Embolism and thrombosis

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Embolism and thrombosis is "a collective term for pathological conditions which are caused by the formation of a blood clot (thrombus) in a blood vessel, or by blocking of a blood vessel with an embolus, undissolved materials in the blood stream."[1]

The United States Surgeon General has announced a call to action to prevent Deep Vein Thrombosis and Pulmonary Embolism.[2]

Classification

Cause/etiology

One risk factor is hypercoagulability due to cancer. Cancer can be found in up to 10% of patients within one year of embolism or thrombosis.[4]

Genetics

The presence of Factor V Leiden but not prothrombin G20210A increases risk of recurrence.[5]

Malignancy

The prevalence of malignancy is about:[6]

  • 3% of patients with first idiopathic venous thrombosis
  • 17% of patients with idiopathic, idiopathic venous thrombosis

The most common sites of cancer that is diagnosed at the time of, or later than the episode embolism and thrombosis of are:[7][8]

Prognosis

A systematic review of cohort studies found:[9]

  • During the initial 3 months of anticoagulation
    • Recurrent VTE = 3.4%
      • Recurrent fatal VTE was 0.4% (case-fatality rate was 11.3%)
    • Major bleeding was 1.6%
      • Fatal major bleeding events was 0.2% (case-fatality rate of 11.3%)
  • After anticoagulation
    • Recurrent VTE = 7.6% per 100 patient-years
      • Recurrent fatal VTE was 0.3% per 100 patient-years (case-fatality rate was 3.6%)

Treatment

Embolism and thrombosis may be prevented by anticoagulation with anticoagulants.

Dabigatran is given orally and may be as effective as warfarin and with less bleeding but increased dyspepsia for the treatment of embolism and thrombosis.[10]

Duration of treatment

Randomized controlled trials since 1995 of the duration of anticoagulation
  Patients Duration of
short course		 Duration of
long course		 findings
Campbell, 2007[11] DVT or PE without prior episode within 3 years 3 mos 6 mos Prolonged tended to do slightly better
Schulman, 2003[12] DVT or PE. 13% had prior VTE. 6 mos 24 mos Prolonged did better
Kearon, 2004[13] First episode of VTE due to transient risk factor 1 mo 3 mos Prolonged did better
Ridker, 2003[14] Idiopathic VTE. 30% had prior VTE 6 mos 2.1 yrs Prolonged did better
Agnelli, 2001[15] First episode of idiopathic DVT 3 mos 1 yr Prolonged did better while anticoagulated, but after two years there was no difference
Kearon, 1999[16] First episode of idiopathic VTE. 3 mos 2 yrs Prolonged did better
Pinede, 2001[17] DVT or PE without prior episode within 3 years 6 wks for distal DVT;
3 mos for proximal or PE		 12 wks for distal DVT;
6 mos for proximal or PE		 Prolonged tended to do slightly better
Levine, 1995[18] Acute DVT with normal normal impedance plethysmogram (IPG) after 4 weeks 1 mo 3 mos Prolonged tended to do better

Clinical practice guidelines by the American College of Chest Physicians address the duration of anticoagulation for deep venous thrombosis and pulmonary embolism.[19] Although initial trials suggested lack of benefit from prolonged anticoaguation[20], trials since 1995 favor longer anticoagulation. In patients who have had recurrent DVTs (two or more), anticoagulation is generally "life-long." The Cochrane Collaboration and others have meta-analyzed the risk and benefits of prolonged anti-coagulation.[21][20]

Recommendations by the American College of Chest Physicians for the Duration of Therapy[19]
Setting Recommended duration
Single DVT due to transient risk factor 3 months
Single unprovoked DVT at least 3 months (longer if favorable risks for anticoagulation)
Second episode of unprovoked VTE long-term treatment
DVT in patients with cancer LMWH for the first 3 to 6 months of long-term anticoagulant therapy

Using D-dimer to determine duration of treatment

For more information, see: D-dimer.


Using Ultrasonography to determine duration of treatment

Ultrasonography, using the following protocol may[22] or may not[23] help determine when to stop anticoaguation[22]:

"If veins had not recanalized, we invited patients to have further ultrasonography after 3 and 9 months in patients with secondary DVT and after 3, 9, 15, and 21 months in those with unprovoked DVT. Anticoagulation was discontinued when the veins had recanalized, along with further ultrasonography"

Prognosis

The presence of Factor V Leiden but not prothrombin G20210A increases risk of recurrence.[5]

Prevention

Among patients with cancer, anticoagulation does not help in the primary prevention of embolism and thrombosis.[24]

Rosuvastatin, a hydroxymethylglutaryl-coenzyme A reductase inhibitor (statin), may reduce embolism and thrombosis according to the Jupiter randomized controlled trial.[25]

References

  1. ↑ Anonymous (2024), Embolism and thrombosis (English). Medical Subject Headings. U.S. National Library of Medicine.
  2. ↑ The Surgeon General's Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism. Office of Public Health and Science (2008).
  3. ↑ Decousus H, Quéré I, Presles E, Becker F, Barrellier MT, Chanut M et al. (2010). "Superficial venous thrombosis and venous thromboembolism: a large, prospective epidemiologic study.". Ann Intern Med 152 (4): 218-24. DOI:10.1059/0003-4819-152-4-201002160-00006. PMID 20157136. Research Blogging.
  4. ↑ Carrier M, Le Gal G, Wells PS, Fergusson D, Ramsay T, Rodger MA (September 2008). "Systematic review: the Trousseau syndrome revisited: should we screen extensively for cancer in patients with venous thromboembolism?". Annals of internal medicine 149 (5): 323–33. PMID 18765702. [e]
  5. ↑ 5.0 5.1 Segal JB, Brotman DJ, Necochea AJ, et al. (June 2009). "Predictive value of factor V Leiden and prothrombin G20210A in adults with venous thromboembolism and in family members of those with a mutation: a systematic review". JAMA 301 (23): 2472–85. DOI:10.1001/jama.2009.853. PMID 19531787. Research Blogging.
  6. ↑ Prandoni P, Lensing AW, Büller HR, Cogo A, Prins MH, Cattelan AM et al. (1992). "Deep-vein thrombosis and the incidence of subsequent symptomatic cancer.". N Engl J Med 327 (16): 1128-33. PMID 1528208.
  7. ↑ Sørensen HT, Mellemkjaer L, Olsen JH, Baron JA (2000). "Prognosis of cancers associated with venous thromboembolism.". N Engl J Med 343 (25): 1846-50. PMID 11117976.
  8. ↑ Sørensen HT, Mellemkjaer L, Steffensen FH, Olsen JH, Nielsen GL (1998). "The risk of a diagnosis of cancer after primary deep venous thrombosis or pulmonary embolism.". N Engl J Med 338 (17): 1169-73. PMID 9554856.
  9. ↑ Carrier M, Le Gal G, Wells PS, Rodger MA (2010). "Systematic review: case-fatality rates of recurrent venous thromboembolism and major bleeding events among patients treated for venous thromboembolism.". Ann Intern Med 152 (9): 578-89. DOI:10.1059/0003-4819-152-9-201005040-00008. PMID 20439576. Research Blogging.
  10. ↑ Schulman S, Kearon C, Kakkar AK, Mismetti P, Schellong S, Eriksson H et al. (2009). "Dabigatran versus warfarin in the treatment of acute venous thromboembolism.". N Engl J Med 361 (24): 2342-52. DOI:10.1056/NEJMoa0906598. PMID 19966341. Research Blogging. Review in: Ann Intern Med. 2010 Apr 20;152(8):JC4-7
  11. ↑ Campbell IA, Bentley DP, Prescott RJ, Routledge PA, Shetty HG, Williamson IJ (March 2007). "Anticoagulation for three versus six months in patients with deep vein thrombosis or pulmonary embolism, or both: randomised trial". BMJ 334 (7595): 674. DOI:10.1136/bmj.39098.583356.55. PMID 17289685. PMC 1839169. Research Blogging.
  12. ↑ Schulman S, Wåhlander K, Lundström T, Clason SB, Eriksson H (October 2003). "Secondary prevention of venous thromboembolism with the oral direct thrombin inhibitor ximelagatran". N. Engl. J. Med. 349 (18): 1713–21. DOI:10.1056/NEJMoa030104. PMID 14585939. Research Blogging.
  13. ↑ Kearon C, Ginsberg JS, Anderson DR, et al (May 2004). "Comparison of 1 month with 3 months of anticoagulation for a first episode of venous thromboembolism associated with a transient risk factor". J. Thromb. Haemost. 2 (5): 743–9. DOI:10.1046/j.1538-7836.2004.00698.x. PMID 15099280. Research Blogging.
  14. ↑ Ridker PM, Goldhaber SZ, Danielson E, et al (April 2003). "Long-term, low-intensity warfarin therapy for the prevention of recurrent venous thromboembolism". N. Engl. J. Med. 348 (15): 1425–34. DOI:10.1056/NEJMoa035029. PMID 12601075. Research Blogging.
  15. ↑ Agnelli G, Prandoni P, Santamaria MG, et al (July 2001). "Three months versus one year of oral anticoagulant therapy for idiopathic deep venous thrombosis. Warfarin Optimal Duration Italian Trial Investigators". N. Engl. J. Med. 345 (3): 165–9. PMID 11463010. [e]
  16. ↑ Kearon C, Gent M, Hirsh J, et al (March 1999). "A comparison of three months of anticoagulation with extended anticoagulation for a first episode of idiopathic venous thromboembolism". N. Engl. J. Med. 340 (12): 901–7. PMID 10089183. [e]
  17. ↑ Pinede L, Ninet J, Duhaut P, et al (May 2001). "Comparison of 3 and 6 months of oral anticoagulant therapy after a first episode of proximal deep vein thrombosis or pulmonary embolism and comparison of 6 and 12 weeks of therapy after isolated calf deep vein thrombosis". Circulation 103 (20): 2453–60. PMID 11369685. [e]
  18. ↑ Levine MN, Hirsh J, Gent M, et al (August 1995). "Optimal duration of oral anticoagulant therapy: a randomized trial comparing four weeks with three months of warfarin in patients with proximal deep vein thrombosis". Thromb. Haemost. 74 (2): 606–11. PMID 8584992. [e]
  19. ↑ 19.0 19.1 Kearon C, Kahn SR, Agnelli G, Goldhaber S, Raskob GE, Comerota AJ (June 2008). "Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)". Chest 133 (6 Suppl): 454S–545S. DOI:10.1378/chest.08-0658. PMID 18574272. Research Blogging.
  20. ↑ 20.0 20.1 Ost D, Tepper J, Mihara H, Lander O, Heinzer R, Fein A (August 2005). "Duration of anticoagulation following venous thromboembolism: a meta-analysis". JAMA 294 (6): 706–15. DOI:10.1001/jama.294.6.706. PMID 16091573. Research Blogging.
  21. ↑ Hutten BA, Prins MH (2006). "Duration of treatment with vitamin K antagonists in symptomatic venous thromboembolism". Cochrane database of systematic reviews (Online) (1): CD001367. DOI:10.1002/14651858.CD001367.pub2. PMID 16437432. Research Blogging.
  22. ↑ 22.0 22.1 Prandoni, Paolo; Martin H. Prins, Anthonie W.A. Lensing, Angelo Ghirarduzzi, Walter Ageno, Davide Imberti, Gianluigi Scannapieco, Giovanni B. Ambrosio, Raffaele Pesavento, Stefano Cuppini, Roberto Quintavalla, Giancarlo Agnelli, for the AESOPUS Investigators (2009-05-05). "Residual Thrombosis on Ultrasonography to Guide the Duration of Anticoagulation in Patients With Deep Venous Thrombosis: A Randomized Trial". Ann Intern Med 150 (9): 577-585. PMID 19414836. Retrieved on 2009-05-06.
  23. ↑ Robinson KS, Anderson DR, Gross M, et al. (September 1997). "Ultrasonographic screening before hospital discharge for deep venous thrombosis after arthroplasty: the post-arthroplasty screening study. A randomized, controlled trial". Ann. Intern. Med. 127 (6): 439–45. PMID 9313000. [e]
  24. ↑ Wells PS (May 2008). "Review: evidence for the effectiveness of anticoagulation therapy or prophylaxis for VTE in cancer is limited". ACP J. Club 148 (3): 7. PMID 18489070. [e]
  25. ↑ Glynn RJ, Danielson E, Fonseca FA, et al (March 2009). "A Randomized Trial of Rosuvastatin in the Prevention of Venous Thromboembolism". N. Engl. J. Med.. DOI:10.1056/NEJMoa0900241. PMID 19329822. Research Blogging.
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