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Deep Vein Thrombosis of the Upper Extremity.

Journal Deutsches Arzteblatt international
Year 2017
Liens Pubmed DOI PubMed Central

Cet article inclut 18 Primary studies Primary studies (18 references) 3 Systematic reviews Systematic reviews (3 references)

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BACKGROUND: Deep venous thrombosis (DVT) arises with an incidence of about 1 per 1000 persons per year; 4-10% of all DVTs are located in an upper extremity (DVT-UE). DVT-UE can lead to complications such as post-thrombotic syndrome and pulmonary embolism and carries a high mortality. METHODS: This review is based on pertinent literature, published from January 1980 to May 2016, that was retrieved by a systematic search, employing the PRISMA criteria, carried out in four databases: PubMed (n = 749), EMBASE (n = 789), SciSearch (n = 0), and the Cochrane Library (n = 12). Guidelines were included in the search. RESULTS: DVT-UE arises mainly in patients with severe underlying diseases, especially cancer (odds ratio [OR] 18.1; 95% confidence interval [9.4; 35.1]). The insertion of venous catheters-particularly central venous catheters-also elevates the risk of DVT-UE. Its clinical manifestations are nonspecific. Diagnostic algorithms are of little use, but ultrasonography is very helpful in diagnosis. DVT-UE is treated by anticoagulation, with heparin at first and then with oral anticoagulants. Direct oral anticoagulants are now being increasingly used. The thrombus is often not totally eradicated. Anticoagulation is generally continued as maintenance treatment for 3-6 months. Interventional techniques can be used for special indications. Patients with DVT-UE have a high mortality, though they often die of their underlying diseases rather than of the DVT-UE or its complications. CONCLUSION: DVT of the upper extremity is becoming increasingly common, though still much less common than DVT of the lower extremity. The treatment of choice is anticoagulation, which is given analogously to that given for DVT of the lower extremity.

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Suboptimal Use of Oral Anticoagulants in Atrial Fibrillation: Has the Introduction of Direct Oral Anticoagulants Improved Prescribing Practices?

Journal American journal of cardiovascular drugs : drugs, devices, and other interventions
Year 2016
Liens Pubmed DOI

Cet article inclut 123 Primary studies Primary studies (123 references) 1 Systematic review Systematic reviews (1 reference)

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BACKGROUND AND OBJECTIVES: Atrial fibrillation (AF) and the associated risk of stroke are emerging epidemics throughout the world. Suboptimal use of oral anticoagulants for stroke prevention has been widely reported from observational studies. In recent years, direct oral anticoagulants (DOACs) have been introduced for thromboprophylaxis. We conducted a systematic literature review to evaluate current practices of anticoagulation in AF, pharmacologic features and adoption patterns of DOACs, their impacts on proportion of eligible patients with AF who receive oral anticoagulants, persisting challenges and future prospects for optimal anticoagulation. LITERATURE SOURCE AND SELECTION CRITERIA: In conducting this review, we considered the results of relevant prospective and retrospective observational studies from real-world practice settings. PubMed (MEDLINE), Scopus (RIS), Google Scholar, EMBASE and Web of Science were used to source relevant literature. There were no date limitations, while language was limited to English. Selection was limited to articles from peer reviewed journals and related to our topic. RESULTS: Most studies identified in this review indicated suboptimal use of anticoagulants is a persisting challenge despite the availability of DOACs. Underuse of oral anticoagulants is apparent particularly in patients with a high risk of stroke. DOAC adoption trends are quite variable, with slow integration into clinical practice reported in most countries; there has been limited impact to date on prescribing practice. CONCLUSION: Available data from clinical practice suggest that suboptimal oral anticoagulant use in patients with AF and poor compliance with guidelines still remain commonplace despite transition to a new era of anticoagulation featuring DOACs.

Broad synthesis / Guideline

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Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report.

Journal Chest
Year 2016
Liens Pubmed DOI

Cet article inclut 42 Primary studies Primary studies (42 references) 9 Systematic reviews Systematic reviews (9 references)

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BACKGROUND: We update recommendations on 12 topics that were in the 9th edition of these guidelines, and address 3 new topics. METHODS: We generate strong (Grade 1) and weak (Grade 2) recommendations based on high- (Grade A), moderate- (Grade B), and low- (Grade C) quality evidence. RESULTS: For VTE and no cancer, as long-term anticoagulant therapy, we suggest dabigatran (Grade 2B), rivaroxaban (Grade 2B), apixaban (Grade 2B), or edoxaban (Grade 2B) over vitamin K antagonist (VKA) therapy, and suggest VKA therapy over low-molecular-weight heparin (LMWH; Grade 2C). For VTE and cancer, we suggest LMWH over VKA (Grade 2B), dabigatran (Grade 2C), rivaroxaban (Grade 2C), apixaban (Grade 2C), or edoxaban (Grade 2C). We have not changed recommendations for who should stop anticoagulation at 3 months or receive extended therapy. For VTE treated with anticoagulants, we recommend against an inferior vena cava filter (Grade 1B). For DVT, we suggest not using compression stockings routinely to prevent PTS (Grade 2B). For subsegmental pulmonary embolism and no proximal DVT, we suggest clinical surveillance over anticoagulation with a low risk of recurrent VTE (Grade 2C), and anticoagulation over clinical surveillance with a high risk (Grade 2C). We suggest thrombolytic therapy for pulmonary embolism with hypotension (Grade 2B), and systemic therapy over catheter-directed thrombolysis (Grade 2C). For recurrent VTE on a non-LMWH anticoagulant, we suggest LMWH (Grade 2C); for recurrent VTE on LMWH, we suggest increasing the LMWH dose (Grade 2C). CONCLUSIONS: Of 54 recommendations included in the 30 statements, 20 were strong and none was based on high-quality evidence, highlighting the need for further research.

Broad synthesis

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Traitement antithrombotique pour la thromboembolie veineuse: Traitement antithrombotique et la prévention de la thrombose, 9ème édition: American College of Physicians Lignes directrices de pratique clinique fondées sur des preuves poitrine.

automatic
Journal Chest
Year 2012
Liens Pubmed DOI PubMed Central

Cet article inclut 75 Primary studies Primary studies (75 references) 10 Systematic reviews Systematic reviews (10 references)

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CONTEXTE: Cet article porte sur le traitement de la maladie de TEV. MÉTHODES: Nous avons généré une forte (Grade 1) et la faiblesse des recommandations (Grade 2) Sur la base (Grade A), (Grade B), et les preuves de haute qualité de qualité moyenne à faible qualité (grade C). RÉSULTATS: Pour thrombose veineuse profonde aiguë ou d'embolie pulmonaire (EP), nous recommandons un traitement initial de l'anticoagulant par voie parentérale (Grade 1B) ou anticoagulation par rivaroxaban. Nous suggérons héparine de bas poids moléculaire (HBPM) ou le fondaparinux sur IV héparine non fractionnée (Grade 2C) ou sous-cutanée d'héparine non fractionnée (Grade 2B). Nous suggérons un traitement thrombolytique pour PE avec hypotension (Grade 2C). Pour TVP proximale ou une EP, nous recommandons un traitement de 3 mois sur des périodes plus courtes (Grade 1B). Pour une première thrombose veineuse profonde proximale ou EP qui est provoquée par une chirurgie ou par un facteur de risque transitoire non chirurgicale, nous recommandons 3 mois de traitement (1b année; Grade 2B si provoquée par un facteur de risque non chirurgicale et le risque faible ou modéré saignements), qui est sans provocation , nous vous proposons un traitement prolongé si le risque de saignement est faible ou modérée (Grade 2B) et nous recommandons 3 mois de traitement si le risque de saignement est élevé (Grade 1B), et qui est associée à un cancer actif, nous recommandons un traitement prolongé (Grade 1B, 2B grade en cas de risque élevé de saignement) et de proposer des HBPM sur les antagonistes de la vitamine K (Grade 2B). Nous suggérons des antagonistes de la vitamine K ou HBPM sur dabigatran ou rivaroxaban (Grade 2B.) Nous suggérons des bas de contention pour éviter le syndrome post-thrombotique (Grade 2B). Pour une thrombose veineuse superficielle, nous vous suggérons fondaparinux prophylactique à dose unique ou HBPM plus aucune anticoagulation (Grade 2B), et suggérons fondaparinux sur HBPM (Niveau 2C). CONCLUSION: Des recommandations fortes s'appliquent à la plupart des patients, alors que les recommandations faibles sont sensibles aux différences entre les patients, y compris leurs préférences.

Broad synthesis

Unclassified

Thromboembolism.

Journal Clinical evidence
Year 2011
Liens Pubmed PubMed Central

Cet article inclut 34 Primary studies Primary studies (34 references) 28 Systematic reviews Systematic reviews (28 references)

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INTRODUCTION: Deep venous thrombosis (DVT) or pulmonary embolism may occur in almost 2 in 1000 people each year, with up to 25% of those having a recurrence. Around 5% to 15% of people with untreated DVT may die from pulmonary embolism. Risk factors for DVT include immobility, surgery (particularly orthopaedic), malignancy, pregnancy, older age, and inherited or acquired prothrombotic clotting disorders. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments for proximal DVT? What are the effects of treatments for isolated calf DVT? What are the effects of treatments for pulmonary embolism? What are the effects of interventions on oral anticoagulation management in people with thromboembolism? We searched: Medline, Embase, The Cochrane Library, and other important databases up to June 2010 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found 45 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review we present information relating to the effectiveness and safety of the following interventions: anticoagulation; compression stockings; low molecular weight heparin (short and long term, once or twice daily, and home treatment); oral anticoagulants (short and long term, high intensity, abrupt discontinuation, and computerised decision support); prolonged duration of anticoagulation; thrombolysis; vena cava filters; and warfarin.