Heart failure in patients with deep vein thrombosis

Patients with heart failure (HF) are particularly vulnerable to the development of venous thromboembolism (VTE) and its related complications of pulmonary embolism and right ventricular failure. To improve our understanding of the clinical characteristics, prophylaxis, and initial management of patients with HF and deep vein thrombosis (DVT), we compared 685 patients with a history of HF with 3,890 patients without HF in a prospective registry of 5,451 consecutive patients with ultrasound-confirmed DVT. We excluded 876 patients for whom data regarding HF status were incomplete. Patients with HF had an increased frequency of co-morbid conditions such as neurologic disease including stroke (33% vs 26%, p = 0.0002), acute lung disease including pneumonia (31% vs 15%, p <0.0001), and acute coronary syndrome (11% vs 4%, p <0.0001) contributing to a higher medical acuity than in patients without HF. Furthermore, patients with HF were more likely to have VTE risk factors of immobilization (53% vs 42%, p <0.0001), acute infection (33% vs 27%, p = 0.01), and chronic obstructive pulmonary disease (29% vs 12%, p <0.0001). Patients with and without HF and DVT had a high frequency of recent hospitalization (48% vs 47%, p = 0.96). Fewer than 12 of patients with HF (46%) who subsequently developed DVT received any VTE prophylaxis. In conclusion, the combination of higher medical acuity, increased frequency of VTE risk factors, and low rate of VTE prophylaxis presents a "triple threat" to patients with HF.     

Postoperative deep vein thrombosis in patients with colorectal cancer

Deep vein thrombosis (DVT) is reported to be common among patients undergoing surgery for colorectal cancer. This randomized controlled trial was aimed to determine the efficacy of low molecular-weight heparin in the prophylaxis of DVT in this high-risk group and was truncated early in view of an unexpectedly low incidence of DVT. Between March 2002 and January 2004, a total of 99 patients with colorectal cancer - selected for surgery in the lithotomy position - were randomized before surgery to either receive dalteparin or no drug (51 and 48 patients, respectively) during the perioperative period. Duplex ultrasonography was performed before and after the surgery. We also looked for distal venous thrombosis, pulmonary embolism, hemorrhage and any mortality. No episode of DVT occurred in either the drug arm or the observation arm. There was no death following surgery. The incidence of DVT in Indian patients operated for colorectal cancer in the lithotomy position was negligible.     

Suspected acute deep vein thrombosis in patients with rheumatoid arthritis

Real-time venous ultrasound has replaced phlebography for making the diagnosis of clinically relevant lower extremity DVT. Phlebography is still useful in suspected calf vein thrombosis when an immediate diagnosis is required and in the postoperative patient. A combination of sonography and contrast phlebography is used to sort out the extent of chronic and acute venous changes in patients with chronic deep vein thrombosis.     

Thrombotic disorders of hemostasis in patients with deep vein thrombosis

For 22 months we investigated the hemostatic status of 93 inpatients (44 male, and 49 female, average age 54.6 years) with a phlebographically objectified deep venous thrombosis of the leg or iliac veins. Corresponding blood samples were taken before, during, and after therapy. In 58 (62.4%) patients we found several kinds of disorders of hemostasis. There were deficiencies of the protein C, protein S, factor XII, antithrombin III, and the thrombocytes function. In most cases there was a single acquired deficiency of one of these factors. Only in one patient (1.07%) could we verify an inherited deficiency of factor XII. The most frequent disorder was a protein C deficiency in 32 (34.4%) patients. In 44 (47%) operatively treated patients we had postoperative complications such as rethrombosis, phlegmasia coerulea dolens, or development of skin necrosis during anticoagulant therapy in 12 (27.3%) cases. In 10 (83%) of these patients with complications we had found preoperatively a disorder of hemostasis. The statistical correlation between a preoperatively measured deficiency of the protein C and the relapse of deep vein thrombosis was significant (p=0.0026).Presented at the 35th World Congress, International College of Angiology, Copenhagen, Denmark, July 1993     

Thrombolytic therapy for deep vein thrombosis

Opinion statement  The incorporation of endovascular interventions into mainstream clinical practice for patients with deep vein thrombosis (DVT) has been changing rapidly as a result of four major trends. First, there now is a much greater appreciation among practicing physicians of the major impact of the postthrombotic syndrome (PTS) on DVT patients’ late quality of life. Second, there have been rapid advances in the methods by which thrombus can be rapidly removed using endovascular techniques, resulting in greater efficiency and treatment safety. Third, these changes together have spurred a major change in recommended DVT treatment paradigms: there is now published expert consensus that adjunctive endovascular DVT thrombolysis should be strongly considered as a first-line treatment strategy for selected patients with extensive acute proximal DVT. Finally, DVT researchers from multiple subspecialties have finally come together in a major multidisciplinary clinical trial project to subject endovascular DVT thrombolysis to the rigorous scientific testing that is needed for clinicians to be confident in its efficacy, safety, and cost-effectiveness as a first-line DVT treatment strategy. Pending the results of this and other studies, medical physicians should routinely inform DVT patients about the long-term consequences of DVT; ensure that they understand the importance of anticoagulant therapy and elastic compression stockings in preventing PTS; provide a balanced discussion of the risks, benefits, and uncertainties associated with endovascular DVT thrombolysis to patients with extensive proximal DVT; and develop collaborative clinical and research relationships with physicians experienced with endovascular DVT therapy.     

Prevention of deep vein thrombosis in cancer patients

Venous thromboembolism (VTE) in patients with cancer follows an aggressive course, and it is often resistant to traditional regimens of pharmacological prophylaxis and treatment. Anticoagulant-related bleeding is also common and can complicate VTE treatment as well as cancer therapy. Consequently, the most effective approach to reducing the burden of VTE and its associated morbidity and mortality is to provide appropriate prophylaxis. Few clinical trials have focused on the prevention of VTE in this high-risk patient population, and they consistently demonstrate the efficacy and safety of anticoagulant prophylaxis in reducing thrombotic complications. Currently, low-molecular-weight heparins and oral vitamin K antagonists are the most commonly used anticoagulants for primary prevention in patients with cancer, but compliance with consensus guidelines is poor. Novel anticoagulants with a convenient and favorable risk/benefit profile may help to improve prophylaxis utilization and treatment. This review will provide a summary of the evidence on the primary prevention of VTE in patients with cancer.     

Distal deep vein thrombosis

Received from the Section of General Internal Medicine, University of Wisconsin Medical Center, 600 Highland Avenue, Madison, Wisconsin 53792.     

Pharmacogenetics of the local thrombolysis in patients with deep vein thrombosis

Thrombophilia, the state of increased tendency for blood clotting, is considered the disorder of a complex etiology, caused by both environmental and genetic factors. As gene variants predisposing to thrombophilia and influencing the increased risk of vein thrombosis might influence response to local thrombolysis, the aim of the work was to characterize the pharmacogenetic conditions for local streptokinase treatment in patients with a deep vein thrombosis (DVT) of lower extremities based on the following polymorphism analyses: G1691A polymorphism of factor V (FV), G20210A polymorphism of prothrombin (PT), A4250G (Thr312Ala) polymorphism of fibrinogen-alpha (FGA), G(-455)A polymorphism of fibrinogen-beta (FGB), 4G/5G polymorphism of plasminogen activator inhibitor type 1(PAI-1) and insertion/deletion (I/D) polymorphism of tissue plasminogen activator (t-PA). The study included 40 DVT patients who underwent a local thrombolytic treatment within 14-day period from diagnosis. Full recanalization was achieved in 20 subjects (50%) [group R(+)], whereas incomplete or total lack of recanalization was identified in the remaining 20 patients [group R(-)]. No major complications of thrombolytic treatment occurred in the studied group. In the case of prothrombin gene all individuals carried homozygous wild type genotype (GG). Prevalence of the genotypes and alleles of the remaining five polymorphisms did not differ significantly between the groups R(+) and R(-). Neither sex nor age, smoking or time period from diagnosis to introduction of the thrombolytic treatment significantly influenced treatment efficacy. The results of the study suggest that a local thrombolysis with streptokinase introduced within two week period from the diagnosis is a safe and efficient method of treatment for deep vein thrombosis of lower extremities. However, size of the group is insufficient to clearly determine the association between investigated polymorphisms and efficacy of local treatment with streptokinase.     

A prospective registry of 5,451 patients with ultrasound-confirmed deep vein thrombosis

We enrolled 5,451 patients with ultrasound-confirmed deep vein thrombosis (DVT), including 2,892 women and 2,559 men, from 183 United States sites in our prospective registry. The 5 most frequent co-morbidities were hypertension (50%), surgery within 3 months (38%), immobility within 30 days (34%), cancer (32%), and obesity (27%). Of the 2,726 patients who had their DVT diagnosed while in the hospital, only 1,147 (42%) received prophylaxis within 30 days before diagnosis.     

Plasma and urine beta-thromboglobulin concentration in patients with deep vein thrombosis

Plasma and urine beta-thromboglobulin (BTG) were measured in 52 patients with established deep vein thrombosis (DVT) and in 100 patients with clinically suspected DVT but with a negative venogram. Both plasma BTG (geometric mean 54: 95% range 12--239 ng/ml) and urine BTG (0.25; 0.03--3.1 ng/ml) were significantly elevated (p less than 0.005) in patients with DVT compared to symptomatic patients with a negative venogram (plasma BTG 32, 9--112 ng/ml; urine BTG 0.12, 0.02-- 0.58 ng/ml). Sensitivity (35%) and specificity (80%) of the plasma BTG assay for the diagnosis of DVT were low. The urine BTG assay had a sensitivity of 37% but a specificity of 100%. There was a significant correlation between plasma and urine BTG (r = 0.68, p less than 0.005). Serial BTG measurements were made in urine (40 patients) and plasma (20 patients) from high-risk neurosurgical cases who were screened with 125I-fibrinogen leg scanning and impedance plethysmography. BTG was elevated postoperatively and returned to normal within 2 or 3 days, but rose again in 10 patients in association with the development of DVT. The rise of BTG preceded the uptake of 125I-fibrinogen and lasted for only a few days. The return to normal of BTG was not related to treatment with anticoagulants. While measurement of BTG in plasma and urine is of limited value in the clinical diagnosis of venous thrombosis, the data indicate platelet activation occurs in venous thrombosis, but is maximal or perhaps limited to the initial phase of thrombus development.     

High prevalence of anti-prothrombin antibody in patients with deep vein thrombosis

The present study was designed to determine the prevalence of lupus anticoagulant (LA) antibody and several antibodies for antiphospholipid syndrome (APS) in patients with deep vein thrombosis (DVT)/pulmonary embolism (PE) (n = 48), cerebral thrombosis (CT, n = 30), systemic lupus erythematosus (SLE, n = 22), and idiopathic thrombocytopenic purpura (ITP, n = 30). The presence of antibodies was examined by using the respective ELISA kits. LA was positive in 38.6% of patients with DVT/PE, suggesting that LA is one of the most important risk factors in DVT/PE. The highest prevalence of anti-beta(2) glycoprotein I (beta(2)GPI) IgG was in CT and SLE, followed by DVT, and none in ITP and healthy volunteers (control, n = 40), suggesting that it is related to thrombosis, particularly arterial thrombosis. The highest prevalence of anti-prothrombin (aPT) IgG antibody was in DVT, followed by CT and SLE, and none in ITP and the control, suggesting that it is related to thrombosis, especially venous thrombosis. The highest prevalence of antiphospholipid (aPL) IgG was in DVT, CT, and SLE, but 0% in ITP and control. On the other hand, aPL IgM, anti-annexin V IgG, and anti-annexin V IgM were positive in patients both with and without thrombosis, suggesting that they are not related to thrombosis. Our results indicated that among the anti-phospholipid antibodies, LA is the most sensitive marker for APS while anti-beta(2)GPI IgG, aPT IgG, and aPL IgG are risk factors for thrombosis. In particular, aPT IgG is a significant marker for DVT/PE.     

Ruling out deep vein thrombosis in patients with superficial vein thrombosis: external validation of the ICARO score

Journal of Thrombosis and Thrombolysis - A clinical score was recently proposed to rule out concomitant DVT in patients with a clinical suspicion of SVT. This study aimed to assess the external...