic conditions. The availability of new methods for the assessment of thrombin generation in terms of endogenous thrombin potential are very promising tools for the identification of those carriers of inherited thrombophilia who will develop thrombosis or who will encounter recurrence of VTE.
Female↗
Upper extremity deep venous thrombosis.
About 10% of all episodes of venous thrombosis are due to upper extremity deep vein thrombosis (UEDVT). Associated risk factors are indwelling central venous catheters, cancer, and coagulation defects; 20% of the episodes are unexplained. The onset of UEDVT is usually heralded by complaints such as arm swelling and pain, but may also be completely asymptomatic, especially in carriers of central venous lines. Objective confirmation is mandatory prior to instituting anticoagulation because the clinical diagnosis is unreliable; ultrasound-based methods represent the preferred diagnostic approach. Prophylaxis with low-dose heparin or low-dose warfarin may be used, especially in carriers of central venous catheters, although its efficacy is still uncertain. Unfractionated or low molecular weight heparins followed by oral anticoagulants should be regarded as the treatment of choice, whereas thrombolysis and surgery may be indicated in selected cases. Up to one third of the patients develop pulmonary embolism that may be fatal; postthrombotic syndrome and recurrent thromboembolism are also frequent complications. UEDVT should no longer be regarded as a rare and benign disease, as reported previously.
Arm↗
Superficial vein thrombosis: risk factors, diagnosis, and treatment.
Superficial vein thrombosis (SVT) is a very common disease even though its incidence has never been assessed properly. Until recently, the literature on this topic has been relatively poor, old, and with numerous methodologic drawbacks, probably because this disease was considered benign and trivial. However, the recent recognition of a frequent association with concomitant venous thromboembolism (VTE) (deep vein thrombosis [DVT] and pulmonary embolism [PE]) and the risk of subsequent VTE complications in patients with isolated SVT has revived interest and has encouraged new clinical research. SVT and VTE share many common predisposing risk factors. Even if varicose veins represent the main cause of SVT, several underlying conditions (e.g., malignancy, thrombophilia, autoimmune diseases) should be sought, especially in idiopathic, migrant, or recurrent SVT of nonvaricose vein patients. The diagnosis is made in a clinical setting but ultrasonography is useful to identify concomitant asymptomatic DVT. Many medical and surgical treatments have been suggested to relieve local symptoms and signs, prevent recurrences, and limit the VTE risk of SVT, but the evidence coming from the limited number of prospective randomized studies does not allow strong recommendations on the optimal treatment of SVT.
Anticoagulants↗
Postthrombotic syndrome.
Despite considerable progress in the diagnosis and treatment of deep vein thrombosis (DVT) of the lower extremities, one of every three patients will develop postthrombotic sequelae within 2 years; these sequelae are severe in approximately 20% of cases and produce considerable socioeconomic consequences. Among factors potentially related to the development of the postthrombotic syndrome (PTS) are older age, obesity, insufficient oral anticoagulant therapy, and recurrent ipsilateral thrombosis. Whether the extent and location of the initial thrombosis are associated with the development of PTS is controversial. Based on recent findings, the lack of vein recanalization within the first 6 months appears to be an important predictor of PTS, whereas the development of transpopliteal venous reflux is not. The diagnosis of PTS can be made on clinical grounds for patients with a history of DVT. The combination of a standardized clinical evaluation with the results of compression ultrasonography and Doppler ultrasound helps diagnose or exclude a previous proximal vein thrombosis. According to the results of recent clinical studies, the prompt administration of adequate compression elastic stockings in patients with symptomatic DVT has the potential to reduce the frequency of late PTS development by half. The management of this condition is demanding and often frustrating. However, when carefully supervised and instructed to wear proper elastic stockings, more than 50% of patients will either remain stable or improve during long-term follow-up. Clinical presentation helps predict the prognosis; the outcome of patients who refer with initially severe manifestations is more favorable than that of patients whose symptoms deteriorate progressively over time.
Clinical Trials as Topic↗
New strategies for the treatment of acute venous thromboembolism.
In recent years, new opportunities have emerged that have the potential to change rapidly the therapeutic scenario of patients with acute venous thromboembolism (VTE). Selected patients with deep vein thrombosis (DVT) can be treated effectively and safely at home with fixed doses of low molecular weight heparins. The prompt administration of compression elastic stockings in addition to anticoagulant drugs in patients with acute DVT has the potential to halve the rate of late postthrombotic sequelae. The long-term use of low molecular weight heparins is likely to be more effective than oral anticoagulants for the secondary prevention of VTE in patients with advanced malignancy. Patients with pulmonary embolism and right ventricular dysfunction might benefit from the early administration of thrombolytic drugs in combination with heparin to a greater extent than from heparin alone. Despite an impressive amount of clinical information on the proper duration of oral anticoagulants in patients with unprovoked VTE, the optimal long-term treatment of these patients remains undefined. Finally, new categories of drugs are emerging that have the potential to replace conventional anticoagulants in the near future. They include compounds that inhibit factor Xa or thrombin.
Anticoagulants↗
The value of four-detector row spiral computed tomography for the diagnosis of pulmonary embolism.
Although spiral computed tomography (CT) is being used increasingly as the first-line imaging procedure in the diagnostic workup of patients with clinically suspected pulmonary embolism (PE), the diagnostic value of negative findings, at least when using the four-detector row scanners, is still controversial. A total of 702 consecutive patients with clinical symptoms suggestive of PE underwent four-slice CT. Patients with negative findings received the determination of D-dimer. Those with positive D-dimer underwent further diagnostic workup to confirm or rule out the diagnosis of PE. Those with negative D-dimer were followed-up to 6 months to detect the development of symptomatic venous thromboembolism (VTE). The CT test was interpreted as negative in 536 patients (76.3%). These patients had the D-dimer determination, which was positive in 279 and negative in the remaining 257 patients. Of the former, PE subsequently was documented in 55 patients (19.7%). Of the latter, symptomatic VTE in the follow-up period developed in three patients (1.17%; 95% confidence interval, 0.24 to 3.38%). In conclusion, when using the four-detector row, the negative predictive value of CT findings in patients with clinically suspected PE and positive D-dimer is low. In contrast, it is safe to withhold anticoagulation from patients with negative findings and negative D-dimer.
Adolescent↗
Anticoagulants and cancer survival.
The association between cancer and activation of blood coagulation has been described since Trousseau's time. The hypercoagulable state often encountered in cancer patients not only acts as an important risk factor for thrombosis, but also may play a role in tumor progression and metastasization. An antineoplastic effect of anticoagulants in this setting has often been hypothesized. The results of recently conducted clinical trials suggest that cancer patients could have a benefit from administration of low molecular weight heparin, particularly in those with nonadvanced disease. Additional clinical trials are needed to provide an important step forward in this challenging setting.
Anticoagulants↗
Thrombosis as a harbinger of cancer.
PURPOSE OF REVIEW: The aim of this review is to explore the state of the art knowledge on the possible association between venous thromboembolism, especially idiopathic venous thromboembolism, and occult cancer, and to speculate on its implications. RECENT FINDINGS: Venous thromboembolism, especially idiopathic venous thromboembolism, is sometimes associated with a subsequent increased risk of newly discovered cancers during the follow-up period. Its incidence approximates 10%. The performance of extensive screening procedures for cancer identification when venous thromboembolism is diagnosed appears advisable if it provides an impact on cancer-related mortality. Recent prospective trials have observed that, thanks to extensive screening procedures, most hidden cancers are detected at baseline or at an earlier stage. Data from these studies do not conclusively demonstrate that earlier diagnosis ultimately prolongs life, but the collective observation makes such a beneficial effect likely. SUMMARY: Venous thromboembolism, especially in its idiopathic presentation, may sometimes be a marker for a hidden cancer. With extensive screening procedures, the earlier discovery of cancer, which might mean identification of the disease at an attachable stage, may be crucial, because innovations in treatment protocols provide increasing chances of success and the eradication of cancer.
Humans↗
Cancer and venous thromboembolism. Clinical implications of strong association.
Venous thromboembolism is a common occurrence inpatients with cancer. Among risk factors for thromboembolism are prolonged immobilization, especially during hospital stay, surgery, and chemotherapy with or without adjuvant hormone therapy. Although prophylaxis and treatment of thromboembolism in cancer patients encompass those agents that are commonly utilised in patients free from malignancy, there are many unique issues in cancer patients that often make their use more problematic. Low-molecular weight heparins are the cornerstone of prophylaxis and treatment of venous thromboembolism in cancer patients. Furthermore, they have the potential to prolong patients survival, at least in those with more favourable prognosis. Approximately 10% of patients with idiopathic venous thromboembolism harbour an underlying malignancy that can be detected by an extensive diagnostic work-up. However, whether screening for occult malignancies ultimately improves prognosis and prolongs survival remains to be demonstrated.
Heparin, Low-Molecular-Weight↗
Acquired risk factors of venous thromboembolism in medical patients.
Acute venous thromboembolism (VTE) is a serious and potentially fatal disorder, which often complicates the course of hospitalized patients, but may also affect ambulatory and otherwise healthy people. While the introduction of thromboprophylactic measures has most likely affected the present occurrence of postoperative VTE, there is an increasing awareness of the importance of medical conditions in determining thromboembolic events. Among the conditions that predispose patients to VTE are increasing age, cancer and its treatment, prolonged immobility, stroke or paralysis, previous VTE, congestive heart failure,acute infection, pregnancy or puerperium, dehydration, hormonal treatment, varicose veins, long air travel, acute inflammatory bowel disease, rheumatologic disease, and nephrotic syndrome. Other factors that have recently been associated with an increased risk of VTE disorders include persistent elevation of D-dimer and atherosclerotic disease. Recognition of the incidence and clinical importance of thrombosis will most likely encourage more widespread use of antithrombotic prophylaxis in medical patients.
Atherosclerosis↗
Does hemophilia protect against atherosclerosis? A case-control study.
Whether carriers of hemophilia are protected against the development of atherosclerosis is controversial. In a case-control study, the presence of atherosclerosis was assessed and quantified with echo-color Doppler of all explorable arterial districts in 50 carriers of hemophilia and in 50 age-matched control individuals. All participants submitted to echo-color Doppler of carotid and femoral axis, of brachial arteries, and of the abdominal aorta. The presence and grade of atherosclerotic plaques were assessed, as well as the intima-media thickness (IMT). At least one atherosclerotic plaque was found in six cases (12.0%) versus 15 controls (30.0%); referring to the total number of plaques, 30% of them were evaluated in patients affected by decreased coagulation while 70% in subjects with normal levels of FVIII. In all the examined districts, the mean IMT was significantly lower in patients with hemophilia than in controls. Hemophilia protects against asymptomatic atherosclerosis.
Adult↗
Low-molecular-weight heparins for the long-term treatment of cancer patients with venous thromboembolism.
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Anticoagulants↗
Double vena cava filter insertion in congenital duplicated inferior vena cava: a case report and literature review.
The complex embryogenesis of the inferior vena cava (IVC) may result in several anomalies, often presenting as an incidental radiological finding. In addition to the differential diagnosis with pathological lesions, recognizing IVC defects is crucial for invasive procedures. This report describes a patient with a right femoral vein thrombosis who could not be given anticoagulant therapy due to a concomitant acute cerebral hemorrhage. He was found to have an asymptomatic duplicated IVC with interiliac communication. A filter had to be inserted in each vena cava to prevent pulmonary embolism. A review of the literature dealing with the few reported cases of filter insertion in congenital duplicated IVC is presented.
Aged, 80 and over↗
Incidence of arterial cardiovascular events in patients with idiopathic venous thromboembolism. A retrospective cohort study.
Recent data have shown a higher incidence of arterial events in patients with venous thromboembolism (VTE) of unknown origin than in those with the secondary form of disease. Whether patients with idiopathic VTE have a higher risk of subsequent arterial events than the general population is unknown. The aim was to evaluate the rates of subsequent arterial events in patients with idiopathic VTE and control subjects. In a retrospective cohort study we compared the rates of subsequent arterial events (i.e. acute myocardial infarction, ischemic stroke and peripheral arterial disease) in 151 consecutive patients with objectively confirmed spontaneous VTE and 151 control subjects randomly selected from the database of two family physicians. We collected information about cardiovascular risk-factors (hypertension, hypercholesterolemia, diabetes, obesity and smoke) at the time of VTE episode, or corresponding date for the controls, and considered the follow-up from this time. Patients and controls who had suffered from arterial events before the index date were excluded. During a mean follow-up of 43.1 (+/- 21.7) months there were 16 arterial events in the VTE patients and six in the control group (HR, 2.84;95% CI,1.11 to 7.27; p = 0.03). The difference remained significant after adjusting for age and other cardiovascular risk factors (HR 2.86;95% CI,1.07 to 7.62). Overall mortality was also higher in the VTE patients (12 vs.4 deaths). In conclusion, arterial events are more common in patients with previous idiopathic VTE than in the general population. These findings may have practical implications.
Arteries↗
Heparin- induced thrombocytopenia occurring in the first trimester of pregnancy: successful treatment with lepirudin. A case report.
The management of heparin-induced thrombocytopenia (HIT) in pregnancy represents a medical challenge. The advent of new antithrombotic agents that do not cross-react with platelet factor 4 and heparin antibodies represents an important progress, and they are of utmost interest in special situations such as early pregnancy, a situation where the teratogenicity of warfarin precludes its use.
Anticoagulants↗
How I treat venous thromboembolism in patients with cancer.
Venous thromboembolism (VTE) is a frequent complication in cancer patients and represents an important cause of morbidity and mortality. Especially in patients who have a poor life expectancy, preventing death from pulmonary embolism is the mainstay of treatment. Critically ill patients should promptly be administered thrombolytic drugs. Except for selected patients requiring aggressive therapy, the initial VTE treatment should be conducted with either adjusted-dose unfractionated heparin or fixed-dose low-molecular-weight heparin (LMWH). LMWHs have the potential to greatly simplify the initial treatment of VTE, making the treatment of suitable patients feasible in an outpatient setting. During anticoagulant therapy, cancer patients have a 2- to 4-fold higher risk of recurrent VTE and major bleeding complications when compared with noncancer patients. The long-term administration of LMWH should be considered as an alternative to anti-vitamin K drugs in patients with advanced disease and in those with conditions limiting the use of oral anticoagulants. Prolongation of anticoagulation should be considered for as long as the malignant disorder is active. The evidence of lowered cancer mortality in patients on LMWH has stimulated renewed interest in these agents as antineoplastic drugs and raises the distinct possibility that cancer and thrombosis share common mechanisms.
Anticoagulants↗