Login to your account

Username *
Password *
Remember Me

Blog With Right Sidebar

    Vous êtes ici :  
  1. Accueil
  2. Blog With Right Sidebar

[New treatments for venous thromboembolic disease].

[New treatments for venous thromboembolic disease].

J Mal Vasc. 2011 Dec;36 Suppl 1:S16-9

Authors: Combe S, Büller HR,

Abstract
Following the landmark study by Barritt and Jordan in 1960, in which patients with venous thromboembolism (VTE) were randomized to no treatment or a combination of heparin and warfarin, antithrombotic therapy for this disease became widely accepted. This study was stopped prematurely because half of the non-treated patients had recurrent pulmonary embolism (PE), or died. It was subsequently found that after a VTE, patients given warfarin alone had a 3-4-fold higher incidence of recurrent VTE than patients given both heparin and warfarin. Since the 1990s, standard therapy for VTE has comprised an initial 5-7 day course of parenteral anticoagulant plus warfarin continued for at least 3 months. Recently, several orally active small molecules have been evaluated in the treatment of VTE, including a direct thrombin inhibitor and direct Factor Xa inhibitors. Other novel oral agents are also in development for VTE treatment. Although the DTI ximelagatran, the first oral agent to be introduced since warfarin was withdrawn from the market in Europe because of hepatotoxicity, evidence from clinical trial evaluating other single target-specific oral agents in the treatment of VTE is encouraging. It is therefore likely that use of warfarin in the treatment and secondary prevention of VTE will decrease should these novel oral agents be introduced for these indications. Additionally, there will be less distinction between initial and long-term therapy, and a great majority of patients will be treated on an outpatient basis for prolonged periods of time. Recently these expectations were fulfilled by the results of two Phase III studies in patients with VTE. The Recover I study indicated that Dabigatran (150mg b.d.) following an initial course of LMWH was non-inferior to the standard treatment of LMWH plus warfarin, with also a similar safety profile. The Einstein DVT study revealed that Rivaroxaban as a single agent can safely replace the standard treatment in patients with DVT. Taken together these studies and a few others that have or are about to be completed will indeed introduce a paradigm shift in the way patients with VTE will be treated.

PMID: 22177764 [PubMed - in process]

[The role of thrombolysis in the clinical management of deep vein thrombosis].

[The role of thrombolysis in the clinical management of deep vein thrombosis].

J Mal Vasc. 2011 Dec;36 Suppl 1:S20-7

Authors: Pernès JM

Abstract
Acute Deep Venous Thrombosis (DVT) therapies have been judged primarily on their ability to prevent symptomatic pulmonary embolism, early thrombus progression, and recurrent VTE. The cornerstones of current management of DVT, supported by the 2008 American College of Chest Physicians (ACCP) guidelines, are the routine use of anticoagulant therapy, graduated elastic compression stockings, and early ambulation. For selected appropriate patients with extensive acute proximal DVT, while the French recommendations (Afssaps 2009) still consider thrombolysis not indicated, ACCP guidelines now suggest in-situ thrombolysis in addition to anticoagulation to reduce the risk of subsequent postthrombotic syndrome (PTS) and recurrent DVT (Grade 2 B recommendation). Contemporary invasive endovascular treatments, called pharmacomechanical treatment, mitigate the drawbacks (major bleeding) historically associated with systemic thrombolytic approaches, by means of intra-thrombus delivery of drugs, followed by mechanical dispersion to accelerate lysis and then aspiration of remaining drug and clot debris. The proof of concept for the "open vein" hypothesis - that a strategy of early thrombus removal can reduce the incidence of PTS long term - comes incrementally and randomized trials (ATTRACT trial with a 2016 target completion date) are currently under way and might lead to a shift of the paradigms of the management of acute DVT focused on active thrombus removal.

PMID: 22177765 [PubMed - in process]

[Optimal duration of anticoagulation of venous thromboembolism].

[Optimal duration of anticoagulation of venous thromboembolism].

J Mal Vasc. 2011 Dec;36 Suppl 1:S28-32

Authors: Noel Savina E, Couturaud F

Abstract
The optimal duration of anticoagulation after venous thromboembolism (VTE) is determined according to the risk of recurrent VTE after stopping anticoagulant therapy and the risk of anticoagulant-related bleeding while on antivitamin K. Clinical risk factors appears to be determinant to predict the risk of recurrence whereas the influence of biochemical and morphological tests is uncertain. The risk of recurrent venous thromboembolism is low when the initial episode was provoked by a reversible major risk factor (surgery) : 3 months of anticoagulation is optimal. Conversely, this risk is high when venous thromboembolism was unprovoked or associated with persistent risk factor (cancer) : 6 months or more prolonged anticoagulation is warranted. After this first estimation, the duration of anticoagulation may be modulated according to the presence of additional minor risk factors (major thrombophilia, chronic pulmonary hypertension, massive pulmonary embolism) : 6 months if VTE was provoked and 12 to 24 months if VTE was unprovoked. If the risk of anticoagulant related bleeding is high, the duration of anticoagulation should be shortened (3 months if VTE was provoked and 6 or 3 months if it was unprovoked). Lastly, if VTE occurred in the setting of a cancer, anticoagulation should be conducted for 6 months or more while cancer is active or on ongoing treatment. Despite an increasing knowledge of the risk factors of recurrent VTE, a number of issues remain unresolved ; randomised trial comparing different duration of anticoagulation are needed.

PMID: 22177766 [PubMed - in process]

[Thrombolytic therapy for pulmonary embolism].

[Thrombolytic therapy for pulmonary embolism].

J Mal Vasc. 2011 Dec;36 Suppl 1:S33-6

Authors: Meyer G

Abstract
Pulmonary embolism with choc carries a 25 to 50% mortality rate. Although no large randomized clinical trial is available, some insights of a meta-analysis suggest that thrombolysis decreases the mortality rate in these patients. In patients without clinical evidence of haemodynamic impairment, the mortality rate is much lower and does not justify more aggressive therapy other than anticoagulants. Recent data however suggest that among clinically stable patients, some may have a higher mortality risk. These so called sub-massive or intermediate-risk pulmonary embolism are defined either by right ventricular dysfunction assessed by echocardiography or by elevated troponin or brain natriuretic peptide. The role of thrombolytic treatment in these patients remains controversial. A large randomized controlled trial is underway to resume the debate.

PMID: 22177767 [PubMed - in process]

[Should we treat subsegmental pulmonary embolism?].

[Should we treat subsegmental pulmonary embolism?].

J Mal Vasc. 2011 Dec;36 Suppl 1:S37-41

Authors: Riopel C, Righini M

Abstract
The expanded use of multi-detector computed tomography has increased the proportion of diagnosed subsegmental pulmonary embolism. The clinical significance and prognosis of these embolisms remain unknown and the benefit of anticoagulation is not yet proven. Several previously validated diagnostic strategies for pulmonary embolism exclusion (based on single-detector computed tomography and ventilation-perfusion lung scan) were unable to detect most of these subsegmental pulmonary embolisms. However, these strategies have been proven safe, with very few thromboembolic events at 3 months. Furthermore, the comparison between studies using single-detector and multi-detector computed tomography suggests increased rates of PE diagnosis and increased rates of anticoagulated patients without improvement of the three-month followup. Subsegmental pulmonary embolisms seem to have less clinical impact than proximal pulmonary embolisms and a better long-term prognosis. In some patients with isolated subsegmental pulmonary embolism, the bleeding risk related to anticoagulation might outweigh the benefit of preventing recurrent thromboembolic event.

PMID: 22177768 [PubMed - in process]

Search

Search