Chapter 111. Venous Thrombosis (Part 6)

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Table 111-3 Long-Term Treatment with Vitamin K Antagonists for Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) Patient Categories Duration, months Comments First episode of DVT or PE secondary to a transient (reversible) risk factor 3 Recommendation applies to both proximal and calf vein thrombosis First episode of 6–12 Continuation of idiopathic DVT or PE anticoagulant therapy after 6–12 months may be considered First episode of DVT 6–12 Continuation of or PE with a documented thrombophilic abnormality anticoagulant therapy after 6–12 months may be considered First episode of DVT or PE with documented 12 Continuation of anticoagulant therapy after 12 months may be considered antiphospholipid or two or more abnormalities thrombophilic The preferred intensity of VKA treatment for DVT is an INR between 2 and 3....

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Chapter 111. Venous Thrombosis (Part 6) Table 111-3 Long-Term Treatment with Vitamin K Antagonists for Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) Patient Categories Duration, Comments months First episode of DVT 3 Recommendation applies or PE secondary to a transient to both proximal and calf vein (reversible) risk factor thrombosis First episode of 6–12 Continuation of idiopathic DVT or PE anticoagulant therapy after 6–12 months may be considered First episode of DVT 6–12 Continuation of
or PE with a documented anticoagulant therapy after 6–12 thrombophilic abnormality months may be considered First episode of DVT 12 Continuation of or PE with documented anticoagulant therapy after 12 antiphospholipid or two or months may be considered more thrombophilic abnormalities The preferred intensity of VKA treatment for DVT is an INR between 2 and 3. Higher intensities are not more effective, whereas lower intensities are less effective with a similar bleeding risk. Although VKAs are generally used for long- term treatment, LMWH is preferred in patients with DVT and concomitant cancer. This treatment is associated with a lower risk of recurrent thrombosis than VKA and a similar risk of bleeding. The role of thrombolytic therapy as well as surgical removal of the thrombus in the initial treatment of DVT is controversial; the current recommendations are to refrain from their use with the single exception of patients with massive, recent ileofemoral DVT at risk of limb gangrene.
Patients with DVT are at risk of developing the postthrombotic syndrome in the first years after the initial episode. This syndrome can range from mild, with some swelling and pain at the end of the day, to severe, with massive swelling and skin ulceration. Graduated elastic compression stockings to the knee with an ankle pressure of 30–40 mmHg fitted in the first weeks after the initial thrombosis and worn for 2 years reduce the risk of the postthrombotic syndrome by ~50%. As a result of the introduction of LMWH for the initial treatment of DVT, most patients with DVT can be treated at home either entirely or after a short hospital stay. The LMWH can be self-injected or given by family members or visiting nurses. Pulmonary Embolism The initial treatment with LMWH followed by a VKA for patients with PE is identical to that for patients with DVT. The intensity and duration of VKA treatment is also no different (Table 111-3). An alternative for LMWH is unfractionated heparin, which is still often used. The main disadvantage of unfractionated heparin is the need for continuous IV infusion and the requirement of frequent laboratory monitoring and dose adjustments. In contrast, LMWH can be given in fixed doses adjusted only for body weight. Another alternative for the initial LMWH therapy is fondaparinux, which can be given as a 2.5-mg once-a- day SC injection, without laboratory monitoring.
The treatment with LWMH or fondaparinux followed by VKA is indicated for PE patients who are hemodynamically stable—the great majority of patients. However, for those patients with PE who are hemodynamically unstable (usually defined as a systolic blood pressure
be considered only for patients with a contraindication for anticoagulant therapy, as well as in those with recurrent PE despite adequate treatment. Further Readings Colman RW et al (eds): Hemostasis and Thrombosis: Basic Principles and Clinical Practice, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006 Prandoni P: Links between arterial and venous disease. J Intern Med 262:341, 2007 [PMID: 17697155] Rosendaal FR: Venous thrombosis, a multicausal disease. Lancet 353:1167, 1999 [PMID: 10209995] The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 126(3 Suppl):167S, 2004