Prevention of Venous Thromboembolism

Prevention of Venous Thromboembolism PowerPoint PPT Presentation


  • 211 Views
  • Uploaded on
  • Presentation posted in: General

Introduction. Venous ThromboembolismPulmonary Embolism150,000 to 200,00 deaths per yearMost common preventable cause of hospital deathFrequency of fatal pulmonary embolismElective general surgery: 0.1 to 0.8%Elective hip replacement: 2 to 3%Hip fracture: 4 to 7%Dismuke SE. Wagner EH. Pulmonary embolism as a cause of death. The changing mortality in hospitalized patients. JAMA 1986 Apr 18;255(15):2039-42.Horlander KT. Mannino DM. Leeper KV. Pulmonary embolism mortality in the United 30879

Download Presentation

Prevention of Venous Thromboembolism

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


1. Prevention of Venous Thromboembolism Henry Niho, M.D. David Geffen School of Medicine

2. Introduction Venous Thromboembolism Pulmonary Embolism 150,000 to 200,00 deaths per year Most common preventable cause of hospital death Frequency of fatal pulmonary embolism Elective general surgery: 0.1 to 0.8% Elective hip replacement: 2 to 3% Hip fracture: 4 to 7% Dismuke SE. Wagner EH. Pulmonary embolism as a cause of death. The changing mortality in hospitalized patients. JAMA 1986 Apr 18;255(15):2039-42. Horlander KT. Mannino DM. Leeper KV. Pulmonary embolism mortality in the United States, 1979-1998: an analysis using multiple-cause mortality data. Arch Intern Med 2003 Jul 28;163(14):1711-7.

3. Risk Factor for Venous Thromboembolism Advanced age Malignacy Previous venous thromboembolism Obesity Heart failure Paralysis Immobilization Pregnancy Hospitalization Hereditary hypercoagulable states Factor V Leiden Prothrombin G 20210A Mutation Antithrombin III Protein C Deficiency Protein S Deficiency

4. Low Risk Surgical Patient under the age of 40 no additional risk factors general anesthesia for less than 30 minutes minor, elective abdominal or thoracic surgery risk of proximal vein thrombosis: <1.0% risk of fatal pulmonary embolism: <0.01% Geerts WH. Et al. Prevention of venous thromboembolism. Chest 2001 Jan;119(1 Suppl):132S-175S.

5. Moderate Risk Surgical Patient over the age of 40 one or more risk factors general anesthesia for more than 30 minutes risk of proximal vein thrombosis: 2 to 10% risk of fatal pulmonary embolism: 0.1 to 0.7% Geerts WH. Et al. Prevention of venous thromboembolism. Chest 2001 Jan;119(1 Suppl):132S-175S.

6. High Risk Surgical Patient over the age of 40 surgery for malignancy or an orthopedic procedure of the lower extremity lasting more than 30 minutes inhibitor deficiency state or other risk factors risk of proximal vein thrombosis: 10 to 20% risk of fatal pulmonary embolism: 1.0 to 5.0% Geerts WH. Et al. Prevention of venous thromboembolism. Chest 2001 Jan;119(1 Suppl):132S-175S.

7. Prevention of Venous Thromboembolism Primary prophylaxis use of medications or physical devices that prevent deep vein thrombosis preferred in most clinical circumstances more cost-effective Secondary prophylaxis early detection and treatment of subclinical venous thrombosis by screening postoperative patients with objective tests that are sensitive for venous thrombosis reserved for patients in whom primary prophylaxis is either contraindicated or ineffective

8. Characteristics of Ideal Prophylaxis for Venous Thromboembolism Effective compared to placebo Safe Good compliance with patients, nurses, and physicians Easily administered No need for laboratory monitoring Cost effective

9. Primary Prophylaxis Medications Low dose heparin Adjusted dose heparin Low molecular weight heparin Oral anticoagulants Warfarin Aspirin Recombinant hirudin Fondaparinux Physical devices Intermitent pneumatic compression Graduated compression stockings

10. Low Dose Heparin Heparin 5000U SC 2 hours preoperatively then q 8 to 12 hrs prospective randomized study over 4000 patients undergoing major surgical procedures reduced the incidence of fatal pulmonary embolism from 0.7 to 0.1% compared to controls Prevention of fatal postoperative pulmonary embolism by low doses of heparin. An international multicentre trial. Lancet 1975 Jul 12;2(7924):45-51.

11. Low Dose Heparin in surgical patients, reduces the incidence of: all deep vein thrombosis all proximal deep vein thrombosis all pulmonary emboli, including fatal pulmonary emboli effective in medical patient Clagett GP. Reisch JS. Prevention of venous thromboembolism in general surgical patients. Results of meta-analysis. Ann Surg 1988 Aug;208(2):227-40. Collins R. et al. Reduction in fatal pulmonary embolism and venous thrombosis by perioperative administration of subcutaneous heparin. Overview of results of randomized trials in general, orthopedic, and urologic surgery. N Engl J Med 1988 May 5;318(18):1162-73. Nurmohamed MT. et al. Low-molecular-weight heparin versus standard heparin in general and orthopaedic surgery: a meta-analysis. Lancet 1992 Jul 18;340(8812):152-6. Harenberg J. et al. Subcutaneous low-molecular-weight heparin versus standard heparin and the prevention of thromboembolism in medical inpatients. The Heparin Study in Internal Medicine Group. Haemostasis 1996 May-Jun;26(3):127-39.

12. Low Dose Heparin no increase in major bleeding complications increase in minor wound hematomas rare occurence of heparin induced thrombocytopenia Prevention of fatal postoperative pulmonary embolism by low doses of heparin. An international multicentre trial. Lancet 1975 Jul 12;2(7924):45-51. Clagett GP. Reisch JS. Prevention of venous thromboembolism in general surgical patients. Results of meta-analysis. Ann Surg 1988 Aug;208(2):227-40. Harenberg J. et al. Subcutaneous low-molecular-weight heparin versus standard heparin and the prevention of thromboembolism in medical inpatients. The Heparin Study in Internal Medicine Group. Haemostasis 1996 May-Jun;26(3):127-39.

13. Adjusted Dose Heparin administration of subcutaneous heparin in variable doses with the goal of keeping the activated partial thromboplastin time (aPTT) in the high normal range in total hip replacements, superior to placebo but not as effective as low molecular weight heparin Leyvraz PF. et al. Adjusted versus fixed-dose subcutaneous heparin in the prevention of deep-vein thrombosis after total hip replacement. N Engl J Med 1983 Oct 20;309(16):954-8. Leyvraz PF. et al. Prevention of deep vein thrombosis after hip replacement: randomised comparison between unfractionated heparin and low molecular weight heparin. BMJ 1991 Sep 7;303(6802):543-8.

14. Low Molecular Weight Heparin Advantanges given once or twice daily at constant dose no laboratory monitoring lower incidence of heparin induced thrombocytopenia

15. Low Molecular Weight Heparin low molecular weight heparin versus unfractionated heparin effective or more effective in preventing thrombosis incidence of major bleeding similar, and possibly superior Liezorovicz A. et al. JP Prevention of perioperative deep vein thrombosis in general surgery: a multicentre double blind study comparing two doses of Logiparin and standard heparin. H.B.P.M. Research Group. Br J Surg 1991 Apr;78(4):412-6. Nurmohamed MT. et al. Low-molecular-weight heparin versus standard heparin in general and orthopaedic surgery: a meta-analysis. Lancet 1992 Jul 18;340(8812):152-6. Kakkar VV. et al. Low molecular weight versus standard heparin for prevention of venous thromboembolism after major abdominal surgery. The Thromboprophylaxis Collaborative Group. Lancet 1993 Jan 30;341(8840):259-65.

16. Low Molecular Weight Heparin preoperative initiation of prophylaxis following total hip replacement reduces total DVT rates (but not proximal DVT rates) major bleeding Hull RD. et al. Preoperative vs postoperative initiation of low-molecular-weight heparin prophylaxis against venous thromboembolism in patients undergoing elective hip replacement. Arch Intern Med 1999 Jan 25;159(2):137-41.

17. Warfarin May be initiated preoperatively May not prevent small venous thrombi from forming during or immediately after surgery even with a “two step” protocol Francis CW. et al. Comparison of two warfarin regimens in the prevention of venous thrombosis following total knee replacement. Thromb Haemost 1996 May;75(5):706-11.

18. Warfarin May be similar to slightly inferior to low molecular weight heparin Incidence of total DVTs: 37.4% v 31.4% Incidence of major bleeding: 1.2% v 2.8% Hull R.et al. A comparison of subcutaneous low-molecular-weight heparin with warfarin sodium for prophylaxis against deep-vein thrombosis after hip or knee implantation. N Engl J Med 1993 Nov 4;329(19):1370-6. Incidence of total DVTs:26% v 15% Incidence of proximal DVT: 8% v 5% (P=0.185) Francis CW. et al. Prevention of deep-vein thrombosis after total hip arthroplasty. Comparison of warfarin and dalteparin. J Bone Joint Surg Am 1997 Sep;79(9):1365-72. incidence of clinically significant DVT: 1.1% vs. 0.3% Colwell CW Jr. et al. Comparison of enoxaparin and warfarin for the prevention of venous thromboembolic disease after total hip arthroplasty. Evaluation during hospitalization and three months after discharge. J Bone Joint Surg Am 1999 Jul;81(7):932-40.

19. Warfarin Warfarin vs external pneumatic compression Total DVT: 31% vs 27% Proximal DVT: 3% vs 12% Calf vein DVT: 21% vs 12% Francis CW. et al. Comparison of warfarin and external pneumatic compression in prevention of venous thrombosis after total hip replacement. JAMA 1992 Jun 3;267(21):2911-5.

20. Warfarin Superior to aspirin and placebo Total DVT: 20% vs 41% vs. 46% Proximal DVT or PE: 9.2% vs 10.6% vs 30.2% Powers PJ. et al. A randomized trial of less intense postoperative warfarin or aspirin therapy in the prevention of venous thromboembolism after surgery for fractured hip. Arch Intern Med 1989 Apr;149(4):771-4.

21. Intermittent Pneumatic Leg Compression valuable alternative in patients who have a high risk of bleeding virtually free of clinically important side effects discomfort contraindications leg ischemia caused by peripheral vascular disease patients on bed rest or immobilized for more than 72 hours without any form of prophylaxis

22. Intermittent Pneumatic Leg Compression enhancing blood flow in the deep veins of the legs preventing venous stasis reduces plasminogen activator inhibitor-1 (PAI-1) levels and consequently increases endogenous fibrinolytic activity Comerota AJ. et al. The fibrinolytic effects of intermittent pneumatic compression: mechanism of enhanced fibrinolysis. Ann Surg 1997 Sep;226(3):306-13; discussion 313-4.

23. Intermittent Pneumatic Leg Compression reduced incidence of venous thromboembolism moderate risk general surgical patients neurosurgery patietns coronary artery bypass grafting Incidence of pulmonary embolism Low dose heparin and intermitent compression: 1.5% Low dose heparin: 4% Roberts, VC. et al. The effect of intermittently applied eternal pressure on the hemodynamics of the lower limb in man. Br J Surg 1972; 59:233. Turpie AG. et al. Prevention of venous thrombosis by intermittent sequential calf compression in patients with intracranial disease. Thromb Res 1979; 15:611. Ramos R. et al. The efficacy of pneumatic compression stockings in the prevention of pulmonary embolism after cardiac surgery. Chest 1996 Jan;109(1):82-5.

24. Intermittent Pneumatic Leg Compression hip surgery knee replacement reduced the frequency of both proximal vein and calf vein thrombosis inferior to warfarin Total DVT: 31% vs 27% Proximal DVT: 3% vs 12% Calf vein DVT: 21% vs 12% Hull RD. et al. Effectiveness of intermittent pneumatic leg compression for preventing deep vein thrombosis after total hip replacement. JAMA 1990 May 2;263(17):2313-7 Hull, RD. et al. Effectiveness of intermittent pulsatile elastic stockings for the prevention of calf and thigh vein thrombosis in patients undergoing elective knee surgery. Thromb Res 1979; 16:37. Francis CW. et al. Comparison of warfarin and external pneumatic compression in prevention of venous thrombosis after total hip replacement. JAMA 1992 Jun 3;267(21):2911-5.

25. Graduated Compression Stockings reduce venous stasis in the limb by applying a graded degree of compression to the ankle and calf, with greater pressure being applied distally

26. Graduated Compression Stockings reduce the incidence of postoperative venous thrombosis only in low risk general surgical patients Turner GM. et al. The efficacy of graduated compression stockings in the prevention of deep vein thrombosis after major gynaecological surgery. Br J Obstet Gynaecol 1984 Jun;91(6):588-91 reduce the incidence of postoperative venous thrombosis selected moderate risk patients Nurmohamed MT. et al. Low molecular weight heparin and compression stockings in the prevention of venous thromboembolism in neurosurgery. Thromb Haemost 1996 Feb;75(2):233-8. Amarigiri SV. Lees TA. Elastic compression stockings for prevention of deep vein thrombosis. Cochrane Database Syst Rev 2000;(3):CD001484.

27. Aspirin 13,356 hip fracture and 4088 elective hip or knee arthroplasty aspirin 160 mg/day or placebo for 35 days, in addition to other prophylactic measures Fatal pulmonary embolism and DVT: absolute risk reduction: 0.4% Wound and gastrointestinal bleeding and need for transfusion were significantly more common Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: Pulmonary Embolism Prevention (PEP) trial. Lancet 2000 Apr 15;355(9212):1295-302.

28. Aspirin some activity in preventing venous thromboembolism lower efficacy than other measures precludes its use as monotherapy

29. Recombinant Hirudin peptide derived from the saliva of the medicinal leech directly binds to the fibrinogen recognition and catalytic sites of heparin

30. Recombinant Hirudin 2079 patients undergoing total hip replacement recombinant hirudin (desirudin) started 30 minutes before surgery or subcutaneous enoxaparin started on the evening before surgery Incidence of deep venous thrombosis: 18.4% vs 25.5% Incidence of proximal deep venous thrombosis: 4.5% vs 7.5% No difference in bleeding complications Eriksson BI. et al. A comparison of recombinant hirudin with a low-molecular-weight heparin to prevent thromboembolic complications after total hip replacement. N Engl J Med 1997 Nov 6;337(19):1329-35.

31. Fondaparinux Synthetic heparin pentasaccharide catalyzes factor Xa inactivation by AT III without inhibiting thrombin superior to enoxaparin incidence of venous thromboembolism knee surgery: 12.5% vs 27.8% hip fracture: 8.3% vs 19.1% same or slightly increased risk of major bleeding Bounameaux H. Perneger T. Fondaparinux: a new synthetic pentasaccharide for thrombosis prevention. Lancet 2002 May 18;359(9319):1710-1. Bauer KA. et al. Fondaparinux compared with enoxaparin for the prevention of venous thromboembolism after elective major knee surgery. N Engl J Med 2001 Nov 1;345(18):1305-10. Eriksson BI. et al. Fondaparinux compared with enoxaparin for the prevention of venous thromboembolism after hip-fracture surgery. N Engl J Med 2001 Nov 1;345(18):1298-304.

32. Investigational Agents ximelagatran (Exanta) orally active synthetic antithrombin agent nematode anticoagulant protein (rNAPc2) inhibits the tissue factor-activated factor VII complex oral heparin and low molecular weight heparin

33. General Recommendations Each hospital should develop a formal strategy for the prevention of venous thromboembolism all risk categories for surgical and medical patients Aspirin for prophylaxis in all patients groups is not recommended Routine ultrasonography screening at discharge or during outpatient follow-up is not recommended Antithrombotic prophylaxis should be used with caution in patients having spinal puncture or epidural catheter placement for regional or continued analgesia

34. Low Risk Surgical Patients early ambulation Geerts WH. Et al. Prevention of venous thromboembolism. Chest 2001 Jan;119(1 Suppl):132S-175S.

35. Moderate Risk Surgical Patients general abdominal, thoracic, or gynecologic surgery heparin 5000units S.Q. q 8 or 12 hours Less expensive low molecular weight heparin Once daily injection Less bleeding in meta-analysis Clagett GP. Reisch JS. Prevention of venous thromboembolism in general surgical patients. Results of meta-analysis. Ann Surg 1988 Aug;208(2):227-40. Collins R. et al. Reduction in fatal pulmonary embolism and venous thrombosis by perioperative administration of subcutaneous heparin. Overview of results of randomized trials in general, orthopedic, and urologic surgery. N Engl J Med 1988 May 5;318(18):1162-73. Liezorovicz A. et al. JP Prevention of perioperative deep vein thrombosis in general surgery: a multicentre double blind study comparing two doses of Logiparin and standard heparin. H.B.P.M. Research Group. Br J Surg 1991 Apr;78(4):412-6. Kakkar VV. et al. Low molecular weight versus standard heparin for prevention of venous thromboembolism after major abdominal surgery. The Thromboprophylaxis Collaborative Group. Lancet 1993 Jan 30;341(8840):259-65.

36. Moderate Risk Surgical Patients High risk of bleeding Intermittent pneumatic compression Geerts WH. Et al. Prevention of venous thromboembolism. Chest 2001 Jan;119(1 Suppl):132S-175S.

37. Moderate Risk Patients intracranial neurosurgical procedure intermittent pneumatic compression ± graduated compression stockings low dose heparin or low molecular weight heparin often started 48 hours post procedure may be combined with physical devices Geerts WH. Et al. Prevention of venous thromboembolism. Chest 2001 Jan;119(1 Suppl):132S-175S.

38. High Risk Patients low molecular weight heparin specific recommendations vary by clinical setting may add intermittent pneumatic compression Geerts WH. Et al. Prevention of venous thromboembolism. Chest 2001 Jan;119(1 Suppl):132S-175S.

39. Knee Replacement low molecular weight heparin adjusted dose oral anticoagulants target INR 2.5, range 2.0 to 3.0 duration: 7 to 10 days no further benefit of prolonged therapy Geerts WH. Et al. Prevention of venous thromboembolism. Chest 2001 Jan;119(1 Suppl):132S-175S. Comp PC. et al. Prolonged enoxaparin therapy to prevent venous thromboembolism after primary hip or knee replacement. Enoxaparin Clinical Trial Group. J Bone Joint Surg Am 2001 Mar;83-A(3):336-45. Hull R. et al. A comparison of subcutaneous low-molecular-weight heparin with warfarin sodium for prophylaxis against deep-vein thrombosis after hip or knee implantation. N Engl J Med 1993 Nov 4;329(19):1370-6. Hamulyak K. et al. Subcutaneous low-molecular weight heparin or oral anticoagulants for the prevention of deep-vein thrombosis in elective hip and knee replacement. Fraxiparine Oral Anticoagulant Study Group. Thromb Haemost 1995 Dec;74(6):1428-31.

40. Hip Replacement low molecular weight heparin adjusted dose oral anticoagulants target INR 2.5, range 2.0 to 3.0 Geerts WH. Et al. Prevention of venous thromboembolism. Chest 2001 Jan;119(1 Suppl):132S-175S. Bergqvist D. et al. Low-molecular-weight heparin (enoxaparin) as prophylaxis against venous thromboembolism after total hip replacement. N Engl J Med 1996 Sep 5;335(10):696-700. Planes A. et al. Risk of deep-venous thrombosis after hospital discharge in patients having undergone total hip replacement: double-blind randomised comparison of enoxaparin versus placebo. Lancet 1996 Jul 27;348(9022):224-8. Comp PC. et al. Prolonged enoxaparin therapy to prevent venous thromboembolism after primary hip or knee replacement. Enoxaparin Clinical Trial Group. J Bone Joint Surg Am 2001 Mar;83-A(3):336-45. Hull R. et al. A comparison of subcutaneous low-molecular-weight heparin with warfarin sodium for prophylaxis against deep-vein thrombosis after hip or knee implantation. N Engl J Med 1993 Nov 4;329(19):1370-6. Hamulyak K. et al. Subcutaneous low-molecular weight heparin or oral anticoagulants for the prevention of deep-vein thrombosis in elective hip and knee replacement. Fraxiparine Oral Anticoagulant Study Group. Thromb Haemost 1995 Dec;74(6):1428-31. Levine MN. et al. Prevention of deep vein thrombosis after elective hip surgery. A randomized trial comparing low molecular weight heparin with standard unfractionated heparin. Ann Intern Med 1991 Apr 1;114(7):545-51. Dahl OE. et al. Prolonged thromboprophylaxis following hip replacement surgery--results of a double-blind, prospective, randomised, placebo-controlled study with dalteparin (Fragmin)/ Thromb Haemost 1997 Jan;77(1):26-31. Lassen MR. et al. Efficacy and safety of prolonged thromboprophylaxis with a low molecular weight heparin (dalteparin) after total hip arthroplasty--the Danish Prolonged Prophylaxis (DaPP) Study. Thromb Res 1998 Mar 15;89(6):281-7. Hull RD. et al. Low-molecular-weight heparin prophylaxis using dalteparin extended out-of-hospital vs in-hospital warfarin/out-of-hospital placebo in hip arthroplasty patients: a double-blind, randomized comparison. North American Fragmin Trial Investigators. Arch Intern Med 2000 Jul 24;160(14):2208-15.

41. Hip Replacement duration: at least 7 to 10 days extended LMWH prophylaxis through postoperative day 27 to 42 significantly reduced incidence of total and proximal DVTs Bergqvist D. et al. Low-molecular-weight heparin (enoxaparin) as prophylaxis against venous thromboembolism after total hip replacement. N Engl J Med 1996 Sep 5;335(10):696-700. Planes A. et al. Risk of deep-venous thrombosis after hospital discharge in patients having undergone total hip replacement: double-blind randomised comparison of enoxaparin versus placebo. Lancet 1996 Jul 27;348(9022):224-8. Comp PC. et al. Prolonged enoxaparin therapy to prevent venous thromboembolism after primary hip or knee replacement. Enoxaparin Clinical Trial Group. J Bone Joint Surg Am 2001 Mar;83-A(3):336-45. Dahl OE. et al. Prolonged thromboprophylaxis following hip replacement surgery--results of a double-blind, prospective, randomised, placebo-controlled study with dalteparin (Fragmin)/ Thromb Haemost 1997 Jan;77(1):26-31. Lassen MR. et al. Efficacy and safety of prolonged thromboprophylaxis with a low molecular weight heparin (dalteparin) after total hip arthroplasty--the Danish Prolonged Prophylaxis (DaPP) Study. Thromb Res 1998 Mar 15;89(6):281-7. Hull RD. et al. Low-molecular-weight heparin prophylaxis using dalteparin extended out-of-hospital vs in-hospital warfarin/out-of-hospital placebo in hip arthroplasty patients: a double-blind, randomized comparison. North American Fragmin Trial Investigators. Arch Intern Med 2000 Jul 24;160(14):2208-15.

42. Multiple Trauma low molecular weight heparin superior to heparin intermittent pneumatic compression eliminates risk of bleeding Geerts WH. et al. A comparison of low-dose heparin with low-molecular-weight heparin as prophylaxis against venous thromboembolism after major trauma. N Engl J Med 1996 Sep 5;335(10):701-7 Geerts WH. et al. Prevention of venous thromboembolism. Chest 2001 Jan;119(1 Suppl):132S-175S.

43. Acute Spinal Cord Injury low molecular weight heparin adjusted dose heparin low dose heparin and intermittent pneumatic compression less effective Geerts WH. et al. Prevention of venous thromboembolism. Chest 2001 Jan;119(1 Suppl):132S-175S.

44. Surgical Oncology low molecular weight heparin 10 day course superior to historical control 4 week course superior to 7 days low dose heparin 10 day course superior to historical control Bergqvist D. et al. Duration of prophylaxis against venous thromboembolism with enoxaparin after surgery for cancer. N Engl J Med 2002 Mar 28;346(13):975-80 Efficacy and safety of enoxaparin versus unfractionated heparin for prevention of deep vein thrombosis in elective cancer surgery: a double-blind randomized multicentre trial with venographic assessment. ENOXACAN Study Group. Br J Surg 1997 Aug;84(8):1099-103

45. Medical Patients decreased incidence of deep venous thrombosis and pulmonary embolism no decrease in mortality no difference between low dose heparin and low molecular weight heparin increase risk of major and minor bleeding with low dose heparin Bergmann JF. Neuhart E. A multicenter randomized double-blind study of enoxaparin compared with unfractionated heparin in the prevention of venous thromboembolic disease in elderly in-patients bedridden for an acute medical illness. The Enoxaparin in Medicine Study Group. Thromb Haemost 1996 Oct;76(4):529-34. Samama MM. et al. A comparison of enoxaparin with placebo for the prevention of venous thromboembolism in acutely ill medical patients. Prophylaxis in Medical Patients with Enoxaparin Study Group. N Engl J Med 1999 Sep 9;341(11):793-800. Mismetti P. et al. Prevention of venous thromboembolism in internal medicine with unfractionated or low-molecular-weight heparins: a meta-analysis of randomised clinical trials. Thromb Haemost 2000 Jan;83(1):14-9. Cohen AT. A safety analysis of thromboprophylaxis in acute medical illness. Thromb Haemost 2003; 89:590.

46. Medical Patients low risk patient graduated compression stockings myocardial infarction heparin warfarin congestive heart failure low dose heparin low molecular weight heparin Ischemic strokes low dose heparin low molecular weight heparin Amarigiri SV. Lees TA. Elastic compression stockings for prevention of deep vein thrombosis. Cochrane Database Syst Rev 2000;(3):CD001484. Geerts WH. et al. Prevention of venous thromboembolism. Chest 2001 Jan;119(1 Suppl):132S-175S. Samama MM. et al. A comparison of enoxaparin with placebo for the prevention of venous thromboembolism in acutely ill medical patients. Prophylaxis in Medical Patients with Enoxaparin Study Group. N Engl J Med 1999 Sep 9;341(11):793-800. Cairns JA. et al. Antithrombotic agents in coronary artery disease. Chest 1998 Nov;114(5 Suppl):611S-633S.

47. Pregnancy low dose heparin data from controlled trials are lacking! McColl MD. et al. Risk factors for venous thromboembolism in pregnancy. Curr Opin Pulm Med 1999 Jul;5(4):227-32 Ginsberg JS. et al. Use of antithrombotic agents during pregnancy. Chest 2001 Jan;119(1 Suppl):122S-131S

  • Login