antithrombotic therapy - tri-ist.com 13 october/debate/turpie.pdfwhat does these guys have in common...
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What does these guys have in common with the Editor of the 9th ACCP Guidelines on
Antithrombotic Therapy
Guidelines Oxford English Dictionary
“ A general rule, principle or piece of advice
Oxford Advanced American Dictionary
“Something that can be used to help you make a decision”
Complex Confusing Contradictory Inconsistent and
Certainly not
“Something that can be used to help you make a decision”
Grading System
Strong Recommendation 1
Weak Recommendation 2
High - quality evidence A
Moderate - quality evidence B
Low or very low - evidence C
ACCP Guidelines - 2012 Major Innovations in AT9 1 Unconflicted methodologists as topic editors.
2 Conflicted experts did not participate in final process of making recommendations.
3 Many evidence profile and summary of finding tables.
4 New insights into evidence
(asymptomatic thrombosis, aspirin).
5 Quantitative specification of values and preferences based on systematic review of relevant evidence and formal preference rating exercise.
6 Article addressing diagnosis of DVT.
CHEST / 141 / 2 / FEBRUARY, 2012 SUPPLEMENT
Innovation 4
Asymptomatic thrombosis is of no clinical significance
Who among us will ignore the source of many fatal PE ?
In patients undergoing THA or TKA, we recommend use of one of the following for a minimum of 10 to 14 days rather than no antithrombotic prophylaxis:
Low-molecular-weight heparin (LMWH), fondaparinux, apixaban, dabigatran, rivaroxaban, low-dose unfractionated heparin (LDUH), adjusted-dose VKA, aspirin
(all Grade 1B) ,
or an intermittent pneumatic compression device (IPCD)
(Grade 1C) .
CHEST / 141 / 2 / FEBRUARY, 2012 SUPPLEMENT
ACCP Guidelines – 2012
For patients undergoing major orthopedic
surgery, we suggest extending
thromboprophylaxis in the outpatient period
for up to 35 days from the day of surgery
rather than for only 10 to 14 days
(Grade 2B) .
CHEST / 141 / 2 / FEBRUARY, 2012 SUPPLEMENT
ACCP Guidelines – 2012
In patients undergoing THA or TKA, irrespective of the concomitant use of an IPCD or length of treatment, we suggest the use of LMWH in preference to the other agents we have recommended as alternatives: fondaparinux, apixaban, dabigatran, rivaroxaban, LDUH (all
Grade 2B) , adjusted-dose VKA, or aspirin (all
Grade 2C) .
Is this evidence based????
ACCP Guidelines – 2012 Orthopaedic Prophylaxis
What is the basis for this statement? In patients undergoing major orthopedic surgery and who decline or are uncooperative with injections or an IPCD, we recommend using apixaban or dabigatran (alternatively rivaroxaban or adjusted-dose VKA if apixaban or dabigatran are unavailable) rather than alternative forms of prophylaxis (all Grade 1B).
ACCP Guidelines – 2012 Orthopaedic Prophylaxis
Pooled estimates of the results of RCTs comparing oral anticoagulants vs. enoxaparin in THR or TKR
Adapted from Eriksson et al. Annu Rev Med 2011;62:41-57
RE-NOVATE
RE-MOBILIZE
RE-MODEL
RE-NOVATE II Overall
Dabigatran
RECORD3
RECORD2
RECORD1
RECORD4 Overall
Rivaroxaban
ADVANCE-3
ADVANCE-2
ADVANCE-1
Overall
Apixaban
RR=1.03 p=0.58
RR=0.46 p<0.001
RR=0.67 p<0.001
RR=1.09 p=0.66
RR=1.85 p=0.07
RR=0.78 p=0.21
Favours enoxaparin
Favours oral drug
Favours enoxaparin
VTE/all-cause death
Favours enoxaparin Favours oral drug
0.1 1.0 10.0 RR (log scale)
Major bleeding
Favours enoxaparin Favours oral drug
0.1 1.0 10.0 RR (log scale)
Favours oral drug
No head-to-head randomised clinical trials comparing apixaban, rivaroxaban and dabigatran have been performed. Results of indirect comparisons need to be interpreted with caution.
New anticoagulants in THR/TKR
Dabigatran: as effective and safe vs enoxaparin 40 mg OD; less effective than enoxaparin 30 mg BID; equal bleeding rate
Rivaroxaban: more efficacious than enoxaparin 40 mg OD/30 mg BID; equal major bleeds but more total bleeds than enoxaparin
Apixaban: less effective than enoxaparin 30 mg BID; more effective than enoxaparin 40 mg OD; equal major bleeds and less total bleeds than enoxaparin 30 mg BID
Prophylaxis in Orthopaedics
New oral anticoagulants have similar or greater efficacy and safety to LMWH, but are easier to administer New agents will streamline VTE prophylaxis in orthopaedic surgery and will facilitate extended therapy
Treatment of VTE ACCP Recommendations 9th Edition Anticoagulant therapy*
– Indicated for most patients vs other approaches (grade 2C) – Initial parenteral anticoagulation (grade 1B)
– Long-term therapy needed (grade 1B)
– VKA if no cancer (grade 2C) and INR 2.0 to 3.0 (grade 1B)
Thrombolytic therapy: IV – Acute PE + hypotension (grade 2c)
– Risk of intracranial bleeding: 1% to 3%
Thrombolytic therapy: catheter – directed – Highly selected patients with low-bleeding risk
IVC filter – Proximal DVT or PE in whom anticoagulants are contraindicated
(grade 1B)
– If IVC filter is inserted, anticoagulant therapy if bleeding risk resolves (grade 2B)
*Duration of therapy depends on bleeding risk. ACCP = American College of Chest Physicians; INR = international normalized ratio; IV = intravenous.
Kearon C et al. Chest. 2012;141(2 suppl):e419S-e494s.
VTE Treatment Guidelines: Treatment Duration
ACCP 2012
First episode, secondary to a transient risk factor
3 months (grade 1B)
Unprovoked DVT of the leg/PE
≥3 months (grade 1B)
Second unprovoked VTE ≥3 months (grade 1B/2B)
VTE and active cancer ≥3 months* (grade 1B/2B)
*Duration of therapy depends on bleeding risk..
Kearon C et al. Chest. 2012;141(2 suppl):e419S-e494s.
There is no high quality evidence for treatment of VTE
What have we been doing for the last 30 years???