Graduated elastic compression stockings on a stroke unit: a feasibility study

BACKGROUND: thrombo-embolic complications are important causes of morbidity and mortality after acute stroke. Anticoagulant prophylaxis is contraindicated in intracerebral haemorrhage and not recommended in acute ischaemic stroke because of increased risk of cerebral haemorrhage. Graduated elastic compression stockings are a simple alternative but are not widely used in stroke patients, perhaps because of perceived contraindications and problems with tolerability. OBJECTIVES: to establish the feasibility and tolerability of graduated compression stockings on a stroke unit. DESIGN: we assessed 112 consecutive stroke patients for contraindications to and tolerability of graduated compression stockings. MEASUREMENTS: we used clinical indices and ankle-brachial Doppler pressure measures to assess suitability. We prospectively assessed tolerability of the stockings. RESULTS: Ninety-four (84%) of the 112 patients had no contraindications to the use of the stockings. The most common contraindication was an ankle-brachial index of <0.8. Other contraindications were marked dependent leg oedema (1/18) and severe venous ulceration. Eighty-nine (95%) of the 94 patients tolerated the stockings and wore them until discharge. Skin irritation was the most common reason for intolerance. CONCLUSIONS: contraindications to the use of graduated compression stockings can be defined using clinical criteria and a Doppler machine to calculate an ankle-brachial pressure index. If this is done, tolerability is excellent. This approach may be a useful alternative in preventing venous thrombo-embolism in stroke patients.     

Graduated compression stockings in the prevention of deep vein thrombosis in patients with acute myocardial infarction

Venous volume (venous capacity) of the calf is low in patientswith acute myocardial infarction, who also have a high riskof deep vein thrombosis (DVT). The effect of graduated compressionstockings on the venous volume and on the incidence of DVT wastherefore studied in 80 patients aged 70 years and above withacute myocardial infarction. Graduated compression stockingswere randomly fitted to one leg, the other serving as a control,after which the venous volume was measured by strain gauge plethysmography.The incidence of DVT was measured by the ¹²⁵I fibrinogen uptaketest. Venous volume was significantly higher in legs treatedwith graduated compression stockings compared to control legs.DVT developed in eight control legs but not in any leg treatedwith graduated compression stockings (P = 0.003). DVT was alsosignificantly more frequent in women compared to men and themajority of DVT developed in legs with very low venous volumevalues.     

Physician alerts to prevent venous thromboembolism

Venous thromboembolism (VTE), which encompasses deep vein thrombosis (DVT) and pulmonary embolism (PE), is a common but usually preventable complication of hospitalization associated with substantial mortality, morbidity, and health care costs. Despite published guidelines for the prevention of VTE among hospitalized patients, underutilization of prophylaxis continues to be a problem in the United States, Canada, and worldwide. Although much of the emphasis placed on prevention has focused on improving in-hospital prophylaxis, nearly 75% of patients develop VTE in the outpatient setting. Of these patients, a substantial proportion had undergone surgery or hospitalization in the three months preceding the diagnosis of VTE. While extended out-of-hospital prophylaxis has been validated in the orthopedic and surgical oncology literature, data regarding the prevention of VTE in other hospitalized patient populations after discharge have been limited. In this review article, we discuss decision support strategies for improving VTE prevention during hospitalization and at the time of discharge.     

Identifying inappropriate hospital stay in patients with venous thromboembolism

Background: Traditionally, venous thromboembolism has been treated in a hospital setting. Nowadays, low molecular weight heparin (LMWH) preparations allow most deep venous thrombosis (DVT) patients to benefit from home therapy. The objective of this study was to evaluate whether the previous treatment of deep venous thrombosis in a hospital setting was appropriate in the context of modern opinion, using the Dutch Appropriateness Evaluation Protocol (DAEP). If so, the DAEP could be used to assess the appropriateness of the present hospital stay of other patient groups. Methods: A retrospective study of patients treated from 1995 to 1998 for DVT or for pulmonary embolism (PE), before the implementation of ambulatory treatment, was conducted that assessed the appropriateness of the patient's hospital stay using the DAEP. Results: Only 27.1% of the treatments for DVT were found to be appropriate in a hospital setting and related to specific hospital care. Inappropriate stay was mostly related to delays in hospital and discharge procedures. Of the patients with PE, 50.2% needed a hospital stay. This proportion was statistically significantly higher than in DVT patients (p<0.001). The extent of the DVT was not related to the length of bed rest prescribed. Conclusions: The DAEP was able to identify inappropriate hospital stay in the past within the DVT patient group. Further exploration of the potential of the DAEP to identify patient groups who could be treated at home is warranted.     

Compression stockings and venous function in patients with acute myocardial infarction.

Venous volume and venous outflow of the calf were studied in 49 patients with acute myocardial infarction. Graded compression stockings were randomly applied to one leg, the other serving as a control, and the above parameters were studied with strain gauge plethysmography during six days. Venous volume increased in the control legs during the first three days and it was significantly higher in the legs with stockings compared to the control legs throughout the study period. Venous outflow did not change during the study period or with the application of compression stockings. A restricted venous function in the calf may contribute to the initiation of deep vein thrombosis. Graded compression stockings improve the venous function in the leg and may thus reduce the incidence of deep vein thrombosis in patients with acute myocardial infarction. This remains, however, to be proved in a controlled clinical trial.     

Screening for occult cancer in patients with acute venous thromboembolism

PURPOSE OF REVIEW: Although usually developing in advanced stages of the disease, venous thromboembolism may also appear before the cancer has become symptomatic and may lead to an earlier diagnosis of cancer. One clinical implication of a high risk of occult cancer in patients with acute venous thromboembolism could be an extensive diagnostic workup at the time of presentation. RECENT FINDINGS: The prevalence of occult cancer is between 2.2% and 12% within the first 2 years after the venous thromboembolism. This variation in reported incidence likely reflects the variation in the intensity of cancer surveillance in each study. Although extensive screening in venous thromboembolism patients may result in early identification of hidden cancer, it is unknown whether the prognosis of the clinical course of the malignancy can be favourably influenced. SUMMARY: Early discovery of occult cancer should improve the potential for cure, not merely advance the date of diagnosis. The absence of demonstrated benefit, as well as the potential for actual harm caused by the use of hazardous invasive diagnostic tests, has led to the recommendation not to use extensive screening procedures, unless indicated by clinical circumstances.     

Interventional approaches to acute venous thromboembolism

During the last decade, advances in minimally invasive technologies have spurred a renaissance in the aggressive treatment of venous thromboembolism (VTE) using percutaneous techniques. In this article, we outline the relative risks and benefits of endovascular VTE therapies, highlight clinical situations in which the benefits of endovascular treatment are likely to outweigh its risks, and provide an update regarding the specific new modalities that may be applied to VTE. Pharmacomechanical thrombolysis represents the most promising currently available method to treat VTE. However, pending demonstration that it actually improves VTE outcomes in randomized trials with long-term follow-up, a highly individualized approach to patient selection is recommended. At present, highly compromised patients with pulmonary emboli (PE) in whom systemic thrombolytic therapy has failed or is contraindicated are reasonable candidates for catheter-based PE interventions. Adjunctive pharmacomechanical catheter-directed deep venous thrombosis (DVT) thrombolysis is best indicated for the first-line treatment of patients with phlegmasia cerulea dolens, acute inferior vena cava (IVC) occlusion, and acute iliofemoral DVT after careful clinical assessment and a balanced discussion with the patient. It is hoped that multidisciplinary clinical trials with involvement by both interventionalists and pulmonary physicians will validate these techniques in the near future.     

Predictive value of D-dimer test for recurrent venous thromboembolism at hospital discharge in patients with acute pulmonary embolism

D-dimer can be used to exclude acute pulmonary embolism (PE) for its high negative predictive value (NPV). Also, it is a predictor of recurrent venous thromboembolism (VTE) after anticoagulation withdrawal. The aim of the present study was to assess the predictive value of D-dimer for recurrent VTE when tested at hospital discharge. Plasma D-dimer levels were repeatedly measured at hospital discharge in 204 consecutive patients with the first episode of acute pulmonary embolism. Patients were categorized to two groups by D-dimer levels at hospital discharge and followed up at 3, 6, and 12 months and yearly thereafter. The primary end point was symptomatic, recurrent fatal or nonfatal VTE. D-dimer levels were persistently abnormal in 66 patients (32%). After 31±19 months follow-up, patients with persistently abnormal D-dimer level levels showed a higher rate of of recurrent VTE (14 patients, 21%) compared to those with D-dimer regression (8 patients, 6%) (P = 0.001). At the multivariate analysis, after adjustment for other relevant factors, persistently abnormal D-dimer level levels were an independent predictor of recurrent VTE in all subjects investigated, (hazard ratio, 4.10; 95% CI, 1.61–10.39; P = 0.003), especially in those with unprovoked PE (hazard ratio, 4.61; 95% CI, 1.85–11.49; P = 0.001). The negative predictive value of D-dimer was 94.2 and 92.9% in all subjects or those with unprovoked PE, respectively. Persistently abnormal D-dimer level levels at hospital discharge have a high negative predictive value for recurrence in patients with acute pulmonary embolism, especially in subjects with an unprovoked previous event.     

Predictive role of D-dimer value at hospital discharge for recurrent venous thromboembolism in patients with acute pulmonary embolism

<正>Objective To assess the predictive value of D-dimer at discharge for recurrent VTE in patients with acute pulmonary embolism.Methods Plasma D-dimer levels were repeatedly measured at admission and at hospital discharge in 204 consecutive patients with the first episode of acute pulmonary embolism.Patients were categorized to two groups by D-dimer levels at hospital discharge (normal or abnormal) and followed up at 3,6,and 12     

Thrombophilic predisposition in stroke and venous thromboembolism in Danish patients.

The present study describes 403 patients with thrombosis, from a uniform ethnic and geographical background. Two-hundred-and-seven individuals had suffered mild or moderate stroke and 196 individuals suffered venous thromboembolism. We recorded levels of antithrombin, protein C and protein S, plasminogen and plasma homocysteine, and the presence of the factor V Leiden mutation, the prothrombin 20210G-->A variant, and the methylenetetrahydrofolate reductase (MTHFR) 677C-->T polymorphism. Controls for the mutation frequencies consisted of Guthrie card blood spots from a cohort of new-born babies. The cumulative prevalence of deficiencies in antithrombin, protein C, protein S or plasminogen was 2.4% in patients with stroke and 11.2% in patients with venous thrombosis. The factor V Leiden mutation was present in 11.1% of patients with stroke and 26.5% of patients with venous thrombosis, compared with 6.6% of controls (n = 4188; P < 0.05 and P < 0.0001, respectively). The prevalence of the prothrombin 20210A variant was 3.1% in patients with venous thrombosis, 1.9% in patients with stroke and 2.0% in controls (n = 500; P > 0.05). Hyperhomocysteinemia was present in 16.0% of patients with stroke and 17.6% of patients with venous thrombosis. The prevalence of the MTHFR 677T/T genotype was no different in patients with stroke (10.6%) and venous thrombosis (8.7%) than in controls (8.3%; n = 1084; P > 0.05); thus, it apparently contributed to thrombosis only via its influence on total plasma homocysteine, which was significantly increased in patients with the T/T genotype (P < 0.001). The MTHFR T/T genotype did not further increase the risk for thrombosis in carriers of the factor V Leiden mutation. Overall, thrombotic events were associated with a known risk factor in 27% of patients with stroke and 55% of patients with venous thrombosis.