International Journal of Hematology

, Volume 76, Supplement 2, pp 40–43

Treatment of venous thromboembolism

  • Walter Ageno
Update on Hypercoagulability

Abstract

The combination of unfractionated heparin or low molecular weight heparin and oral anticoagulants is currently the treatment of choice for most patients with venous thromboembolism. Oral anticoagulants are started at the same time and heparin is discontinued after at least 5 days when the levels of the International Normalized Ratio reach the therapeutic range between 2.0 and 3.0. Low molecular weight heparin has potential advantages over heparin and is administered in subcutaneous weight-adjusted fixed doses without need for monitoring. This has made the home treatment of a large proportion of patients possible. Randomized clinical trials and several subsequent reports from clinical practice have demonstrated the efficacy and safety of this approach. The results of currently ongoing trials aimed to assess the efficacy and safety of newer compounds for the initial treatment of venous thromboembolism are expected. Oral direct thrombin inhibitors or selective factor-Xa inhibitors have the potential to become the treatment of choice in the next decade. The optimal duration of the secondary prophylaxis with oral anticoagulants is still a matter of debate. The rate of recurrence has been shown to be elevated, particularly in patients with idiopathic venous thromboembolism. A 3-month therapy is therefore currently recommended when a transient risk factor is identified, life-long treatment is recommended for patients with a second episode of venous thromboembolism. The presence of active cancer or a thrombophilic state may require long-term anticoagulation, although not all the congenital hypercoagulable states seem to carry the same level of risk. In all other cases, 6 months are recommended, but a long-term monitoring of the patients is advisable. The use of more aggressive strategies such as thrombolysis is limited to patients presenting with massive pulmonary embolism or signs of right ventricular dysfunction.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Hyers TM, Agnelli G, Hull RD, et al. Antithrombotic therapy for venous thromboembolic disease.Chest. 2001;119(suppl 1):176S-193S.PubMedCrossRefGoogle Scholar
  2. 2.
    Brandjes DPM, Heijboer H, Bller HR, et al. Acenocoumarol and heparin compared with acenocoumarol alone in the initial treatment of proximal vein thrombosis.N Engl J Med. 1992;327:1485–1489.PubMedCrossRefGoogle Scholar
  3. 3.
    Hirsh J, Dalen JE, Anderson DR, et al. Oral anticoagulants. Mechanism of action, clinical effectiveness, and optimal therapeutic range.Chest. 2001;119:8S-21S.PubMedCrossRefGoogle Scholar
  4. 4.
    Young E, Cosmi B, Weitz J, et al. Comparison of the nonspecific binding of unfractionated heparin and low molecular weight heparin to plasma proteins.Thromb Haemost. 1993;70:625–630.PubMedGoogle Scholar
  5. 5.
    Young E, Prins M, Levine MN, et al. Heparin binding to plasma proteins, an important mechanim for heparin resistance.Thromb Haemost. 1992;67:639–643.PubMedGoogle Scholar
  6. 6.
    Hirsh J, Levine MN. Low molecular weight heparin.Blood. 1992;79(1):1–17.PubMedGoogle Scholar
  7. 7.
    Leizorovicz A, Simonneau G, Decousus H, et al. Comparison of efficacy and safety of low molecular weight heparins and unfractionated heparin in initial treatment of deep venous thrombosis: meta-analysis.BMJ. 1994;309:299–304.PubMedGoogle Scholar
  8. 8.
    Lensing AWA, Prins MH, Davidson BL, et al. Treatment of deep venous thrombosis with low molecular weight heparins.Arch Intern Med. 1995;155:601–607.PubMedCrossRefGoogle Scholar
  9. 9.
    Siragusa S, Cosmi B, Piovella F, et al. Low molecular weight heparins and unfractionated heparin in the treatment of patients with acute venous thromboembolism: Results of a meta-analysis.Am J Med. 1996;100:269–277.PubMedCrossRefGoogle Scholar
  10. 10.
    Dolovich J, Ginsberg J. Low molecular weight heparins in the treatment of venous thromboembolism.Vessels. 1997;3:4–11.Google Scholar
  11. 11.
    Koopman MMW, Prandoni P, Piovella F, et al. Treatment of venous thrombosis with intravenous unfractionated heparin administered in hospital as compared with subcutaneous low molecular weight heparin administered at home.N Engl J Med. 1996;334:682–687.PubMedCrossRefGoogle Scholar
  12. 12.
    Levine M, Gent M, Hirsh, J, et al. A comparison of low molecular weight heparin administered primarily at home with unfractionated heparin administered in the hospital for proximal deep-vein thrombosis.N Engl J Med. 1996;334:677–681.PubMedCrossRefGoogle Scholar
  13. 13.
    Wells PS, Kovacs MJ, Bormanis J, et al. Expanding eligibility for outpatient treatment of deep venous thrombosis and pulmonary embolism with low molecular weight heparin.Arch Intern Med. 1998;158:1809–1812.PubMedCrossRefGoogle Scholar
  14. 14.
    Harrison L, McGinnis J, Crowther M, et al. Assessment of outpatient treatment of deep vein thrombosis with low molecular weight heparin.Arch Intern Med. 1998;158:2001–2003.PubMedCrossRefGoogle Scholar
  15. 15.
    Ageno W, Steidl L, Marchesi C, et al. Selecting patients for home treatment of deep vein thrombosis: the problem of cancer.Haematologica. 2002;87:286–291.PubMedGoogle Scholar
  16. 16.
    Ageno W, Turpie AGG. Outpatient treatment of deep vein thrombosis.Emergency Medicine. 2001;33:74–81.Google Scholar
  17. 17.
    Hirsh J. Oral anticoagulant drugs.N Engl J Med. 1991;324:1865–1875.PubMedGoogle Scholar
  18. 18.
    Coon WW, Willis PW. Recurrence of venous thromboembolism.Surgery. 1973;73:823–827.PubMedGoogle Scholar
  19. 19.
    Schulman S, Rhedin AS, Lindmarker P, et al. A comparison of six weeks with six months of oral anticoagulant therapy after a first episode of venous thromboembolism.N Engl J Med. 1995;332:1661–1665.PubMedCrossRefGoogle Scholar
  20. 20.
    Kearon C, Gent M, Hirsh J, et al. A comparison of three months of anticoagulation with extended anticoagulation for a first episode of idiopathic venous thromboembolism.N Engl J Med. 1999;340:901–907.PubMedCrossRefGoogle Scholar
  21. 21.
    Agnelli G, Prandoni P, Santamaria MG, et al. Three months versus one year of oral anticoagulant therapy for idiopathic deep venous thrombosis.N. Engl J Med. 2001;345:165–169.PubMedCrossRefGoogle Scholar
  22. 22.
    Palareti G, Legnani C, Cosmi B, et al. Risk of venous thromboembolism recurrence: high negative predictive value of D-dimer performed after oral anticoagulation is stopped.Thromb Haemost 2002;87:7–12.PubMedGoogle Scholar
  23. 23.
    Piovella F, Crippa L, Barone M, et al. Normalization rates of compression ultrasonography in patients with a first episode of deep vein thrombosis of the lower limbs: association with recurrence and new thrombosis.Haematologica. 2002;87:515–522.PubMedGoogle Scholar

Copyright information

© The Japanese Society of Hematology 2002

Authors and Affiliations

  • Walter Ageno
    • 1
  1. 1.Department of Internal MedicineUniversity of InsubriaVareseItaly

Personalised recommendations