Assuntos
Obesidade , Assistência Perioperatória , Tromboembolia Venosa , Humanos , Tromboembolia Venosa/prevenção & controle , Tromboembolia Venosa/etiologia , Obesidade/complicações , Obesidade/cirurgia , Assistência Perioperatória/métodos , Assistência Perioperatória/normas , Europa (Continente) , Anticoagulantes/administração & dosagem , Complicações Pós-Operatórias/prevenção & controle , Complicações Pós-Operatórias/etiologia , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Fatores de RiscoRESUMO
Knee arthroscopy is the most common orthopedic procedure worldwide. While incidence of post-arthroscopy venous thromboembolic events (VTE) is low, treatment patterns and patient outcomes have not been described. Patients from the "Registro Informatizado Enfermedad TromboEmbolica" who had confirmed post-arthroscopy VTE were compared to patients with provoked, post bone-fracture, and to patients with unprovoked VTE. Baseline characteristics, presenting signs and symptoms, treatment and outcomes including recurrent VTE, bleeds or death were compared. A total of 101 patients with post-arthroscopy VTE and 19,218 patients with unprovoked VTE were identified. Post-arthroscopy patients were younger (49.5 vs. 66 years, P < 0.0001) and had less history of VTE [5.9% vs. 20%, OR 0.26 (0.11-0.59)]. Among patients with isolated DVT, there were fewer proximal DVT in the post-arthroscopy group [40% vs. 86%, OR 0.11 (0.06-0.19)]. Treatment duration was shorter in the post-arthroscopy group (174 ± 140 vs. 311 ± 340 days, P < 0.0001) and more often with DOAC [OR 3.67 (1.95-6.89)]. Recurrent VTE occurred in 6.18 (1.96-14.9) and 11.9 (11.0-12.8) per 100 patient years [HR 0.52 (0.16-1.26)] after treatment in the post-arthroscopy and unprovoked groups, respectively. Recurrent VTE occurred in 5.17 (1.31-14.1) per 100 patient years in a separate post bone-fracture group (n = 147), also not statistically different than the post-arthroscopy recurrence rate. After anticoagulation cessation, some patients post-knee arthroscopy develop VTE. While our small sample size precludes drawing firm conclusions, this signal should warrant further research into the optimal treatment duration for these patients, as some patients may be at increased risk for long-term recurrence.
Assuntos
Artroscopia/efeitos adversos , Tromboembolia Venosa/etiologia , Idoso , Anticoagulantes/uso terapêutico , Feminino , Humanos , Incidência , Articulação do Joelho/cirurgia , Masculino , Pessoa de Meia-Idade , Recidiva , Sistema de Registros , Resultado do Tratamento , Tromboembolia Venosa/patologia , Tromboembolia Venosa/terapia , Trombose VenosaRESUMO
BACKGROUND: Venous thromboembolism (VTE) is a major cause of morbidity and mortality postoperatively. The use of pharmacologic prophylaxis is effective in reducing the incidence of VTE. However, the prophylaxis is often discontinued at hospital discharge, especially for those with benign disease. The implications of this practice are not known. We assessed the data from a large, ongoing registry regarding the time course of VTE and outcomes after noncancer surgery. METHODS: We analyzed the RIETE (Computerized Registry on Venous Thromboembolism) registry, which includes data from consecutive patients with symptomatic confirmed VTE. In the present study, we focused on general surgical patients who had developed symptomatic postoperative VTE in the first 8 weeks after noncancer surgery. The main objective was to assess the interval between surgery and the occurrence of VTE. Additional variables included the clinical presentation associated with the event, the use of thrombosis prophylaxis, and unfavorable outcomes. RESULTS: The data from 3296 patients were analyzed. The median time from surgery to the detection of VTE was 16 days (interquartile range, 8-30 days). Of the VTE events, 77% were detected after the first postoperative week and 27% after 4 weeks. Overall, 43.9% of the patients with VTE had received pharmacologic prophylaxis after surgery for a median of 8 days (interquartile range, 5-14 days), and three quarters of the VTE events were detected after pharmacologic prophylaxis had been discontinued. Overall, 54% of the patients with VTE had presented with pulmonary embolism. For 15% of the patients, the clinical outcome was unfavorable, including 4% who had died within 90 days. CONCLUSIONS: The risk of VTE after noncancer general surgery remains high for ≤2 months. More than one half of the patients had presented with symptomatic PE as the VTE event, and 15% had had unfavorable outcomes. Only 44% of these patients had received pharmacologic prophylaxis for around 1 week.
Assuntos
Complicações Pós-Operatórias/diagnóstico , Tromboembolia Venosa/diagnóstico , Adulto , Idoso , Anticoagulantes/uso terapêutico , Esquema de Medicação , Feminino , Heparina de Baixo Peso Molecular/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/prevenção & controle , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/prevenção & controle , Sistema de Registros , Fatores de Risco , Fatores de Tempo , Tromboembolia Venosa/prevenção & controle , Trombose Venosa/diagnóstico , Trombose Venosa/prevenção & controleRESUMO
There is little literature about the clinical presentation and time-course of postoperative venous thromboembolism (VTE) in different surgical procedures. RIETE is an ongoing, prospective registry of consecutive patients with objectively confirmed, symptomatic acute VTE. In this analysis, we analysed the baseline characteristics, thromboprophylaxis and therapeutic patterns, time-course, and three-month outcome of all patients with postoperative VTE. As of January 2006, there were 1,602 patients with postoperative VTE in RIETE: 393 (25%) after major orthopaedic surgery (145 elective hip arthroplasty, 126 knee arthroplasty, 122 hip fracture); 207 (13%) after cancer surgery; 1,002 (63%) after other procedures. The percentage of patients presenting with clinically overt pulmonary embolism (PE) (48%, 48%, and 50% respectively), the average time elapsed from surgery to VTE (22 +/- 16, 24 +/- 16, and 21 +/- 15 days, respectively), and the three-month incidence of fatal PE (1.3%, 1.4%, and 0.8%, respectively), fatal bleeding (0.8%, 1.0%, and 0.2%, respectively), or major bleeding (2.3%, 2.9%, and 2.8%, respectively) were similar in the three groups. However, the percentage of patients who had received thromboprophylaxis (96%, 76% and 52%, respectively), the duration of prophylaxis (17 +/- 9.6, 13 +/- 8.9, and 12 +/- 11 days, respectively) and the mean daily doses of low-molecular-weight heparin (4,252 +/- 1,016, 3,260 +/- 1,141, and 3,769 +/- 1,650 IU, respectively), were significantly lower in those undergoing cancer surgery or other procedures. In conclusion, the clinical presentation, time-course, and three-month outcome of VTE was similar among the different subgroups of patients, but the use of prophylaxis in patients undergoing cancer surgery or other procedures was suboptimal.
Assuntos
Fibrinolíticos/uso terapêutico , Embolia Pulmonar/etiologia , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Tromboembolia Venosa/etiologia , Idoso , Argentina , Europa (Continente) , Feminino , Fibrinolíticos/efeitos adversos , Hemorragia/induzido quimicamente , Humanos , Incidência , Israel , Masculino , Pessoa de Meia-Idade , Neoplasias/cirurgia , Procedimentos Ortopédicos/efeitos adversos , Estudos Prospectivos , Embolia Pulmonar/mortalidade , Embolia Pulmonar/prevenção & controle , Recidiva , Sistema de Registros , Fatores de Tempo , Tromboembolia Venosa/complicações , Tromboembolia Venosa/tratamento farmacológico , Tromboembolia Venosa/mortalidadeRESUMO
During the last few years, the number of patients receiving anticoagulant and antiplatelet therapy has increased worldwide. Since this is a chronic treatment, patients receiving it can be expected to need some kind of surgery or intervention during their lifetime that may require treatment discontinuation. The decision to withdraw antithrombotic therapy depends on the patient's thrombotic risk versus hemorrhagic risk. Assessment of both factors will show the precise management of anticoagulant and antiplatelet therapy in these scenarios. The aim of this consensus document, coordinated by the Cardiovascular Thrombosis Working Group of the Spanish Society of Cardiology, and endorsed by most of the Spanish scientific societies of clinical specialities that may play a role in the patient-health care process during the perioperative or periprocedural period, is to recommend some simple and practical guidelines with a view to homogenizing daily clinical practice.
Assuntos
Anticoagulantes/uso terapêutico , Fibrinolíticos/uso terapêutico , Hemorragia/etiologia , Inibidores da Agregação Plaquetária/uso terapêutico , Tromboembolia/etiologia , Idoso , Idoso de 80 Anos ou mais , Substituição de Medicamentos , Feminino , Hemorragia/prevenção & controle , Humanos , Cuidados Intraoperatórios/métodos , Masculino , Cuidados Pré-Operatórios/métodos , Medição de Risco , Fatores de Risco , Tromboembolia/prevenção & controleRESUMO
BACKGROUND AND OBJECTIVES: Elderly patients with venous thromboembolism (VTE) have an increased rate of bleeding complications on therapeutic doses of anticoagulant therapy. DESIGN AND METHODS: Using data in RIETE, an international registry of consecutive patients with objectively confirmed, symptomatic acute VTE, we analyzed the clinical characteristics and outcome within 90 days of therapy of all enrolled patients aged > or = 80 years old. RESULTS: Of the 13,011 patients with VTE enrolled in RIETE up tp September 2005, 2890 (22%) were aged > or = 80 years old. During the study period 99 patients (3.4%) aged > or = 80 years, and 212 aged < 80 years (2.1%) had major bleeding events (odds ratio: 1.7; 95% CI: 1.3-2.1). Fatal bleeding occurred in 0.8% and 0.4%, respectively (odds ratio: 2.0; 95% CI: 1.2-3.4). The incidence of recurrent VTE was 2.1% and 2.8%. However, 3.7% of patients > or = 80 years and 1.1% < 80 years died of pulmonary embolism (PE) (odds ratio: 3.6; 95% CI: 2.7-4.7). On multivariate analysis, patients > or = 80 years with symptomatic PE, heart failure, long-term therapy with low-molecular-weight heparin (LMWH) or a vena cava filter had an increased risk of recurrent VTE. Those with recent bleeding, abnormal renal function, use of corticosteroids or long-term therapy with LMWH had an increased risk of major bleeding. INTERPRETATION AND CONCLUSIONS: In patients aged > or = 80 years old the 3.4% incidence of major bleeding exceeded the 2.1% incidence of VTE recurrences. However, the 3.7% incidence of fatal PE outweighed the 0.8% of fatal bleeding. Thus, there seems to be more reason to be concerned about fatal PE than about bleeding in elderly patients with VTE.
Assuntos
Tromboembolia/fisiopatologia , Trombose Venosa/fisiopatologia , Idoso de 80 Anos ou mais , Seguimentos , Humanos , Estudos Prospectivos , Embolia Pulmonar/epidemiologia , Taxa de Sobrevida , Tromboembolia/mortalidade , Trombose Venosa/mortalidadeRESUMO
PURPOSE: To provide current recommendations about the prophylaxis and treatment of venous thromboembolism (VTE) in patients with cancer. METHODS: PubMed and the Cochrane Library were searched for randomized controlled trials, systematic reviews, meta-analyses, and clinical practice guidelines from November 2012 through July 2014. An update committee reviewed the identified abstracts. RESULTS: Of the 53 publications identified and reviewed, none prompted a change in the 2013 recommendations. RECOMMENDATIONS: Most hospitalized patients with active cancer require thromboprophylaxis throughout hospitalization. Routine thromboprophylaxis is not recommended for patients with cancer in the outpatient setting. It may be considered for selected high-risk patients. Patients with multiple myeloma receiving antiangiogenesis agents with chemotherapy and/or dexamethasone should receive prophylaxis with either low-molecular weight heparin (LMWH) or low-dose aspirin. Patients undergoing major surgery should receive prophylaxis starting before surgery and continuing for at least 7 to 10 days. Extending prophylaxis up to 4 weeks should be considered in those undergoing major abdominal or pelvic surgery with high-risk features. LMWH is recommended for the initial 5 to 10 days of treatment for deep vein thrombosis and pulmonary embolism as well as for long-term secondary prophylaxis (at least 6 months). Use of novel oral anticoagulants is not currently recommended for patients with malignancy and VTE because of limited data in patients with cancer. Anticoagulation should not be used to extend survival of patients with cancer in the absence of other indications. Patients with cancer should be periodically assessed for VTE risk. Oncology professionals should educate patients about the signs and symptoms of VTE.
Assuntos
Anticoagulantes/administração & dosagem , Neoplasias/sangue , Tromboembolia Venosa/prevenção & controle , Aspirina/administração & dosagem , Fibrinolíticos/administração & dosagem , Heparina de Baixo Peso Molecular/administração & dosagem , HumanosRESUMO
BACKGROUND: There is scarce evidence to identify which acutely ill medical patients might benefit from prophylaxis against venous thromboembolism (VTE). METHODS: The Spanish National Discharge Database was used to identify predictors of bleeding and VTE during hospitalization for an acute medical illness. RESULTS: Of 1,148,301 patients, 3.10% bled, 1.21% were diagnosed with VTE, and 8.64% died. The case-fatality rate was: 20.8% for bleeding and 19.7% for VTE. Eight clinical variables were independently associated with an increased risk for VTE and bleeding, one with a decreased risk for both events, 4 with an increased risk for VTE and a decreased risk for bleeding, 2 with an increased risk for bleeding but a decreased risk for VTE, and 1 with a decreased risk for bleeding. When all these variables were considered, we composed a risk scoring system, in which we assigned points to each variable according to the ratio between the odds ratio for bleeding and for VTE. Overall, 21% of patients scored less than 0 points and had a bleeding vs. VTE ratio of 1.19; 55% scored 0 to 1.0 points and had a ratio of 2.13; and 24% scored over 1.0 points and had a ratio of 6.10. CONCLUSIONS: A risk score based on variables documented at admission can identify patients with different ratios (near 1.0; about 2.0; and >6.0) between the rate of bleeding and of VTE.
Assuntos
Insuficiência Cardíaca/epidemiologia , Hemorragia/epidemiologia , Hospitalização/estatística & dados numéricos , Embolia Pulmonar/epidemiologia , Insuficiência Respiratória/epidemiologia , Tromboembolia Venosa/epidemiologia , Trombose Venosa/epidemiologia , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/uso terapêutico , Quimioprevenção , Comorbidade , Bases de Dados Factuais , Feminino , Fondaparinux , Heparina/uso terapêutico , Heparina de Baixo Peso Molecular/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Polissacarídeos/uso terapêutico , Embolia Pulmonar/prevenção & controle , Medição de Risco , Fatores de Risco , Espanha/epidemiologia , Tromboembolia Venosa/prevenção & controle , Trombose Venosa/prevenção & controleRESUMO
PURPOSE: To provide recommendations about prophylaxis and treatment of venous thromboembolism (VTE) in patients with cancer. Prophylaxis in the outpatient, inpatient, and perioperative settings was considered, as were treatment and use of anticoagulation as a cancer-directed therapy. METHODS: A systematic review of the literature published from December 2007 to December 2012 was completed in MEDLINE and the Cochrane Collaboration Library. An Update Committee reviewed evidence to determine which recommendations required revision. RESULTS: Forty-two publications met eligibility criteria, including 16 systematic reviews and 24 randomized controlled trials. RECOMMENDATIONS: Most hospitalized patients with cancer require thromboprophylaxis throughout hospitalization. Thromboprophylaxis is not routinely recommended for outpatients with cancer. It may be considered for selected high-risk patients. Patients with multiple myeloma receiving antiangiogenesis agents with chemotherapy and/or dexamethasone should receive prophylaxis with either low-molecular weight heparin (LMWH) or low-dose aspirin. Patients undergoing major cancer surgery should receive prophylaxis, starting before surgery and continuing for at least 7 to 10 days. Extending prophylaxis up to 4 weeks should be considered in those with high-risk features. LMWH is recommended for the initial 5 to 10 days of treatment for deep vein thrombosis and pulmonary embolism as well as for long-term (6 months) secondary prophylaxis. Use of novel oral anticoagulants is not currently recommended for patients with malignancy and VTE. Anticoagulation should not be used for cancer treatment in the absence of other indications. Patients with cancer should be periodically assessed for VTE risk. Oncology professionals should provide patient education about the signs and symptoms of VTE.
Assuntos
Neoplasias/sangue , Tromboembolia Venosa/terapia , Humanos , Guias de Prática Clínica como Assunto , Medição de Risco , Estados Unidos , Tromboembolia Venosa/tratamento farmacológico , Tromboembolia Venosa/prevenção & controleRESUMO
The impact of venous thromboembolism (VTE) and bleeding in patients undergoing major joint surgery has not been thoroughly studied. The Spanish National Discharge Database during the years 2005-2006 was used to assess the frequency and clinical impact of VTE and bleeding after elective total knee (TKA) or hip (THA) arthroplasty. Of 58,037 patients undergoing TKA, 0.18% (95% confidence interval [CI]: 0.15-0.22) were diagnosed with pulmonary embolism (PE), 0.57% (95% CI: 0.51-0.63) with deep-vein thrombosis (DVT), 1.20% (95% CI: 1.12-1.30) had bleeding complications, and 0.09% (95% CI: 0.07-0.12) died. Of 54 patients who died, 20.4% (95% CI: 10.7-35.4) had been diagnosed with PE, 3.70% (95% CI: 0.63-11.7) with DVT, and 13.0% (95% CI: 5.67-25.6) had bled. Of 31,769 patients undergoing elective THA, 0.23% (95% CI: 0.18-0.29) were diagnosed with PE, 0.44% (95% CI: 0.37-0.52) with DVT, 1.21% (95% CI: 1.10-1.34) bled, and 0.16% (95% CI: 0.12-0.21) died. Of 52 patients who died, 13.5% (95% CI: 6.08-24.8) had been diagnosed with PE, and 9.61% (95% CI: 3.52-21.3) had bled. On multivariable analysis, PE (odds ratio [OR]: 157; 95% CI: 75-328), DVT (OR: 6.3; 95% CI: 1.5-27) and bleeding (OR: 8.5; 95% CI: 3.6-20) were independent predictors for death after TKA. After THA, only PE (OR: 65; 95% CI: 26-160) and bleeding (OR: 6.4; 95% CI: 2.3-17) predicted the risk for death. Bleeding, DVT, and PE, arising after TKA were all independent predictors for death. Their increase in risk was, however, substantially higher for PE. After THA, only PE and bleeding independently predicted death.
Assuntos
Artroplastia de Quadril/efeitos adversos , Artroplastia do Joelho/efeitos adversos , Artropatias/epidemiologia , Artropatias/terapia , Hemorragia Pós-Operatória/etiologia , Tromboembolia Venosa/epidemiologia , Tromboembolia Venosa/terapia , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Feminino , Humanos , Artropatias/mortalidade , Artropatias/fisiopatologia , Masculino , Pessoa de Meia-Idade , Risco , Espanha , Análise de Sobrevida , Tromboembolia Venosa/mortalidade , Tromboembolia Venosa/fisiopatologiaRESUMO
Postoperative venous thromboembolic disease (VTED) affects approximately one in four general surgery patients who do not receive preventive measures. In addition to the risk of pulmonary embolism, which is often fatal, patients with VTED may develop long-term complications such as post-thrombotic syndrome or chronic pulmonary hypertension. In addition, postoperative VTED is usually asymptomatic or produces clinical manifestations that are attributed to other processes and consequently this complication is often unnoticed by the surgeon who performed the procedure. Thus, the most effective strategy consists of effective prevention of VTED using the most appropriate prophylactic measures against the patient's thromboembolic risk. There is sufficient evidence that VTED can be prevented by pharmacological methods, especially heparin and its derivatives and with mechanical methods such as support tights or intermittent pneumatic compression of the lower extremities. To reduce the incidence of VTED as far as possible, strategies have been proposed that include a combination of drugs and mechanical methods, new antithrombotic drugs, or prolonging the duration of prophylaxis in patients at very high risk, such as those who have undergone surgery for cancer. Another important aspect is the optimal moment to initiate prophylaxis with anticoagulant drugs with the aim of achieving an adequate equilibrium between antithrombotic efficacy and the risk of hemorrhagic complications. The present article reviews the available evidence to attempt to optimize prevention of VTED in general surgery and in some special groups, such as laparoscopic surgery, short-stay surgery and obesity.