Tratamiento de TVP y TEP / DVT and PE management

Febrero 10, 2016. No. 2232

Tratamiento anticoagulante de la TVP y TEP: Elestado actualdel manejo. Anticoagulant Treatment of Deep Vein Thrombosis and Pulmonary Embolism: The Present State of the Art. Thaler J, Pabinger I, Ay C. Front Cardiovasc Med. 2015 Jul 14;2:30. doi: 10.3389/fcvm.2015.00030. eCollection 2015. Abstract Venous thromboembolism (VTE), a disease entity comprising deep vein thrombosis (DVT) and pulmonary embolism (PE), is a frequent and potentially life-threatening event. To date different agents are available for the effective treatment of acute VTE and the prevention of recurrence. For several years, the standard of care was the subcutaneous application of a low molecular weight heparin (LMWH) or fondaparinux, followed by a vitamin K antagonist (VKA). The so-called direct oral anticoagulants (DOAC) were introduced rather recently in clinical practice for the treatment of VTE. DOAC seem to have a favorable risk-benefit profile compared to VKA. Moreover, DOAC significantly simplify VTE treatment because they are administered in fixed doses and no routine monitoring is needed. Patients with objectively diagnosed DVT or PE should receive therapeutic anticoagulation for a minimum of 3 months. Whether a patient ought to receive extended treatment needs to be evaluated on an individual basis, depending mainly on risk factors determined by characteristics of the thrombotic event and patient related factors. In specific patient groups (e.g., pregnant women, cancer patients, and elderly patients), treatment of VTE is more challenging than that in the general population and additional issues need to be considered in those patients. The aim of this review is to give an overview of the currently available treatment modalities of acute VTE and secondary prophylaxis. In particular, specific aspects regarding the initiation of VTE treatment, duration of anticoagulation, and specific patient groups will be discussed. KEYWORDS: anticoagulation; deep vein thrombosis; pulmonary embolism; secondary prevention; venous thromboembolism PDF  Anticoagulantes orales directos en el tratamiento del tromboembolismo venoso, con un enfoque en los pacientes con embolia pulmonar: una revisión basada en la evidencia. Direct oral anticoagulants in the treatment of venous thromboembolism, with a focus on patients with pulmonary embolism: an evidence-based review. Gómez-Outes A, Suárez-Gea ML, Lecumberri R, Terleira-Fernández AI, Vargas-Castrillón E. Vasc Health Risk Manag. 2014 Nov 7;10:627-39. doi: 10.2147/VHRM.S50543. eCollection 2014. Abstract Pulmonary embolism (PE) is a relatively common cardiovascular emergency. PE and deep vein thrombosis (DVT) are considered expressions of the same disease, termed as venous thromboembolism (VTE). In the present review, we describe and meta-analyze the efficacy and safety data available with the direct oral anticoagulants (DOAC; dabigatran, rivaroxaban, apixaban, edoxaban) in clinical trials testing these new compounds in the acute/long-term and extended therapy of VTE, providing subgroup analyses in patients with index PE. We analyzed ten studies in 35,019 randomized patients. A total of 14,364 patients (41%) had index PE. In the acute/long-term treatment of VTE, the DOAC showed comparable efficacy in preventing recurrent VTE to standard treatment in patients with index PE (risk ratio [RR]: 0.88; 95% confidence interval [CI]: 0.70-1.11) and index DVT (RR: 0.93; 95% CI: 0.75-1.16) (P for subgroup differences =0.76). VTE recurrence depending on PE anatomical extension and presence/absence of right ventricular dysfunction was only reported in two trials, with results being consistent with those obtained in the overall study populations. In the single trial comparing extended therapy of VTE with DOAC versus warfarin, the point estimate for recurrent VTE tended to disfavor the DOAC in patients with index PE (RR: 2.05; 95% CI: 0.83-5.03) and in patients with index DVT (RR: 1.11; 95% CI: 0.49-2.50) (P for subgroup differences =0.32). In trials that compared DOAC versus placebo for extended therapy, the reduction in recurrent VTE was consistent in patients with PE (RR: 0.15; 95% CI: 0.01-1.82) and in patients with DVT (RR: 0.25; 95% CI: 0.10-0.61) (P for subgroup differences =0.71). The DOAC were associated with a consistently lower risk of clinically relevant bleeding (CRB) than standard treatment of acute VTE and higher risk of CRB than placebo for extended therapy of VTE regardless of index event. In summary, the DOAC were as effective as, and safer than, standard treatment of (hemodynamically stable) PE. Their efficacy in preventing recurrent VTE seemed consistent regardless of anatomical extension of PE (extensive, intermediate, or limit) or presence/absence of right ventricular dysfunction although the data are limited. For extended therapy, the DOAC were more effective than placebo in preventing recurrent VTE but were associated with an increase in CRB regardless of index event. KEYWORDS: anticoagulant; apixaban; dabigatran; edoxaban; pulmonary embolism; rivaroxaban PDF  Los avances en el manejo y tratamiento de la embolia pulmonar. Developments in the management and treatment of pulmonary embolism. Limbrey R, Howard L. Eur Respir Rev. 2015 Sep;24(137):484-97. doi: 10.1183/16000617.00006614. Abstract Pulmonary embolism (PE) is a serious and costly disease for patients and healthcare systems. Guidelines emphasise the importance of differentiating between patients who are at high risk of mortality (those with shock and/or hypotension), who may be candidates for thrombolytic therapy or surgery, and those with less severe presentations. Recent clinical studies and guidelines have focused particularly on risk stratification of intermediate-risk patients. Although the use of thrombolysis has been investigated in these patients, anticoagulation remains the standard treatment approach. Individual risk stratification directs initial treatment. Rates of recurrence differ between subgroups of patients with PE; therefore, a reviewof provoking factors, along with the risks of morbidity and bleeding, guides the duration of ongoing anticoagulation. The direct oral anticoagulants have shown similar efficacy and, in some cases, reduced major bleeding compared with standard approaches for acute treatment. They also offer the potential to reduce the burden on patients and outpatient services in the post-hospital phase. Rivaroxaban, dabigatran and apixaban have been shown to reduce the risk of recurrent venous thromboembolism versus placebo, when given for >12 months. Patients receiving direct oral anticoagulants do not require regular coagulation monitoring, but follow-up, ideally in a specialist PE clinic in consultation with primary care providers, is recommended. PDF

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Manejo extendido de TEP / Extended treatment of PE

Febrero 11, 2016. No. 2233

Tratamiento anticoagulante extendido y aspirina para la prevención secundaria de la enfermedad tromboembólica: una revisión sistemática y meta-análisis. Extended Anticoagulant and Aspirin Treatment for the Secondary Prevention of Thromboembolic Disease: A Systematic Review and Meta-Analysis. Marik PE, Cavallazzi R. PLoS One. 2015 Nov 20;10(11):e0143252. doi: 10.1371/journal.pone.0143252. eCollection 2015. Abstract BACKGROUND: Patients who have had an unprovoked deep venous thrombosis (DVT) or pulmonary embolus (PE) are at a high risk for recurrent venous thromboembolism (VTE). Extended "life-long" anticoagulation has been recommended in these patients. However, the risk benefit ratio of this approach is controversial and the role of the direct oral anticoagulants (DOACs) and aspirin is unclear. Furthermore, in some patients with a "weak provoking factor" there is clinical equipoise regarding continuation or cessation of anticoagulant therapy after treatment of the acute VTE event. OBJECTIVE: A systematic review and meta-analysis to determine the risks (major bleeding) and benefits (recurrent VTE and mortality) of extended anticoagulation with vitamin k antagonists (VKA), DOACs and aspirin in patients with an unprovoked VTE and in those patients with clinical equipoise regarding continuation or cessation of anticoagulant therapy. In addition, we sought to determine the risk of recurrent VTE events once extended anti-thrombotic therapy was discontinued. DATA SOURCES: MEDLINE, Cochrane Register of Controlled Trials, citation review of relevant primary and review articles. STUDY SELECTION: Randomized placebo-controlled trials (RCTs) that compared the risk of recurrent VTE in patients with an unprovoked DVT or PE who had been treated for at least 3 months with a VKA or a DOAC and were then randomized to receive an oral anti-thrombotic agent or placebo for at least 6 additional months. We included studies that included patients in whom clinical equipoise existed regarding the continuation or cessation of anticoagulant therapy. DATA EXTRACTION: Independent extraction of articles by both authors using predefined data fields, including study quality indicators. Data were abstracted on study size, study setting, initial event (DVT or PE), percentage of patients where the initial VTE event was unprovoked, the number of recurrent VTE events, major bleeds and mortality during the period of extended anticoagulation in the active treatment and placebo arms. In addition, we recorded the event rate once extended treatment was stopped. Meta-analytic techniques were used to summarize the data. Studies were grouped according to the type of anti-thrombotic agent. DATA SYNTHESIS: Seven studies which enrolled 6778 patients met our inclusion criteria; two studies evaluated the extended use of Coumadin, three studies evaluated a DOAC and two studies evaluated the use of aspirin. The duration of followup varied from 6 to 37 months. In the Coumadin and aspirin studies 100% of the randomized patients had an unprovoked VTE, while in the DOAC studies between 73.5% and 93.2% of the VTE events were unprovoked. In the control group recurrent VTE occurred in 9.7% of patients compared to 2.8% in the active treatment group (OR 0.21; 95% CI 0.11-0.42, p<0.0001). VKA, DOACs and aspirin significantly reduced the risk of recurrent VTE, with VKA and DOACs being significantly more effective than aspirin. Major bleeding events occurred in 12 patients in the control group (0.4%) and 25 of 3815 (0.6%) patients in the active treatment group (OR 1.64; 95% CI 0.69-3.90, NS). There were 39 (1.3%) deaths in control patients and 33 (0.9%) deaths in the anti-thrombotic group during the treatment period (OR 0.73; 95% CI 0.40-1.33, NS). Patients whose initial VTE event was a PE were more likely to have a recurrent PE than a DVT. The annualized event rate after discontinuation of extended antithrombotic therapy was 4.4% in the control group and 6.5% in the active treatment arm. CONCLUSIONS: VKA, DOACs and aspirin significantly reduced the risk of recurrent VTE, with DOACs and VKA being more effective than aspirin. The decision regarding life-long anticoagulation following an unprovoked DVT or PE should depend on the patients' risk for recurrent PE as well as the patients' values and preferences. PDF

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Compresión neumática intermitente / Intermittent pneumatic compression

Febrero 12, 2016. No. 2234

Efectividad de los dispositivos de compresión neumática intermitente para laprofilaxis del tromboembolismo venoso en pacientes quirúrgicos y médicos de alto riesgo Effectiveness of Intermittent Pneumatic Compression Devices for Venous Thromboembolism Prophylaxis in High-risk Surgical and Medical Patients [Internet]. Editors Pavon JM, Williams JW Jr, Adam SS, Razouki ZA, McDuffie JR, Lachiewicz PF, Kosinski AS, Beadles CA, Ortel TL, Nagi A. Source. Washington (DC): Department of Veterans Affairs (US); 2015 Jun. VA Evidence-based Synthesis Program Reports. Excerpt CONTEXT: Venous thromboembolism (VTE), which encompasses deep vein thrombosis (DVT) and pulmonary embolism (PE), is a serious potential complication in hospitalized patients. Thromboprophylaxis regimens include pharmacological and mechanical options such as intermittent pneumatic compression devices (IPCDs). There are a wide variety of IPCDs available, but it is uncertain if they vary in effectiveness or ease of use. OBJECTIVE: To systematically review the literature on the comparative effectiveness of IPCDs for selected outcomes (mortality, VTE, symptomatic or asymptomatic DVT, major bleeding, ease of use, and adherence) in post-operative surgical and high-risk medical patients. DATA SOURCES AND STUDY SELECTION: We searched MEDLINE (via PubMed), Embase, CINAHL, and Cochrane CENTRAL from January 1, 1995, to October 30, 2014, for peer-reviewed, English-language randomized controlled trials (RCTs). All searches used terms for IPCDs and the conditions of interest, along with validated search terms for RCTs. We also used terms to identify relevant observational studies on ease of use and adherence. Bibliographies of identified articles were further reviewed. To assess for possible publication bias, we searched ClinicalTrials.gov to identify completed but unpublished studies meeting our eligibility criteria. DATA SYNTHESIS: Eighteen RCTs and 3 observational studies were eligible; most were conducted in patients undergoing joint replacement surgery. Our review considered 3 types of evidence: 1) head-to-head comparisons of IPCDs; 2) indirect comparisons of IPCDs to a common comparator (eg, foot vs calf devices, each compared to anticoagulation); and 3) data on ease of use or adherence from patients or staff. The methodological quality of the included studies was variable and generally suboptimal. The most commonly studied devices were the Kendall SCD™ and A-V Impulse System™. Only 3 trials compared different IPCDs directly. One showed lower VTE rates for a VenaFlow® compared to the Kendall SCD, but 2 other studies showed no difference between the PlexiPulse® and the Kendall SCD. IPCDs were comparable to anticoagulation for major clinical outcomes (VTE: risk ratio [RR] 1.39; 95% confidence interval [CI], 0.73 to 2.64). Limited data suggest that concurrent use of anticoagulation with IPCD may lower the risk of VTE compared to anticoagulation alone (RR 0.27; 95% CI 0.05 to 1.64) and that IPCD compared to anticoagulation may lower the risk of major bleeding (RR 0.33; 95% CI 0.07 to 1.51). Subgroup analyses did not show significant differences by device location, mode of inflation, or risk of bias elements. Overall, there were no consistent associations between specific brand-name IPCDs or sleeve location and ease of use or adherence. Chief limitations of the literature were the paucity of head-to-head comparisons between IPCDs in surgical and medical patients, and the identification of primarily asymptomatic DVTs of uncertain clinical importance. CONCLUSIONS: IPCDs are appropriate for VTE thromboprophylaxis when used in accordance with current clinical guidelines. The current evidence base to guide selection of a specific device or type of device is limited. When choosing a specific IPCD, focusing on device flexibility, acceptability by nursing staff and patients, and the most frequently studied devices, as well as on cost, can help direct selection of appropriate IPCDs. Comparative effectiveness studies are urgently needed to address current gaps in evidence.  PDF   Meta-análisis estratificado de la compresión neumática intermitente de las extremidades inferiores para prevenir el tromboembolismo venoso en pacienteshospitalizados. Stratified meta-analysis of intermittent pneumatic compression of the lower limbs to prevent venous thromboembolism in hospitalized patients. Ho KM1, Tan JA. Circulation. 2013 Aug 27;128(9):1003-20. doi: 10.1161/CIRCULATIONAHA.113.002690. Epub 2013 Jul 12. Abstract BACKGROUND: Optimal thromboprophylaxis for patients at risk of bleeding remains uncertain. This meta-analysis assessed whether intermittentpneumatic compression (IPC) of the lower limbs was effective in reducing venous thromboembolism and whether combining pharmacological thromboprophylaxis with IPC would enhance its effectiveness. METHODS AND RESULTS: Two reviewers searched MEDLINE, EMBASE, and the Cochrane controlled trial register (1966-February 2013) for randomized, controlled trials and assessed the outcomes and quality of the trials independently. Trials comparing IPC with pharmacological thromboprophylaxis, thromboembolic deterrent stockings, no prophylaxis, and a combination of IPC and pharmacological thromboprophylaxis were considered. Trials that used IPC <24 hours or compared different types of IPC were excluded. A total of 16 164 hospitalized patients from 70 trials met the inclusion criteria and were subjected to meta-analysis. IPC was more effective than no IPC prophylaxis in reducing deep vein thrombosis (7.3% versus 16.7%; absolute risk reduction, 9.4%; 95% confidence interval [CI], 7.9-10.9; relative risk, 0.43; 95% CI, 0.36-0.52; P<0.01; I(2)=34%) and pulmonary embolism (1.2% versus 2.8%; absolute risk reduction, 1.6%; 95% CI, 0.9-2.3; relative risk, 0.48; 95% CI, 0.33-0.69; P<0.01; I(2)=0%). IPC was also more effective than thromboembolic deterrent stockings in reducing deep vein thrombosis and appeared to be as effective as pharmacological thromboprophylaxis but with a reduced risk of bleeding (relative risk, 0.41; 95% CI, 0.25-0.65; P<0.01; I(2)=0%). Adding pharmacological thromboprophylaxis to IPC further reduced the risk of deep vein thrombosis (relative risk, 0.54; 95% CI, 0.32-0.91; P=0.02; I(2)=0%) compared with IPC alone. CONCLUSIONS: IPC was effective in reducing venous thromboembolism, and combining pharmacological thromboprophylaxis with IPC was more effective than using IPC alone. KEYWORDS: prevention & control; venous thromboembolism PDF   Extensa complicación bullosa asociada con la compresión neumática intermitente Extensive bullous complication associated with intermittent pneumatic compression. Won SH, Lee YK, Suh YS, Koo KH. Yonsei Med J. 2013 May 1;54(3):801-2. doi: 10.3349/ymj.2013.54.3.801. Abstract Intermittent pneumatic compression (IPC) device is an effective method to prevent deep vein thrombosis. This method has been known to be safe with very low rate of complications compared to medical thromboprophylaxis. Therefore, this modality has been used widely in patients who underwent a hip fracture surgery. We report a patient who developed extensive bullae, a potentially serious skin complication, beneath the leg sleeves during the use of IPC device after hip fracture surgery. KEYWORDS: Venous thromboembolism; extensive bullae; fragile skin; intermittent pneumatic compression device  PDF

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