Identification and treatment of arterial thrombophilia

Article

Opinion statement

Once the diagnosis of a thrombophilic state has been established, management must include one or more strategies designed to attenuate thrombotic risk and the likelihood of clinical events. In the case of drug-induced arterial thrombosis provoked by oral contraceptives, hormone replacement therapy, heparinoids, cocaine, or thienopyridine-related thrombotic thrombocytopenic purpura (TTP), the offending agent should be discontinued immediately. Anticoagulant therapy and platelet-directed therapies, either alone or in combination, should be considered for patients experiencing a single arterial or venous thrombosis (secondary prevention), with treatment duration determined by diagnostic studies and the persistence of a prothrombotic state. Other specific therapies should be directed at the underlying thrombophilic disorder. These treatments include direct thrombin inhibitors such as argatroban for heparin-induced thrombocytopenia (HIT), myelosuppressive drugs such as hydroxyurea for essential thrombocytosis, plasma exchange for thrombotic thrombocytopenic purpura, and phlebotomy for polycythemia vera. Additionally, the treating physician must seek input early from a hematologist or rheumatologist when managing patients with known or suspected HIT, TTP, and myeloproliferative disorders, or the antiphospholipid syndrome, respectively. This interdisciplinary interface is critical to ensure an optimal outcome when treating patients with arterial thrombophilia.

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References and Recommended Reading

  1. 1.
    Andreotti F, Becker RC: Atherothrombotic disorders: new insights from hematology. Circulation 2005, 111:1855–1863.PubMedCrossRefGoogle Scholar
  2. 2.
    Kim, RJ, Becker RC: Association between factor V Leiden, prothrombin G20210A, and methylenetetrahydrofolate reductase C677T mutations and events of the arterial circulatory system: a meta-analysis of published studies. Am Heart J 2003, 146:948–957.PubMedCrossRefGoogle Scholar
  3. 3.
    Adams HP Jr: Patent foramen ovale: paradoxical embolism and paradoxical data. Mayo Clin Proc 2004, 79:15–20.PubMedCrossRefGoogle Scholar
  4. 4.
    Homocysteine Studies Collaboration: Homocysteine and risk of ischemic heart disease and stroke: a meta-analysis. JAMA 2002, 288:2015–2022.CrossRefGoogle Scholar
  5. 5.
    Toole JF, Malinow MR, Chambless LE, et al.: Lowering homocysteine in patients with ischemic stroke to prevent recurrent stroke, myocardial infarction, and death: the Vitamin Intervention for Stroke Prevention (VISP) randomized controlled trial. JAMA 2004, 291:565–575.PubMedCrossRefGoogle Scholar
  6. 6.
    Bonaa KH, Njolstad I, Ueland PM, et al.: Homocysteine lowering and cardiovascular events after acute myocardial infarction. N Engl J Med 2006, 354:1578–1588.PubMedCrossRefGoogle Scholar
  7. 7.
    Lonn E, Yusuf S, Arnold MJ, et al.: Homocysteine lowering with folic acid and B vitamins in vascular disease. N Engl J Med 2006, 354:1567–1577.PubMedCrossRefGoogle Scholar
  8. 8.
    Becker RC, Fintel DJ, Green D: Thrombotic disorders. In Antithrombotic Therapy, edn 4. Edited by Becker RC, Fintel DJ, Green D. Caddo, OK: Professional Communications, Inc.; 2006:199–218.Google Scholar
  9. 9.
    George JN: Clinical practice: thrombotic thrombocytopenic purpura. N Engl J Med 2006, 354:1927–1935.PubMedCrossRefGoogle Scholar
  10. 10.
    Ohman EM, Granger CB, Rice L, et al.: Identification, diagnosis and treatment of heparin-induced thrombocytopenia and thrombosis: a registry of prolonged heparin use and thrombocytopenia among hospitalized patients with and without cardiovascular disease. The Complication After Thrombocytopenia Caused by Heparin (CATCH) Registry Steering Committee. J Thromb Thrombolysis 2005, 19:11–19.PubMedCrossRefGoogle Scholar
  11. 11.
    Schafer AI: Molecular basis of the diagnosis and treatment of polycythemia vera and essential thrombocythemia. Blood 2006, 107:4214–4222.PubMedCrossRefGoogle Scholar
  12. 12.
    Anderson JL, Adams CD, Antman EM, et al.: ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction. J Am Coll Cardiol 2007, 50:e1–e157.PubMedCrossRefGoogle Scholar
  13. 13.
    Cattaneo M: P2Y12 receptor antagonists: a rapidly expanding group of antiplatelet agents. Eur Heart J 2006, 27:1010–1012.PubMedCrossRefGoogle Scholar
  14. 14.
    Bauer K: New anticoagulants: anti IIa vs anti Xa—is one better? J Throm Thrombolysis 2006, 21:67–72.CrossRefGoogle Scholar
  15. 15.
    Howard EL, Becker KCD, Rusconi CP, Becker RC: Factor IXa inhibitors as novel anticoagulants. Arterioscler Thromb Vasc Biol 2007, 27:722–727.PubMedCrossRefGoogle Scholar
  16. 16.
    Giugliano RP, Wiviott SD, Stone PH, et al.: Recombinant nematode anticoagulant protein c2 in patients with non-ST-segment elevation acute coronary syndrome: the ANTHEM-TIMI-32 trial. J Am Coll Cardiol 2007, 49:2398–2407.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  1. 1.Duke Clinical Research InstituteDurhamUSA

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