Page 2369 - Hematology_ Basic Principles and Practice ( PDFDrive )

Chapter 142 Venous Thromboembolism 2111

greater than 80% of cases. Clinical prediction rules such as the Wells basic principles and clinical practice, ed 3, Philadelphia, 1994, JB Lip-
score and the use of D-dimer testing have not been validated in this pincott, p 3.
setting. A high index of suspicion should be maintained in pregnant Daly E, Vessey MP, Hawkins MM, et al: Risk of venous thromboem-
women presenting with signs or symptoms of VTE. bolism in users of hormone replacement therapy. Lancet 348:977,
Pregnant women with suspected DVT should undergo proximal 1996.
compression ultrasonography. However, standard compression ultra- Eriksson BI, Dahl OE, Rosencher N, et al: Dabigatran etexilate versus
sound techniques are less sensitive for pelvic and iliac vein thromboses, enoxaparin for prevention of venous thromboembolism after total hip
which are more common in pregnancy. Pregnant women with sus- replacement: a randomised, double-blind, non-inferiority trial. Lancet
pected DVT and negative proximal compression ultrasound should 370:949, 2007.
undergo serial compression ultrasounds at 3 and 7 days. Anticoagu- Eriksson BI, Dahl OE, Rosencher N, et al: Oral dabigatran etexilate vs.
lants can be safely withheld in patients with negative serial compres- subcutaneous enoxaparin for the prevention of venous thromboembolism
sion ultrasounds. after total knee replacement: the RE-MODEL randomized trial. J Thromb
Pregnant women with suspected PE should undergo chest Haemost 5:2178, 2007.
radiography with shielding of the abdomen to exclude alternative Freiman D: The structure of thrombi. In Colman RW, Hirsh J, Marder
causes of presenting symptoms. Bilateral proximal compression VJ, et al, editors: Hemostasis and thrombosis: basic principles and clinical
ultrasounds should be done to assess for concurrent DVT in women practice, ed 2, Philadelphia, 1987, JB Lippincott.
with clinical suspicion of DVT which, if positive, would obviate Ginsberg JS, Brill-Edwards P, Burrows RF, et al: Venous thrombosis during
the need for CTPA or V/Q scanning. Because of the low prevalence pregnancy: leg and trimester of presentation. Thromb Haemost 67:519,
of coexistent DVT in pregnant women with suspected PE, routine 1992.
compression ultrasonography in the absence of DVT symptoms may Ginsberg JS, Wells PS, Brill-Edwards P, et al: Application of a novel and
lead to delays in definitive diagnosis and treatment of PE. V/Q rapid whole blood assay for D-dimer in patients with clinically suspected
scanning is preferred over CTPA for diagnosis of PE in pregnancy pulmonary embolism. Thromb Haemost 73:35, 1995.
because of reduced maternal exposure and similar fetal exposure to Gómez-Outes A, Terleira-Fernández AI, Suárez-Gea ML, et al: Dabigatran,
radiation. rivaroxaban, or apixaban versus enoxaparin for thromboprophylaxis after
Weight-adjusted LMWH is the treatment of choice for pregnancy- total hip or knee replacement: systematic review, meta-analysis, and
associated VTE. Although warfarin use during the first trimester is indirect treatment comparisons. BMJ 344:e3675, 2012.
associated with teratogenicity, it is safe during breastfeeding. DOACs Grodstein F, Stampfer MJ, Goldhaber SZ, et al: Prospective study of exog-
and fondaparinux, however, should be avoided during both pregnancy enous hormones and risk of pulmonary embolism in women. Lancet
and breastfeeding. The duration of anticoagulant treatment for 348:983, 1996.
pregnancy-associated VTE is a minimum of 3 months, including the Hull RD, Hirsh J, Carter CJ, et al: Diagnostic value of ventilation-perfusion
6-week postpartum period. lung scanning in patients with suspected pulmonary embolism. Chest
88:819, 1985.
Hull RD, Hirsh J, Jay RM: Different intensities of anticoagulation in
CANCER-ASSOCIATED VENOUS THROMBOSIS the long-term treatment of proximal vein thrombosis. N Engl J Med
307:1676, 1982.
VTE occurs in up to 20% of patients with cancer and confers an Kearon C, Ginsberg JS, Anderson DR, et al; SOFAST Investigators: Com-
increased risk of death, VTE recurrence, and bleeding. LMWH is the parison of 1 month with 3 months of anticoagulation for a first episode
recommended treatment for acute cancer-associated VTE based on of venous thromboembolism associated with a transient risk factor. J
clinical data showing reduced risk of VTE recurrence with no Thromb Haemost 2:743, 2004.
increased risk of bleeding compared with VKA therapy. Anticoagulant Kearon C, Ginsberg JS, Julian JA, et al: Comparison of fixed-dose weight-
treatment should be given for at least 3 months, with consideration adjusted unfractionated heparin and low-molecular-weight heparin
of prolonged therapy for patients receiving ongoing cancer treatment for acute treatment of venous thromboembolism. JAMA 296:935,
or those with metastatic disease and who are not at high risk of 2006.
bleeding. Lee AY, Levine MN, Baker AI, et al: Low-molecular-weight heparin versus
Postoperative VTE prophylaxis with LMWH or low-dose UFH a coumarin for the prevention of recurrent venous thromboembolism in
should be provided for cancer patients undergoing surgery. Extended- patients with cancer. N Engl J Med 349:146, 2003.
duration prophylaxis (4 weeks) can be considered for cancer patients Lensing AW, Prandoni P, Brandjes D, et al: Detection of deep-vein throm-
at high risk for VTE and low risk for bleeding who are undergoing bosis by real-time B-mode ultrasonography. N Engl J Med 320:342,
abdominal or pelvic surgery for cancer. Hospitalized cancer patients 1989.
with reduced mobility should receive VTE prophylaxis with LMWH Miller GA, Sutton GC, Kerr IH, et al: Comparison of streptokinase and
or low-dose UFH. In the outpatient setting, pharmacologic VTE heparin in treatment of isolated acute massive pulmonary embolism.
prophylaxis is generally reserved for cancer patients with additional BMJ 33:616, 1971.
risk factors for VTE such as previous VTE, immobilization, or hor- Prandoni P, Lensing AW, Cogo A, et al: The long-term clinical course of acute
monal therapy treatment with angiogenesis inhibitors (thalidomide deep venous thrombosis. Ann Intern Med 125:1, 1996.
and lenalidomide). Quiroz R, Kucher N, Zou KH, et al: Clinical validity of a negative computed
tomography scan in patients with suspected pulmonary embolism: a
systematic review. JAMA 293:2012, 2005.
SUGGESTED READINGS Simonneau G, Sors H, Charbonnier B, et al: A comparison of low-molecular
weight heparin with unfractionated heparin for acute pulmonary embo-
Bell WR, Simon TL, DeMets DL: The clinical features of submassive and lism. N Engl J Med 337:663, 1997.
massive pulmonary emboli. Am J Med 62:355, 1977. The PIOPED Investigators: Value of the ventilation/perfusion scan in
Castellucci LA, Cameron C, Le Gal G, et al: Clinical and safety outcomes acute pulmonary embolism. Results of the Prospective Investigation
associated with treatment of acute venous thromboembolism: a systematic of Pulmonary Embolism Diagnosis (PIOPED). JAMA 263:2753,
review and meta-analysis. JAMA 312(11):1122–1135, 2014. 1990.
Collins R, Scrimgeour A, Yusuf S, et al: Reduction in fatal pulmonary Tibbutt DA, Davies JA, Anderson JA, et al: Comparison by controlled
embolism and venous thrombosis by perioperative administration of clinical trial of streptokinase and heparin in treatment of life-threatening
subcutaneous heparin. Overview of results of randomized trials in general, pulmonary embolism. BMJ 1:343, 1974.
orthopedic, and urologic surgery. N Engl J Med 318:1162, 1988. Turkstra F, van Beek EJ, ten Cate JW, et al: Reliable rapid blood test for
Colman RW, Marder VJ, Salzman EW, et al: Overview of hemostasis. In the exclusion of venous thromboembolism in symptomatic outpatients.
Colman RW, Hirsh J, Marder VJ, et al, editors: Hemostasis and thrombosis: Thromb Haemost 76:9, 1996.