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PubMed1977

[Quantitative assessment of drug-induced prophylaxis of postoperative thromboembolism. Comparison of frequencies of deep vein thrombosis and pulmonary embolism using acetylsalicylic-acid, dextran, dihydroergotamine, low-dose heparin and the fixed combination of heparin and dihydroergotamine (author's transl)].

2136 patients in general surgery, gynaecology and urology were investigated by the 125I-fibrinogen-uptake-test for detection of postoperative deep vein thrombosis (DVT). They received at random one of low-dose heparin, dihydroergotamine, the fixed combination of both drugs (Heparin-Dihydergot), low molecular weight dextran and acetylsalicylic-acid (ASS). When DVT was detected repeated lung perfusion scintigraphies were carried out for diagnosis of embolic pulmonary perfusion defects. Results demonstrate the outstanding effect of Heparin-Dihydergot, which is not only 2-3 times better than the anti-thrombotic standard low-dose heparin but also eliminates almost completely the risk of postoperative embolism. The preventive efficacy of ASS and dextran must be considered to be poor and not comparable to that obtained when using heparin, dihydroergotamine or the combination. Now Heparin-Dihydergot is the new standard with which all prophylactic procedures should be compared.

Adult↗
PubMed2001

Treatment of deep venous thrombosis and pulmonary embolism with low molecular weight heparin in the geriatric patient population.

Low-molecular-weight heparins have provided a new approach to treating DVT-PE. These anticoagulants have better bioavailability, a longer half-life, and a more predictable antithrombotic effect than UFH. In the studies reviewed, LMWHs were shown to be safe and effective in preventing recurrent thrombotic events when compared with the more precise UFH dosing schedules. There has been no evidence of an increased incidence of major bleeding or recurrent thromboembolic events based on age in these trials. With these findings LMWHs given subcutaneously, without laboratory monitoring, in a dose determined by actual body weight allows clinicians involved in the care of the elderly to manage these patients with DVT with or without PE in the nursing home setting, skilled nursing care facilities, rehabilitation units, acute care hospital setting, or as described in this article at home. These patients can continue their physical therapy programs because intravenous infusion lines and the necessity to be maintained at bedrest do not encumber them.

Aged↗
PubMed2000

Predictive value of a rapid semiquantitative D-dimer assay in critically ill patients with suspected venous thromboembolic disease.

OBJECTIVE: To evaluate the performance of a new, rapid semi-quantitative assay for the detection of circulating D-dimer in whole blood from critically ill patients with suspected venous thromboembolic disease. DESIGN: Prospective, blinded, single-center study. SETTING: Medical intensive care unit (ICU) of Barnes-Jewish Hospital, St. Louis, MO, a university-affiliated urban teaching hospital. PATIENTS: Two hundred thirty-nine adult patients with clinical suspicion of venous thromboembolic disease admitted to a medical ICU. INTERVENTIONS: Collection of blood samples within 24 hrs of clinical suspicion of venous thromboembolic disease. MEASUREMENTS AND MAIN RESULTS: The main outcome measures evaluated included the occurrence of venous thromboembolic disease (i.e., lower extremity venous thrombosis, pulmonary embolism, catheter-associated venous thrombosis) and hospital mortality. Fifty-seven patients (23.8%) were classified as having venous thromboembolic disease during their ICU stays (pulmonary embolism, 21 patients; lower extremity thrombosis, 44 patients; line-associated venous thrombosis, 3 patients). The semiquantitative whole-blood assay for circulating D-dimer had a 96.4% sensitivity and a negative predictive value of 92.1% for identifying patients with venous thromboembolic disease. The specificity of this assay was 19.7%, and its positive predictive value was 26.9%. There was a strong correlation between the semiquantitative assay for circulating D-dimer and the quantitative measurement of circulating D-dimer using an enzyme immunoassay (Spearman's correlation coefficient, 0.8643; p<.001). We also identified a strong correlation between both the quantitative and semiquantitative measurements of circulating D-dimer with the sepsis classification proposed by the American College of Chest Physicians/Society of Critical Care Medicine (i.e., systemic inflammatory response syndrome, sepsis, severe sepsis, septic shock) for patients without venous thromboembolic disease (n = 182; quantitative measure: Spearman's correlation coefficient, 0.207; p = .002; semiquantitative measure: Spearman's correlation coefficient, 0.3519; p<.001). CONCLUSIONS: These preliminary findings suggest that a rapid whole-blood assay for the semiquantitative detection of circulating D-dimer may be a useful diagnostic tool for the exclusion of venous thromboembolic disease among critically ill patients.

Adolescent↗
PubMed1983

A new method of management using the Kim-Ray Greenfield filter for deep venous thrombosis and pulmonary embolism in spinal cord injury.

In this study, it is documented that the proper location of the Kim-Ray Greenfield filter offers excellent protection against PE in patients with SCI and DVT. The device has been associated with thrombosis of the IVC in two of 21 patients, and the thrombosis was well tolerated. The incidence of complications has been quite low. We believe that this is a most acceptable method of managing patients with SCI and DVT or PE when heparin is either inadequate or contraindicated.

Adult↗
PubMed2000

Treatment of acute deep venous thrombosis and pulmonary embolism: use of low molecular weight heparin.

Over the past decade, the use of low molecular weight heparin (LMWH) preparations has revolutionized the approach to preventing and treating venous thromboembolism. For established deep venous thrombosis, numerous prospective clinical trials have indicated that these drugs are at least as safe and as effective as standard, unfractionated heparin (UFH) and perhaps even more effective at preventing recurrences. Advantages of low molecular weight heparin include superior bioavailability compared with standard heparin, once- or twice-daily subcutaneous delivery, and the lack of need to monitor in most clinical circumstances. Because of these advantages, increasing numbers of stable, compliant patients with deep venous thrombosis are being treated as outpatients. This approach requires an organized team effort with comprehensive patient education and carefully planned follow-up. Cost-benefit analyses have unequivocally proved that when treatment with low molecular weight heparin is utilized in the outpatient setting, there are substantial cost savings.

Journal Article↗
PubMed1993

Diagnostic approaches and surgical treatment of deep venous thrombosis and pulmonary embolism.

Diagnostic approaches for thromboembolism include Doppler probe examination, impedance plethysmography, phleborheography, radio-labeled fibrinogen scanning, magnetic resonance imaging, duplex imaging, and venography. The two primary diagnostic approaches for pulmonary embolism include ventilation/perfusion lung scanning and pulmonary arteriography. Surgical options available for venous thromboembolism are generally limited to those condition in which limb viability is threatened from acute iliofemoral thrombosis. Vena caval interruption, performed in patients with a contraindication to anticoagulation, a complication during anticoagulant therapy, and recurrent pulmonary embolism in the presence of adequate anticoagulation (among other indications) is best accomplished with the Greenfield filter. Surgical approaches for pulmonary embolism, limited to patients with massive embolism with hypotension, include catheter pulmonary embolectomy and open pulmonary embolectomy.

Humans↗
PubMed1976

Warfarin sodium in prevention of deep venous thrombosis and pulmonary embolism in patients with fractured neck of femur.

In a prospective controlled randomised trial, the prophylactic value of warfarin sodium (in doses aimed at maintaining a "Thrombotest" value of 10% and given from the day of admission until independent mobility had been achieved or for 3 mo, whichever was the sooner) was assessed in 160 elderly patients who had sustained a fracture of the femoral neck. Treatment significantly reduced the frequency of deep venous thrombosis (D.V.T.), whether indicated by the 125I-fibrinogen test during life or assessed by detailed post-mortem studies. Pulmonary embolism was eliminated in treated patients, but the difference in mortality between the treatment and control groups was not significant, indicating that causes of death other than pulmonary embolism are of major importance in these elderly patients. A case is made out for prophylactic anticoagulation on a selective basis.

Aged↗
PubMed2005

Screening for deep vein thrombosis and pulmonary embolism in outpatients with suspected DVT or PE by the sequential use of clinical score: a sensitive quantitative D-dimer test and noninvasive diagnostic tools.

The requirement for a safe diagnostic strategy should be based on an overall posttest incidence of venous thromboembolism (VTE) of less than 1% during 3-month follow-up. The negative predictive value (NPV) during 3 months of follow-up is 98.1 to 99% after a normal venogram, 97 to 98% after a normal compression ultrasonography (CUS), and > 99% after serial CUS testing. Serial CUS testing is safe but 100 CUS must be repeated to find one or two CUS positive for deep vein thrombosis (DVT), which is not cost-effective and indicates the need to improve the diagnostic workup of DVT by the use of clinical score assessment and D-dimer testing. The NPV varies from 97.6 to 99.4% for low clinical score followed by a negative SimpiRED test, indicating the need for a first CUS. The NPV is 98.4 to 99.3% for a normal rapid enzyme-linked immunosorbent assay (ELISA) VIDAS D-dimer test result (< 500 ng/mL) irrespective of clinical score. The NPV is more than 99% for a negative CUS followed by either a negative SimpiRED test or an ELISA VIDAS test result of < 1000 ng/mL without the need to repeat a second CUS within 1 week. The sequential use of a sensitive, rapid ELISA D-dimer and clinical score assessment will safely reduce the need for CUS testing by 40 to 60%. Large prospective outcome studies demonstrate that with one negative examination with complete duplex color ultrasonography (CCUS) of the proximal and distal veins of the affected leg with suspected DVT, it is safe to withhold anticoagulant treatment, with a negative predictive value of 99.5%. This may indicates that CCUS is equal to serial CUS or the combined use of clinical score, D-dimer testing, and CUS. Pulmonary angiography is the gold standard for segmental pulmonary embolism (PE) but not for subsegmental PE. A normal perfusion lung scan and a normal rapid ELISA VIDAS D-dimer test safely excludes PE. Helical spiral computed tomography (CT) detects all clinically relevant PE and a large number of alternative diagnoses in symptomatic patients with suspected PE and can replace both the ventilation perfusion scan and pulmonary angiography to safely rule in PE and to rule out PE with an NPV of > 99%. The combination of clinical assessment, a rapid ELISA VIDAS D-dimer, followed by CUS will reduce the need for helical spiral CT by 40 to 50%.

Ambulatory Care↗
PubMed1980

Primary ('stress') thrombosis of the upper arm associated with multiple pulmonary embolism.

Primary venous thrombosis of the upper arm is an uncommon but distinct syndrome. Although there is a high incidence of residual disability due to failure of the vein to recanalize, pulmonary embolism is unusual, and residual pulmonary symptoms or fatalities have not previously been reported. A case of thrombo-embolic pulmonary hypertension complicating primary thrombosis in the upper arm is described. Prompt recognition and treatment of the condition are recommended.

Adult↗
PubMed1995

Mutation in the gene coding for coagulation factor V and the risk of myocardial infarction, stroke, and venous thrombosis in apparently healthy men.

BACKGROUND: A specific point mutation in the gene coding for coagulation factor V is associated with resistance to degradation by activated protein C, a recently described abnormality of coagulation that may be associated with an increased risk of venous thrombosis. Whether this mutation also predisposes patients to arterial thrombosis is unknown, as is the value of screening for the mutation in order to define the risk of venous thrombosis among unselected healthy people. METHODS: Among 14,916 apparently healthy men in the Physicians' Health Study who provided base-line blood samples, 374 had myocardial infarctions, 209 had strokes, and 121 had deep venous thrombosis, pulmonary embolism, or both, during a mean follow-up of 8.6 years. We determined whether a mutation at nucleotide position 1691 of the factor V gene was present or absent in these 704 men and in an equal number of matched participants who remained free of vascular disease. RESULTS: The prevalence of heterozygosity for the mutation among men who had myocardial infarctions (6.1 percent, P = 0.9) or strokes (4.3 percent, P = 0.4) was similar to that among men who remained free of vascular disease (6.0 percent). However, the prevalence of the mutation was significantly higher among men who had venous thrombosis, pulmonary embolism, or both (11.6 percent, P = 0.02). In adjusted analyses, the relative risk of venous thrombosis among men with the mutation was 2.7 (95 percent confidence interval, 1.3 to 5.6; P = 0.008). This increased risk was seen with primary venous thrombosis (relative risk, 3.5; 95 percent confidence interval, 1.5 to 8.4; P = 0.004) but not with secondary venous thrombosis (relative risk, 1.7; 95 percent confidence interval, 0.6 to 5.3; P = 0.3), and it was most apparent among older men. Specifically, the prevalence of the mutation among men over the age of 60 in whom primary venous thrombosis developed was 25.8 percent (relative risk, 7.0; 95 percent confidence interval, 2.6 to 19.1; P < 0.001). CONCLUSIONS: In a large cohort of apparently healthy men, the presence of a specific point mutation in the factor V gene was associated with an increased risk of venous thrombosis, particularly primary venous thrombosis. The presence of the mutation was not associated with an increased risk of myocardial infarction or stroke. This mutation appears to be the most common inherited factor thus far recognized that predisposes patients to venous thrombosis.

Aged↗