Low Molecular Weight Heparin and the Treatment of Pulmonary Embolus. John Powers November 14, 2000. Cases. 84 wf with known DVT, suspected PE transferred to renal service ? UFH or LMWH in hospital? 38 wm with post-op DVT and PE ? UFH or LMWH? Hospital or Home?
Low Molecular Weight Heparin and the Treatment of Pulmonary Embolus
November 14, 2000
1. What is the evidence for the use of LMW Heparin in PE?
2. What is the evidence for home treatment or early discharge in PE patients treated with LMW Heparin?
Reduced binding to plasma proteins
Reduced binding to macrophages
Reduced binding to platelets
More predictable dose response
Decreased need for laboratory monitoring
Longer half life
Event 6.9% 2.8%
Bleed 5.0% 0.5%
Death 9.6% 4.7%
Koopman, et al
Event 9.0% 7.0%
PE 2.5% 1.8%
Bleed 2.0% 0.5%
Death 8.0% 6.9%
Event 6.0% 5.0%
Bleed 1.2% 2.0%
Death 6.7% 4.4%
Hospital stay reduced - (6.5 days vs.1.1 days)
LMW Heparin Is safe and effective for home treatment of proximal DVT
1021 randomized to LMWH (reviparin) or UFH. Patients had PE(1/3), DVT, or both
Thrombolytics planned - 12
Contraindication - 68
Anticoag w/in 24 hrs - 200
Difficult followup - 59
Event 4.9% 5.3%
Bleed 2.3% 3.1%
Death 7.6% 7.1%
“LMW Heparin is as effective and safe as UFH for initial management of VTE regardless of PE or previous VTE event.”
Evaluated combined endpoint of recurrent event, major bleed, and death
Event 4.5% 3.9%
Bleed 1.9% 1.6%
Death 4.5% 3.9%
“LMW Heparin is as effective and as safe as UFH in patients with acute PE.”
Event 6.8% 0%
Bleed 1.9% 1.0%
Death 8.7% 6.2%
American-Canadian Thrombosis Study
“LMWH is no less effective and probably more effective than UFH in the initial treatment of patients with submassive PE.”
American College of Chest Physicians Consensus Recommendations (1998):“LMW Heparin can be substituted for unfractionated heparin in the treatment of DVT and stable condition patients with PE.”
Columbus vs. Wells
Event 5.3% 3.6%
Bleed 3.1% 2.0%
Death 7.1% 7.0%
38 wm with post-op DVT and PE
? UFH or LMWH? Hospital or Home?
84 wf with known DVT, suspected PE transferred to renal service
? UFH or LMWH in hospital?
25 bf with PE and hypoxia (4L NC)? UFH or LMWH? Discharge when?
43 wm s/p craniotomy, now with saddle embolus? UFH or LMWH?