Impact of Prolonged Anticoagulation with Rivaroxaban on Provoked Venous Thromboembolism Recurrence: IMPROVE-VTE

Background

We sought to evaluate the real-world effectiveness and safety of prolonged anticoagulation with rivaroxaban following a provoked venous thromboembolism.

即时检验血糖仪检测指尖血及静脉全血血糖的临床分析

目的：探讨即时检验血糖仪检测指尖血及静脉全血血糖检验结果的临床可行性。方法随机选取该院2011年6月—2012年7月所接收治疗的50例糖尿病患者,采取静脉血和指尖血,采用即时检验血糖仪检测所有患者的血糖数值,同时,还在生化分析仪上进行检测血浆葡萄糖,对比分析两部位生化分析仪检测结果和血样检测结果的偏倚程度。结果即时检验血糖仪指尖血血糖为（9.38±4.28）mmol/L,静脉全血血糖为（9.17±4.05）mmol/L,生化仪测定血浆葡萄糖为（9.96±5.01）mmol/L,三者之间进行统计学分析,差异有统计学意义（P＜0.05）,两部位生化分析仪检测结果和血样检测结果的偏移程度都是负偏倚,其中,偏倚范围最高是13.8%,最低为1.4%,都没有超过20%。静脉全血血糖偏倚显著高于指尖血血糖偏倚,差异具备统计学意义（P＜0.05）。结论对于即时检验血糖仪检测指尖血及静脉全血血糖检验结果的临床可行性,不管是采用静脉采血,还是指尖采血,即时检验血糖的数值都在接受范围内,但是采取指尖血样,检测结果更加接近血浆葡萄糖。     

肝素联合低分子肝素预防动静脉内瘘术后早期血栓形成

摘 要 目的： 研究肝素联合低分子肝素对预防动静脉内瘘（AVF）术后早期血栓形成的影响。方法: 采用前瞻性研究方法,将299例行AVF术的患者随机分为两组,对照组患者术后给予低分子肝素5 000 IU皮下注射qd×7 d;观察组术中在游离动脉端与静脉端分别推注1 500 u肝素钠,术后给予低分子肝素5 000 IU皮下注射qd×7 d。观察两组患者术后1周和4周AVF血栓形成率及药品不良反应（ADR）发生情况。结果: 术后1周,对照组和观察组的AVF血栓形成率分别为3.4%和0;术后4周分别为4.8%和0.67%,观察组均明显低于对照组（P<0.05）。两组ADR发生率差异无统计学意义（P>0.05）,未发生严重不良反应。结论: 肝素联合低分子肝素可降低AVF术后早期血栓形成率,提高手术成功率,安全性较好。     

Peripherally Inserted Central Catheter Thrombosis After Placement via Electrocardiography vs Traditional Methods

BackgroundPeripherally inserted central catheter tip placement at the cavoatrial junction is associated with reduced catheter-related deep vein thrombosis. Electrocardiographic tip confirmation purportedly improves accuracy of tip placement, but whether this approach can reduce deep vein thrombosis is unknown.MethodsProspectively collected data from patients that received peripherally inserted central catheters at 52 Michigan hospitals were analyzed. The method used to confirm tip confirmation at insertion and deep vein thrombosis outcomes were extracted from medical records. Multivariate models (accounting for the clustered nature of the data) were fitted to assess the association between peripherally inserted central catheter-related deep vein thrombosis and method of tip confirmation (electrocardiographic vs radiographic imaging).ResultsA total of 42,687 peripherally inserted central catheters (21,098 radiology vs 21,589 electrocardiographic) were included. Patients receiving electrocardiographic-confirmed peripherally inserted central catheters had fewer comorbidities compared with those that underwent placement via radiology. Overall, deep vein thrombosis occurred in 594 (1.3%) of all peripherally inserted central catheters. Larger catheter size (odds radio [OR] 1.32; 95% confidence interval [CI], 0.93-1.90 per unit increase in gauge), history of deep vein thrombosis, and cancer were associated with increased risk of deep vein thrombosis (OR 2.00; 95% CI, 1.65-2.43 and OR 1.62; 95% CI, 1.16-2.26, respectively) using logistic regression. Following adjustment, electrocardiographic guidance was associated with a significant reduction in peripherally inserted central catheter-related deep vein thrombosis compared with radiographic imaging (OR 0.74; 95% CI, 0.58-0.93; P = .0098).ConclusionThe use of electrocardiography to confirm peripherally inserted central catheter tip placement at the cavoatrial junction was associated with significantly fewer deep vein thrombosis events than radiographic imaging. Use of this approach for peripherally inserted central catheter insertion may help improve patient safety, particularly in high-risk patients.     

Should We Reintroduce Previous Venous Thromboembolism Into Decision-Making for Anticoagulation in Atrial Fibrillation?

BackgroundWe aimed to investigate whether history of venous thromboembolism should be considered a prognostic factor for future thromboembolic events in patients with atrial fibrillation.MethodsThis was a nationwide cohort study of patients with incident atrial fibrillation from 2000-2017, defined and characterized using Danish health registries. Cox regression analyses were used to calculate hazard ratios and 95% confidence intervals for the outcomes ischemic stroke or systemic embolism, and ischemic stroke, systemic embolism, or venous thromboembolism, according to history of venous thromboembolism. Analyses were adjusted for components of the CHA₂DS₂-VASc score and time-varying use of oral anticoagulation.ResultsThe study included 246,313 patients with incident atrial fibrillation, of which 6,516 (2.6%) had previous venous thromboembolism. Patients with previous venous thromboembolism carried an overall similar adjusted risk of ischemic stroke or systemic embolism compared with patients without previous venous thromboembolism (reference; hazard ratio 0.99; 95% confidence interval, 0.90-1.09). When analyzing a composite thromboembolic outcome of ischemic stroke, systemic embolism, or venous thromboembolism, patients with previous venous thromboembolism were at high-risk (hazard ratio 1.76; 95% confidence interval, 1.64-1.90). Similar conclusions were drawn when stratifying by venous thromboembolism subtype, and when restricting to patients with low CHA₂DS₂-VASc scores or the non-anticoagulated subset of the study population.ConclusionPatients with atrial fibrillation and previous venous thromboembolism carried similar risk of ischemic stroke or systemic embolism compared with patients with atrial fibrillation without previous venous thromboembolism. Nonetheless, patients with previous venous thromboembolism remain a high-risk population due to an excess risk of future venous thromboembolism. Patients and physicians should keep this excess thromboembolic risk in mind when weighing the expected risks and benefits of oral anticoagulation in patients with atrial fibrillation.     

In-Hospital Risks and Management of Deep Venous Thrombosis According to Location of the Thrombus

BackgroundWhether deep venous thrombosis involving the pelvic veins or inferior vena cava is associated with higher in-hospital mortality or higher prevalence of in-hospital pulmonary embolism than proximal or distal lower extremity deep venous thrombosis is not known.MethodsThis was a retrospective cohort study based on administrative data from the Nationwide Inpatient Sample, 2016, 2017. Patients hospitalized with a primary diagnosis of deep venous thrombosis at known locations were identified by International Classification of Diseases-10-Clinical Modification codes.ResultsIn-hospital all-cause mortality with deep venous thrombosis involving the inferior vena cava in patients treated only with anticoagulants was 2.2% versus 0.8% with pelvic vein deep venous thrombosis (p<0.0001), 0.7% with proximal deep venous thrombosis (p<0.0001) and 0.2% with distal deep venous thrombosis (p<0.0001). Mortality with anticoagulants was similar with pelvic vein deep venous thrombosis compared with proximal lower extremity deep venous thrombosis, 0.8% versus 0.7% (p=0.39). Lower mortality was shown with pelvic vein deep venous thrombosis treated with thrombolytics than with anticoagulants, 0% versus 0.8% (p<0.0001). In-hospital pulmonary embolism occurred in 11% to 23%, irrespective of the site of deep venous thrombosis.ConclusionPatients with deep venous thrombosis involving the inferior vena cava had higher in-hospital mortality than patients with deep venous thrombosis at other locations. Pelvic vein deep venous thrombosis did not result in higher mortality or more in-hospital pulmonary embolism than proximal lower extremity deep venous thrombosis. The incidence of in-hospital pulmonary embolism was considerable with deep venous thrombosis at all sites.     

The safety and effectiveness of salvianolate in preventing perioperative venous thromboembolism in China: A PRISMA-compliant meta-analysis based on RCTs

Background:Salvianolate, a common drug for stabilizing heart disease and Angina Pectoris, is considered to be off-label for preventing venous thromboembolism (VTE) or anticoagulation at present. However, many clinical studies have showed that salvianolate can effectively inhibit the deep-vein thrombosis (DVT) incidence, and prevent VTE of perioperative patients in the real world in China.Objective:This analysis aimed to evaluate the effectiveness and safety of salvianolate in preventing VTE in perioperative patients.Methods:Databases of PubMed, Cochrane Library, Embase, CNKI, Wanfang and VIP were searched until July 2019. Literature retrieval, data extraction and quality assessment were independently completed by two researchers and checked with each other. Review Manager 5.2 software was applied for meta-analysis.Results:A total of 429 studies were retrieved, including 11 randomized controlled trials (RCTs) with a total of 1149 subjects. Compared with low molecular weight heparin (LMWH) group alone, salvianolate combined LMWH group had lower DVT incidence in preventing perioperative thrombosis (2.75% and 14.23%, OR: 0.21, 95% CI:[0.08,0.53]; P = .0009). The incidence of adverse reactions of experimental group was similar to that of control group (1.79% and 2.31%, OR: 0.65, 95% CI:[0.18,2.35]. P = .51). Compared with the control group, D-dimer level (D-D), platelet count (PLT), fibrinogen (FIB), whole blood high shear viscosity (WBHSV), and whole blood low shear viscosity (WBLSV) were all significantly decreased (P < .01), and prothrombin time (PT) was significantly increased (P < .05).Conclusion:Salvianolate combined LMWH has better effectiveness and the same safety in preventing venous thromboembolism in perioperative patients. However, due to the small number of included literatures, large sample studies are still needed to further verify this conclusion.     

Apport de la détection des anticorps antiphosphatidylsérine/prothrombine (aPS/PT) dans le diagnostic et la prise en charge du syndrome des antiphospholipides (SAPL)

Antiphospholipid syndrome (APS) is an autoimmune disease and one of the most common causes of acquired thrombophilia. It is characterised by the occurrence of thrombotic or obstetric events associated with the presence of persistent antiphospholipid antibodies. The diagnosis can be challenging, particularly because some biological tests can be disturbed by anticoagulant treatment or inflammation.In the recent years, new antiphospholipid antibodies, including anti-phosphatidylserine/prothrombin antibodies (anti-PS/PT), have emerged but their clinical significance and causality remain uncertain.Biologically, several studies have found a strong correlation between the presence of lupus anticoagulant (LA) and anti-PS/PT antibodies. Clinically, the presence of anti-PS/PT antibodies is associated with an increased risk of thrombosis and obstetric complications. There is also an association with thrombocytopenia, suggesting that the presence of anti-PS/PT antibodies may be associated with more severe clinical APS. Among seronegative APS patients, 6–17% of patients are positive for anti-PS/PT antibodies. This might influence the therapeutic management of patients.This article aims to provide an update on contribution of anti-PS/PT antibodies detection for the diagnosis and management of APS.     

Treatment of DVT: how long is enough and how do you predict recurrence

Abstract Currently available anticoagulants are effective in reducing the recurrence rate of venous thromboembolism (VTE). However, anticoagulant treatment is associated with an increased risk for bleeding complications. Thus, anticoagulation has to be discontinued when benefit of treatment no longer clearly outweigh its risks. The duration of anticoagulant treatment is currently framed based on the estimated individual risk for recurrent VTE. The incidence of recurrent VTE can be estimated through a two-step decision algorithm. Firstly, the features of the patient (gender), of the initial event (proximal or distal deep vein thrombosis or pulmonary embolism), and the associated conditions (cancer, surgery, etc) provide essential information on the risk for recurrence after anticoagulant treatment discontinuation. Secondly, at time of anticoagulant treatment discontinuation, d-dimer levels and residual thrombosis have been indicated as predictors of recurrent VTE. Current evidence suggests that the risk of recurrence after stopping therapy is largely determined by whether the acute episode of VTE has been effectively treated and by the patient’s intrinsic risk of having a new episode of VTE. All patients with acute VTE should receive oral anticoagulant treatment for three months. At the end of this treatment period, physicians should decide for withdrawal or indefinite anticoagulation. Based on intrinsic patient’s risk for recurrent VTE and for bleeding complications and on patient preference, selected patients could be allocated to indefinite treatment with VKA with scheduled periodic re-assessment of the benefit from extending anticoagulation. Alternative strategies for secondary prevention of VTE to be used after conventional anticoagulation are currently under evaluation. Cancer patients should receive low molecular-weight heparin over warfarin in the long-term treatment of VTE. These patients should be considered for extended anticoagulation at least until resolution of underlying disease. Abbreviated abstract The risk for recurrent venous thromboembolism can be estimated through a two-step algorithm. Firstly, the features of the patient (gender), of the initial event (proximal or distal deep vein thrombosis or pulmonary embolism), and the associated conditions (cancer, surgery, etc) are essential to estimate the risk for recurrence after anticoagulant treatment discontinuation. Secondly, a correlation has been shown between d-dimer levels and residual thrombosis at time of anticoagulant treatment discontinuation and the risk of recurrence. Currently available anticoagulants are effective in reducing the incidence of recurrent venous thromboembolism, but they are associated with an increased risk for bleeding complications. All patients with acute venous thromboembolism should receive oral anticoagulant treatment for three months. At the end of this treatment period physicians should decide for definitive withdrawal or indefinite anticoagulation with scheduled periodic re-assessment of the benefit from extending anticoagulation.