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PubMed2002

Integrated diagnostic approach to suspected deep vein thrombosis and pulmonary embolism.

Diagnosing deep vein thrombosis and pulmonary embolism has become definitely easier and more reliable over the past fifteen years, especially thanks the development of lower limbs venous compression ultrasonography and fibrin D-Dimer measurement. These tests allowed reducing the requirement for venography and pulmonary angiography to a small minority of patients. Simultaneously, ventilation/perfusion lung scan criteria have been standardized, and the performance of spiral computed tomography has been analyzed in an appropriate way. New sequential, mainly noninvasive strategies could be developed that proved to be safe in large-scale prospective cohort studies with prolonged follow-up. They should now be implemented in daily practice according to cost-effectiveness analyses as well as local facilities and expertise.

Diagnostic Imaging↗
PubMed1992

Deep venous thrombosis and pulmonary embolism in pregnancy.

Deep venous thrombosis and pulmonary embolism are relatively frequent occurrences in pregnancy and the postpartum period. The diagnosis of deep venous thrombosis and pulmonary embolism requires accurate objective tests because clinical diagnosis is unreliable. Procedures that expose the fetus to ionizing radiation must sometimes be performed to make an accurate diagnosis; current evidence suggests that the adverse effects to the fetus associated with such procedures are minimal. Heparin is the anticoagulant of choice during pregnancy and is used for both the treatment and prevention of venous thrombosis and pulmonary embolism. Patients with deficiencies of antithrombin III, protein C, or protein S as well as patients with antiphospholipid antibodies are at increased risk for thrombotic complications and require particular vigilance during pregnancy.

Acute Disease↗
PubMed2000

Heparin, low molecular weight heparin and physical methods for preventing deep vein thrombosis and pulmonary embolism following surgery for hip fractures.

BACKGROUND: Hip fracture patients have a high risk of thromboembolic complications following surgical management. OBJECTIVES: To examine the effects of heparin (unfractionated (U), and low molecular weight (LMW) heparins), and physical methods (compression stockings, calf or foot pumps) for prevention of deep venous thrombosis (DVT) and pulmonary embolism after surgery for hip fracture in the elderly. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group trials register, Medline, Embase, and reference lists of published papers and books. We contacted trialists and other workers in the field. Date of most recent search: September 1996. SELECTION CRITERIA: Randomised and quasi-randomised trials evaluating the use of heparins and physical agents for prevention of DVT and pulmonary embolism in patients undergoing surgery for hip fracture. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed methodological quality and extracted data. Trials were grouped into four categories (heparin versus control, mechanical versus control, LMW heparin versus U heparin, and miscellaneous) and results pooled where possible. MAIN RESULTS: The 26 included trials involved 2600 predominantly female and elderly patients. Overall, trial quality was disappointing. Ten trials involving 826 patients which compared U heparin with control, and four trials of 471 patients which compared LMW heparin with control, showed a reduction in the incidence of lower limb DVT (121/511 (24%) versus 203/519 (39%); Peto odds ratio 0.41; 95% confidence interval 0.31 to 0.55). There were insufficient data to confirm the efficacy of either agent in the prevention of pulmonary embolism. There was a non significant increase in overall mortality in the heparin group (46/420 (11%) versus 35/423 (8%); Peto odds ratio 1.39; 95% confidence interval 0. 86 to 2.23). Data were inadequate for all other outcomes including wound complications. There is insufficient evidence from five trials, involving 644 patients, to establish if LMW heparin was superior to U heparin. Most trials evaluating heparins had methodological defects. Four trials, involving 442 patients, testing mechanical pumping devices were also methodologically flawed, and so pooled results need to be viewed cautiously. Mechanical pumping devices may protect against DVT (12/202 (6%) versus 42/212 (19%); Peto odds ratio 0.24; 95% confidence interval 0.13 to 0.44). Although the limited data indicated a potential benefit, they were inadequate to establish any effect on the incidence of pulmonary embolism and overall mortality. Problems with skin abrasion and compliance were reported. REVIEWER'S CONCLUSIONS: U and LMW heparins protect against lower limb DVT. There is insufficient evidence to confirm either protection against pulmonary embolism or overall benefit, or to distinguish between various applications of heparin. Foot and calf pumping devices appear to prevent DVT, may protect against pulmonary embolism, and reduce mortality, but compliance remains a problem. Good quality trials of mechanical methods as well as direct comparisons with heparin should be considered.

Anticoagulants↗
PubMedDate not supplied

Deferment of objective assessment of deep vein thrombosis and pulmonary embolism without increased risk of thrombosis: a practical approach based on the pretest clinical model, D-dimer testing, and the use of low-molecular-weight heparins.

BACKGROUND: Treatment of patients with suspected deep vein thrombosis (DVT) or pulmonary embolism (PE) is problematic if diagnostic imaging is not immediately available. Pretest clinical probability (PCP) and D-dimer assessment can be used to identify patients for whom empirical protective anticoagulation is indicated. To evaluate whether PCP and D-dimer assessment, together with the use of low-molecular-weight heparins (LMWHs), allow objective appraisal of DVT and PE to be deferred for up to 72 hours, patients with suspected DVT and PE were prospectively examined. METHODS: Patients identified with a high PCP or a moderate PCP with positive D-dimer test results received a protective full-dose treatment of LMWH; the remaining patients were discharged without anticoagulant administration. However, all patients were scheduled to undergo objective tests for DVT or PE within 72 hours. Standard antithrombotic therapy was administered when deferred diagnostic tests confirmed venous thromboembolism. RESULTS: In total, 409 consecutive patients with suspected DVT and 124 with suspected PE were included in this study. A total of 23.8% (95% confidence interval [CI], 20.3%-27.3%) of patients had confirmed venous thromboembolism. At the short-term follow-up (72 hours), only a single thromboembolic event (0.2%; upper 95% CI, 0.6%) had occurred, whereas at the 3-month follow-up, 5 events (1.2%; 95% CI, 0.2%-2.1%) had occurred in patients in whom diagnosis of DVT or PE had previously been ruled out. None of the patients had major bleeding events. Ninety percent of patients were treated as outpatients. CONCLUSION: Our study demonstrates that this approach allows the safe deferral of diagnostic procedures for DVT and PE for up to 72 hours.

Adolescent↗
PubMed1998

Deep vein thrombosis and pulmonary embolism in the Chinese population.

Deep vein thrombosis and pulmonary embolism is a well-recognised major health problem in the West. There is a deep-rooted belief among clinicians that deep vein thrombosis is rare in Asians, particularly in the Chinese population. However, it appears that the incidence of venous thrombosis and pulmonary embolism is increasing in Chinese patients. Prophylaxis reduces the incidence of venous thrombosis by 66% and of pulmonary embolism by 50%--- prophylaxis should therefore be considered for Chinese patients who have a high risk of developing postoperative deep vein thrombosis. This report reviews the current literature on this subject.

Journal Article↗
PubMed1983

Prophylaxis of postoperative deep vein thrombosis and pulmonary embolism.

Routine prophylaxis of deep vein thrombosis and pulmonary embolism is justified by the importance of these complications as sources of major morbidity and mortality in otherwise healthy patients more than 40 years old undergoing extensive elective operations. As no one prophylactic technique is ideal, the continuing controversy is over the choice of technique for each patient. Appropriate selection of a prophylactic technique requires a careful preoperative assessment based upon the relative risk of thromboembolism due to associated disease, the risk of bleeding complications secondary to an underlying bleeding diathesis, the possibility of major morbidity from unexpected postoperative bleeding determined by the anatomic site of surgical procedure and the risk of thromboembolism imposed by the surgical procedure itself (57). For patients at high risk, warfarin remains the prophylactic agent of choice. To date, the available data on combinations of mechanical and chemical techniques are incomplete and contradictory, but future studies may identify synergistic combinations. In patients at high risk who also greatly risk having bleeding complications, vena caval interruption should be considered. In patients undergoing operation at moderate risk, low dose heparin, dextran and external pneumatic compression devices are beneficial. In patients undergoing elective hip and knee operation at moderate risk, aspirin appears especially safe and effective. When major morbidity may result from anticoagulation in patients at moderate risk for deep vein thrombosis and pulmonary embolism, external pneumatic compression devices, gradient elastic stockings or elevation of the leg should be used. Further carefully controlled clinical trials are needed to identify even better options for prophylaxis.

Adult↗
PubMed1983

Strategies to diagnosis and screening of deep venous thrombosis and pulmonary embolism.

The clinical diagnosis of venous thrombosis or pulmonary embolism is unreliable and must be confirmed by objective methods. The available objective diagnostic tests which have been evaluated for deep vein thrombosis and shown to be of value are venography, IPG, and (125I)-fibrinogen leg scanning. All these methods have certain disadvantages, but the potential advantages of accurate diagnosis using a combination of non-invasive tests as an alternative to venography are considerable. This approach is cost-effective, because it avoids unnecessary hospital admissions and reserves anticoagulant treatment for those in whom diagnosis of deep venous thrombosis is confirmed. Non-invasive techniques can also be used to screen high risk surgical patients for whom no inexpensive, effective, safe form of prophylaxis is available. The correct diagnostic approach in suspected pulmonary embolism remains to be established. The initial screening by perfusion lung scan with ventilation studies, followed by either the demonstration of pulmonary emboli with angiography, or the demonstration of peripheral deep venous thrombosis, is considered to be the safest approach.

Fibrinogen↗