lifeblood the thrombosis charity venous thromboembolism – treatment and secondary prevention ulcus...
TRANSCRIPT
LIFEBLOODTHE
ThrombosisCHARITY
Venous thromboembolism –Treatment and secondary prevention
Ulcus cruris Chronic PE
PE
DVT
Post-thromboticsyndrome
Death
Deep vein
insufficiency
Pulmonaryhypertension
LIFEBLOODTHE
ThrombosisCHARITY Deep vein thrombosis
Common femoral vein
Thrombus
KneeProximal
Distal
LIFEBLOODTHE
ThrombosisCHARITY
VTE event
Acute Continue
Treatment and secondary prevention of VTE
Heparin or LMWHtogether with a VKA (e.g. warfarin) until an INR of 2.0-3.0 is achieved
VKA (e.g. warfarin)INR 2.0-3.0
LIFEBLOODTHE
ThrombosisCHARITY
VTE - treatment options
Acute Acute Long-term Long-term
Anticoagulation - UFH/LMWH
Thrombolysis
Thrombectomy
Inferior vena cava filters (IVCF)
Anticoagulation- VKAs (e.g. warfarin)- LMWH
Stockings
LIFEBLOODTHE
ThrombosisCHARITY 7th ACCP recommendations
- Initial treatment for acute DVT or PE
Confirmed DVT or non-massive PE
– Initial treatment with sc LMWH or iv UFH (or sc if DVT) [Grade 1A] for at least 5 days [Grade 1C]
– Start VKA with LMWH or UFH on day 1 [Grade 1A]
– Stop LMWH or UFH when INR stable >2.0 [Grade 1A]
High clinical suspicion of VTE
– Anticoagulation until outcome of diagnostic tests [Grade 1C+]
Büller H et al. Chest 2004;126:401S–428S
LIFEBLOODTHE
ThrombosisCHARITY
VTE event
Acute Continue
Heparin or LMWHtogether with a VKA (e.g. warfarin) untill an INR of 2.0-3.0is achieved
VKA (e.g. warfarin)INR 2.0-3.0
3-6-12 months or lifelong
Decision point
Risk of VTE (5-7%/year)vs. Risk of bleeding (3-4%/year)
How long?
Treatment and secondary prevention of VTE
LIFEBLOODTHE
ThrombosisCHARITY
• First episode with a transient risk factor– 3 months after distal or proximal DVT [Grade 1A]– At least 3 months after PE [Grade 1A]
• First episode of idiopathic DVT/PE– VKA for at least 6–12 months [Grade 1A] but
consider indefinite duration [Grade 2A]
• Two or more episodes of DVT/PE– Suggest indefinite treatment [Grade 2A]
• Target INR 2.5 (range 2.0–3.0) [Grade 1A]
Büller H et al. Chest 2004;126:401S–428S
7th ACCP recommendations- Long-term treatment for DVT or PE
LIFEBLOODTHE
ThrombosisCHARITY
Long-term treatment of DVT
• Recurrence rate of VTE in patients with DVT dependent on – Underlying risk factors for DVT – Duration of treatment
• Decision regarding duration of treatmentdependent on – Underlying risk factors for DVT – Risk of haemorrhage from oral anticoagulation– Patient preference
• Numerous regimens studied to improve benefit of long-term treatment while reducing the dose
LIFEBLOODTHE
ThrombosisCHARITY
Recurrence of VTE after stopping oral anticoagulation
0
5
10
15
Event rate (%)
0 3 6 12 24
Months
3 months treatment
LIFEBLOODTHE
ThrombosisCHARITY
0
5
10
15
Event rate(%)
3 months treatment
0 3 6 12 24
Months
6 months treatment
Recurrence of VTE after stopping oral anticoagulation
LIFEBLOODTHE
ThrombosisCHARITY
0
5
10
15
Event rate(%)
0 3 6 12 24
Months
3 months treatment
6 months treatment
1 year treatment
Recurrence of VTE after stopping oral anticoagulation
LIFEBLOODTHE
ThrombosisCHARITY
Optimal duration of anticoagulation after VTE
DURAC I 897 6 1.5 24 9.5% 18.1% 1.1% 0.2%
LAFIT 162 27 3 10 1.3% 27.4% 3.8% 0.0%
WODIT-DVT 267 12 3 12 3.0% 8.3% 3.0% 0.8%
WODIT-PE 326 6-12 3 32.7 4.1% 9.1% 1.8% 0.0%
DOTAVK 539 6 3 15 8.7% 8.1% 2.6% 1.9%
DURAC II 227 Indefinite 6 43 2.6% 20.7% 8.6% 2.7%
months months months LongOAC
OAC, oral anticoagulation
ShortOAC
LongOAC
ShortOAC
Reference No. ofpatients
LongOAC
ShortOAC
Followup
RecurrentVTE
Major bleeding
LIFEBLOODTHE
ThrombosisCHARITY
Intensity of anticoagulant therapyRecurrent VTECumulative event rate (%)
0.25
0.20
0.15
0.10
0.05
0.00
0 1 2 3 4Years of follow-up
Low INR – PREVENT
Conventional INR - ELATE
Placebo - PREVENT
Low INR – ELATE
Ridker PM et al. N Engl J Med 2003; 348:1425-34Kearon C et al. N Engl J Med 2003;349:631-9