prevention of dvt recurrence. a practical approach...dacus study ultrasound first episode dvt...
Post on 31-Aug-2020
1 Views
Preview:
TRANSCRIPT
Prevention of DVT Recurrence.
A Practical Approach
Andrew Nicolaides
Emeritus Prof. of Vascular Surgery, Imperial College, London, UK
Honorary Prof. of Surgery,
Nicosia University Medical School, Cyprus
Disclosures
Received Honoraria for lectures from:
Covidien/Medronic
Servier
Alpha Wasserman
Pierre Fabre
Recurrent VTE Following Cessation of Anticoagulation
Unprovoked
Provoked
11%
30%
40%
Prandoni et al Haematologica 1997; 82:423
Are there any markers of recurrence?
CompressionNo Compression
B-mode Ultrasound
Normal vein
Residual Vein Thrombus (DACUS study)
Siragusa S et al Blood 2008;112:511-515
Residual Thrombus(N=180)
No RVT(N=78)
Siragusa S et al Blood 2008; 112:511-515
Residual Thrombus in CF and/or Popliteal Vein and Recurrent DVT
DACUS Study
Ultrasound
First Episode DVT
(N=258)
AnnualRecurrence
0.63% 12.8%
p<0.001
3 Months VKA
D-dimer and Recurrence of DVT
Idiopathic VTE
(N=619)
Randomized
No Anticoagulation
(N=385)
Normal D-dimer
(N=385)
Elevated D-dimer
(N=227)
Resume Anticoagulation
(N=105)
No Anticoagulation
(N=122)
D-dimer 1 Month after
Anticoagulation Discontinued
15.0%6.2% 2.9%Events at 18 months
(VTE or Bleed)
Palareti G et al NEJM 2006;355:1780
NEJM 2012; 366:1959
NEJM 2012; 367:1979
WA
RF
AS
AA
SP
IRE
Brighton TA et al NEJM 2012;367:1979
Recurrent VTE/Death
Ris
k
Months
p=0.001 p=0.03
11.5%
5.6%
0.4%
7.6%
Extended Use of Dabigatran
Schulman S et al NEJM 2013;368:709
Any
Bleeding
Months
P<0.003
10.5 %
5.9 %
Extended Use of Dabigatran
Major or
CRNMB
5.3 %
1.8 %
P<0.001
Schulman S et al NEJM 2013;368:709
Extended Use of Rivaroxaban in VTERecurrent VTE
Major or CRNMB
1.2 %
6.0 %
P<0.001
EINSTEIN Investigators NEJM 2010;363:2499
RRR 75%
After completion of 6-12 months anticoagulant therapy, 2486 patients
were randomized 1:1:1 to:
(a) Placebo
(b) 2.5mg apixaban
(c) 5.0mg apixaban
for 12 months
Extended Use of Apixaban in VTE(Amplify-Extension Study)
Agnelli G et al NEJM 2013;368:699-708
RRR = 81%
P<0.001
Recurrent VTE / VTE Death8.8 %
1.7 %
Extended Use of Apixaban in VTE(Amplify-Extension Study)
Agnelli G et al NEJM 2013;368:699-708
P=NS
4.3 %
3.2 %2.7 %
Extended Use of Apixaban in VTE(Amplify-Extension Study)
Major or CRNMB
Agnelli G et al NEJM 2013;368:699-708
Sulodexide: Multicenter RCT615 patients with 1st unprovoked VTE after completion of VKA therapy
Efficacy: 54% reduction in VTE Bleeding
No Major bleeding
2 patients in each group had
clinically relevant bleeding
episodes
Andreozzi MA et al. The SURVET Study: Circulation 2015;132:1891-7
Current Thinking
1. “One approach fits all” is not appropriate
2. Can we balance risk of recurrence vs. risk of bleeding?
Risk of VTE Recurrence after 1st Episode
High (one or more risk factors)Unprovoked 2 or more VTE Episodes
Iliofemoral DVT
Residual thrombus (>40%)
Active cancer
Serious thrombophilia
D-dimer > 500 1-3 months after stopping
anticoagulation
Life threatening PE
Inflammatory bowel disease
Moderate (one risk factor)Unprovoked isolated calf DVT
Male
Obesity
Low (one transient risk factor)Post major surgery or bed rest for > 4 days.
Post POP or post major trauma
Post estrogen therapy or pregnancy
Risk of Bleeding during Anticoagulant Therapy
HighHistory of major bleeding
Platelet count < 50,000
Need for double antiplatelet therapy
Portal hypertension (Bleeding esoph.
varices)
History of stroke or cerebral changes
Metastatic Carcinoma
Renal insufficiency
Liver failure
Diabetes
Age > 75
ModerateHistory of clinically relevant non-major
bleeding
One antiplatelet drug
Platelet count 50,000- 100,000
Age 65-75
LowNo history of bleeding
No bleeding during previous antig. Therapy
No associated pro-hemorrhagic drugs
Age < 65
BLEEDING RISKRefused or
Contraindication
to DOAsLOW MODERATE HIGH
DVT RISK HIGH ≥ 20%
in 2 years
Rivaroxaban or
Apixaban
Apixaban Sulodexide or
Apixaban
Sulodexide
DVT RISK MODERATE
5-20% in 2 years
Rivaroxaban or
Apixaban
Sulodexide or
Apixaban
Sulodexide or
Apixaban
Sulodexide
DVT RISK LOW < 5%
in 2 years
Sulodexide or
Aspirin*
Sulodexide* Sulodexide* Sulodexide or
Aspirin*
* If patient would like to have cover
The Evidence for DVT Reduction in Cancer Patients
LMWH vs VKA in Cancer Patients: Efficacy
LMWH vs VKA in Cancer Patients: Major Bleeding
DOAC vs LMWH in Cancer Patients: Efficacy
LMWH
DOAC vs LMWH in Cancer Patients: Major Bleeding
LMWH
Conclusions
Reduction in recurrent VTE without any increase in bleeding is
now possible; it should contribute to the reduction in PTS
In patients with active cancer:➢ LMWH are more effective than VKA in preventing VTE recurrence
without any increase in bleeding
➢ DOAC are more effective than LMWH in preventing VTE recurrence
but caused more major bleeding (6.5% vs 3.7%).
➢ More studies with DOAC are needed.
top related