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Query: UMLS:C0149871 (deep vein thrombosis)
 12,364 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Low-molecular-weight heparin prophylaxis is an acceptable, if not superior, alternative to heparin and warfarin prophylaxis in TKA. Considering the current popularity of pharmacologic prophylaxis after total hip and total knee arthroplasty and the advantages of low-molecular-weight heparins over traditional pharmacologic agents, these agents have the potential to become the prophylactic agent of choice against DVT in TKA. There are several practical differences between low molecular weight heparins and warfarin. Low molecular weight heparins are administered by subcutaneous injection and do not require drug-level or blood monitoring. Warfarin, although administered orally, must be maintained within an appropriate international normalized ratio (INR=2-3) with daily dose adjustments and takes 36 hours to produce a measurable effect, which may leave patients relatively unprotected during the early postoperative period. Comparative trials have demonstrated that low molecular weight heparins are more efficacious than warfarin in producing a greater overall reduction in the incidence and risk of DVT, but show similar rates of PE. Some studies suggest that bleeding may be a greater problem with low molecular weight heparin. Despite the superior efficacy of low molecular weight heparin, the prevalence of venous thromboembolism after TKA continues to be substantial compared with total hip arthroplasty, with at least a quarter of patients still affected. Additional prophylaxis strategies for this indication are needed and could include combining mechanical prophylaxis (eg, external pneumatic compression) with low molecular weight heparin. An appropriate management strategy should be established for all patients undergoing TKA. This should include identification of high-risk patients, cautious transfusion of blood products, pharmacologic prophylaxis with an acceptable agent for TKA, early mobilization, postoperative screening in high-risk patients, and continuing pharmacologic prophylaxis for an appropriate period postoperatively.
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PMID:The role of low molecular weight heparin in total knee arthroplasty. 1005 Jun 95

Pulmonary thromboembolism remains a major cause of maternal death in the Western world. The frequency of antepartum deaths, including deaths in the first and second trimester, which can be associated with early pregnancy problems such as hyperemesis, is similar in number to the deaths occurring following delivery. Risk factors for deep vein thrombosis have been identified and include age > 35 years, operative delivery (particularly emergency Caesarean section), obesity and a personal or family history of thrombosis or thrombophilia. These risk factors should be used to guide administration of thromboprophylaxis during both pregnancy and the post-partum period, particularly after Caesarean section. Specific consideration towards thromboprophylactic agents is required. Warfarin crosses the placenta, is a known teratogen when used in early pregnancy and can also be associated with bleeding problems in the foetus, particularly at the time of delivery. Thus, warfarin has a limited use in the antenatal period and is usually only employed in patients such as those with artificial heart valves who require long-term anticoagulation. However, as warfarin does not cross the breast in any significant amount, it is suitable during breast feeding. In contrast, heparin does not cross the placenta or the breast therefore foetal problems are not associated with this treatment. However, heparin can be associated with problems such as heparin-induced osteoporosis, allergy and heparin-induced thrombocytopenia. The risk of some of these complications can be reduced by the use of low-molecular-weight heparins. When venous thromboembolism is suspected in pregnancy, it is critically important to obtain an objective diagnosis. This will include real-time or duplex ultrasound scan of the legs to elaborate the venous system, ventilation perfusion lung scan and, occasionally, venography. Treatment of established venous thromboembolism is similar to that in the non-pregnant patient and it is likely that low-molecular-weight heparins will play a major role in thromboprophylaxis in the future.
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PMID:The special case of venous thromboembolism in pregnancy. 1006 59

Upper extremity deep vein thrombosis (DVT) is now recognized as a major cause of morbidity and mortality. There is little information regarding the most effective treatment of this condition. We report a prospective cohort study of the use of low molecular weight heparin (LMWH) in the outpatient management of upper extremity DVT. Forty-six patients were managed as outpatients for objectively documented upper extremity DVT with dalteparin (200 aXa u/kg), for a minimum of five days. Warfarin was usually initiated on the first day with a target INR of 2.0-3.0. Most patients had an underlying malignancy or a history of a central line. All patients were followed for 12 weeks from diagnosis. Only one patient had a major bleed. No patients developed pulmonary emboli. One patient had a recurrence of DVT during the treatment with LMWH with extension of the existing thrombus. Seven patients died, all due to their underlying disease. This study supports the safety and effectiveness of dalteparin in the treatment of upper extremity DVT. Given that these patients were treated as outpatients, there is a potential for huge cost savings.
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PMID:Outpatient use of low molecular weight heparin (Dalteparin) for the treatment of deep vein thrombosis of the upper extremity. 1049 54

Twice-daily, inpatient, subcutaneous unfractionated heparin is at least as effective and safe as continuous intravenous unfractionated heparin for the treatment of acute deep vein thrombosis. Subcutaneous unfractionated heparin therefore may be suitable for outpatient treatment of deep vein thrombosis. The purpose of this study was to develop a dosing nomogram for a dose each 12 hours (2 doses per day) 12-hourly subcutaneous unfractionated heparin that is suitable for outpatient treatment of acute deep vein thrombosis. A cohort study was performed in patients with acute deep vein thrombosis in two phases. In both phases, the first subcutaneous loading dose of unfractionated heparin was 317 U/kg, and the second dose was 231 U/kg. The activated partial thromboplastin time was measured daily, 6 hours after the morning injection, and subsequent doses of unfractionated heparin were adjusted according to a nomogram, which was modified for phase II. Warfarin was started with unfractionated heparin. In phase I (14 outpatients), activated partial thromboplastin time results were frequently subtherapeutic (9:14) the day after starting unfractionated heparin (day 1), and were frequently supratherapeutic (27:40) after the first 2 days of unfractionated heparin therapy. In phase II (21 patients), to explain the frequently subtherapeutic activated partial thromboplastin time results that were obtained on day 1, the activated partial thromboplastin time results were measured after the initial loading dose. Mean activated partial thromboplastin time results of 86 and 61 seconds were obtained 6 and 12 hours after this dose, suggesting that 317 U/kg is a suitable subcutaneous loading dose. In contrast to phase I, in phase II, unfractionated heparin dose was not increased on day 1 in response to a low activated partial thromboplastin time result. This reduced the frequency of supratherapeutic activated partial thromboplastin time results during the early days of therapy without increasing the frequency of subtherapeutic results. Warfarin therapy had a substantal effect on the activated partial thromboplastin time that appeared to account for a high frequency of supratherapeutic results during the later days of unfractionated heparin therapy; the activated partial thromboplastin time increased by 20 seconds (95% CI, 14-27 seconds) with each increase in the International Normalized Ratio of 1.0. We had limited success at developing a dosing nomogram for subcutaneous unfractionated heparin that reliably achieved activated partial thromboplastin time results within the therapeutic range. However, as oral anticoagulants directly increased activated partial thromboplastin time results, we suggest that adjusting unfractionated heparin dose to achieve prespecified activated partial thromboplastin time results may not be appropriate in patients who are receiving concomitant warfarin therapy.
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PMID:Optimal dosing of subcutaneous unfractionated heparin for the treatment of deep vein thrombosis. 1070 48

Evidence-based medicine is currently a fashionable term. The evidence that warfarin is safe, effective, and cost beneficial in preventing stroke in AF, DVT treatment, and DVT prophylaxis is mounting. However, the evidence that warfarin remains underutilized in these conditions is also mounting. There is new evidence that supports conservative management of overanticoagulation without bleeding. The amount of time, if any, that patients are off warfarin for various procedures is being reduced. Warfarin interactions with other agents continue to be reported so that practitioners can avoid or treat them. Even the contraindication of warfarin in pregnancy is being reexamined. Those with expertise in anticoagulation therapy have an imperative to inform colleagues about the evidence in favor of warfarin.
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PMID:Warfarin therapy: a review of the literature since the Fifth American College of Chest Physicians' Consensus Conference on Antithrombotic Therapy. 1072 12

The management of deep venous thrombosis (DVT) and pulmonary embolism (PE) is changing dramatically. The US Food and Drug Administration has approved outpatient treatment of DVT with the low-molecular-weight heparin enoxaparin as a bridge to warfarin. Warfarin use is improved by avoiding loading doses and by recognizing previously unappreciated interactions and potentiation with commonly used medications such as acetaminophen. The importance of isolated calf and upper-extremity venous thromboses has been validated, so that patients with these conditions routinely undergo anticoagulation. Risk stratification for PE is becoming more sophisticated because practitioners now assess right ventricular function (usually by echocardiography) instead of relying solely on systemic arterial blood pressure and heart rate to determine prognosis. Among patients with massive DVT or hemodynamically unstable PE, thrombolysis, thrombectomy, and embolectomy (often performed in an interventional angiography laboratory) are being used with increasing skill and improved outcomes.
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PMID:Management of deep venous thrombosis and pulmonary embolism. 1080 Jun 64

The anticoagulant effect of warfarin should be kept at an international normalised ratio (INR) of about 2.5 (desirable range, 2.0-3.0), although a higher level may be better in a few clinical conditions. The risk of bleeding increases exponentially with INR and becomes clinically unacceptable once the INR exceeds 5.0. Warfarin therapy should be continued for around six weeks for symptomatic calf vein thrombosis, and for 3-6 months after proximal deep vein thrombosis (DVT) that occurs after surgery or limited medical illness. Therapy for six months or longer could be considered for DVT occurring without an obvious precipitating factor, proven recurrent venous thromboembolism (VTE), or if there are continuing risk factors. Oral anticoagulants prevent ischaemic stroke in atrial fibrillation (AF). Maximum efficacy requires an INR > 2.0, but some benefit remains at an INR of 1.5-1.9. Patients aged over 75 years are at greatest risk of intracranial bleeding during warfarin therapy for AF, and the target INR may be reduced to 2.0-2.5, or perhaps as low as 1.5-2.0, in such patients. Warfarin should be withheld if it is more likely to cause major bleeding than to protect from stroke (e.g., in young people with isolated AF where the annual baseline risk of stroke is < 1%). In patients with AF, aspirin is less effective than warfarin (much less effective after such patients have had a stroke or transient cerebral ischaemia). In people with prosthetic heart valves, an INR of 2.5-3.5 is probably sufficient for bileaflet or tilting disc valves, but a higher target INR is necessary for caged ball or caged disc valves. The addition of aspirin (100 mg/day) further decreases the risk of embolism but increases the risk of gastrointestinal bleeding.
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PMID:Consensus guidelines for warfarin therapy. Recommendations from the Australasian Society of Thrombosis and Haemostasis. 1091 7

Warfarin induced skin necrosis occurs in 0.01-0.1% of warfarin treated patients. The usual presentation is that of painful lesions developing in obese women after the initiation of warfarin treatment. The lesions usually evolve into full thickness skin necrosis within a few days. Although the exact mechanism is not totally clear, low levels of Protein C or S, either functional or inherited, are associated with many of the cases. We report the case of a 17-year-old patient treated with warfarin because of iliofemoral deep vein thrombosis post abortion. The patient developed several huge haemorrhagic blisters on the affected leg. The condition rapidly developed into full thickness skin and fat necrosis. The necrotic lesions were excised and eventually covered with skin graft. The combination of the patient tendency towards hyper-coagulation and the local factors is discussed.
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PMID:Warfarin skin necrosis: local and systemic factors. 1100 83

Pulmonary embolus (PE) after cardiac bypass surgery is an uncommon complication but carries with it high morbidity and mortality. The incidence of deep vein thrombosis (DVT) and PE after cardiac bypass varies depending on postoperative thromboprophylaxis, the presence of indwelling central venous catheters in the lower extremities, and early ambulation. The clinical diagnosis of DVT remains difficult and challenging. Pulmonary embolus is often the first occurring clinical event. The safety and effectiveness of preventative pharmacologic agents, such as subcutaneous unfractionated or fractionated heparin or oral coumadin, remain largely unknown. Heparin-induced thrombocytopenia, generally associated with a high incidence of DVT and PE, occurs in approximately 3.8% of patients who have undergone cardiac surgery and are placed postoperatively on high-dose intravenous unfractionated heparin. Sequential compression devices (SCD) have not been effective in reducing the incidence of DVT in an ambulating cardiac bypass patient when added to routine elastic graded compression stockings (GCS). Very large clinical trials are necessary to prove the effectiveness of pharmacologic or mechanical preventative measures in reducing the incidence of PE after cardiac surgery above the commonly used GCS, early ambulation, and aspirin. In a nonambulating, higher-risk cardiac bypass patient with slow recovery, a more aggressive prophylaxis regimen might be necessary for optimal prevention, although further data are needed to support this hypothesis.
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PMID:Pulmonary embolus after coronary artery bypass surgery: a review of the literature. 1101 12

We report a case of a 76 year-old woman who had been taking warfarin for seven years because of relapsing deep venous thrombosis. Her daily maintenance dose was 5 mg. Monthly measurements of international normalised ratio (INR) were stable between 2-3. She developed oral candidiasis and miconazole gel was prescribed. One week later she developed bleeding gums. Eight days later she was admitted to the hospital with haematuria. INR was > 10. Warfarin and the miconazole gel were withdrawn. She was treated with phytonadione. INR normalised after four days and she continued warfarin treatment. Caution should be exercised whenever the combination of warfarin and miconazole gel are prescribed.
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PMID:[Interaction between warfarin and oral miconazole gel]. 1106 29


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