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?
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 hundreds of thrombin molecules
Reduced binding to macrophages
Reduced binding to platelets
More predictable dose response
Decreased need for laboratory monitoring
Longer half life
Less thrombocytopeniaAdvantages of LMWH
Results hundreds of thrombin molecules
Event 6.9% 2.8%
Bleed 5.0% 0.5%
Death 9.6% 4.7%
Koopman, et al hundreds of thrombin molecules
Event 9.0% 7.0%
PE 2.5% 1.8%
Bleed 2.0% 0.5%
Death 8.0% 6.9%
Levine Results hundreds of thrombin molecules
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
Evaluated: hundreds of thrombin molecules
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 - 59Columbus Investigators
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.”
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.”
American-Canadian Results and death
Event 6.8% 0%
Bleed 1.9% 1.0%
Death 8.7% 6.2%
“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 and death
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?