Diagnosis of Venous Thromboembolism: 20 Years of Progress.

Many guidelines suggest incorporating clinical assessment, imaging, and D-dimer testing into diagnostic algorithms in patients with suspected deep venous thrombosis (DVT) and pulmonary embolism (PE). This special article reviews the evidence supporting the use of algorithms and their individual components for diagnosis of upper- and lower-extremity DVT and PE in adults, including pregnant women. The authors identified evidence through several electronic database searches to April 2017, evaluated the robustness of selected evidence, assessed whether diagnostic approaches that do not use algorithms are acceptable, and identified knowledge gaps that require further research.

Risk factors predictive of occult cancer detection in patients with unprovoked venous thromboembolism.

Risk factors predictive of occult cancer detection in patients with a first unprovoked symptomatic venous thromboembolism (VTE) are unknown. Cox proportional hazard models and multivariate analyses were performed to assess the effect of specific risk factors on occult cancer detection within 1 year of a diagnosis of unprovoked VTE in patients randomized in the Screening for Occult Malignancy in Patients with Idiopathic Venous Thromboembolism (SOME) trial. A total of 33 (3.9%; 95% CI, 2.8%-5.4%) out of the 854 included patients received a new diagnosis of cancer at 1-year follow-up. Age ≥ 60 years (hazard ratio [HR], 3.11; 95% CI, 1.41-6.89; ITALIC! P= .005), previous provoked VTE (HR, 3.20; 95% CI, 1.19-8.62; ITALIC! P= .022), and current smoker status (HR, 2.80; 95% CI, 1.24-6.33; ITALIC! P= .014) were associated with occult cancer detection. Age, prior provoked VTE, and smoking status may be important predictors of occult cancer detection in patients with first unprovoked VTE. This trial was registered atwww.clinicaltrials.govas #NCT00773448.

The use of anticoagulants for the treatment and prevention of venous thromboembolism in obese patients: implications for safety.

INTRODUCTION: Obesity is a growing problem and is associated with a high risk of venous thromboembolism (VTE). Clinicians are increasingly challenged with prescribing adequate anticoagulants dosing while balancing the risk of bleeding. AREAS COVERED: In this narrative review, we address the safety of unfractionated heparin (UFH), low-molecular-weight heparins (LMWH), fondaparinux, warfarin and direct oral anticoagulants (DOAC) in obese patients. EXPERT OPINION: Obese patients have been under-represented in clinical trials and, therefore, the optimal dosing for both safety and efficacy in this subgroup remains unknown. Current data are based on pharmacokinetic studies in healthy subjects and small-scale cohort studies not adequately powered to detect differences in bleeding or thrombosis. Weight-based dosing of UFH and LMWH should be used over fixed dosing in most obese patients for VTE treatment and prophylaxis. For fondaparinux, increasing the dose with increasing weight is required for VTE treatment and consideration should be given to increasing the dose for VTE prophylaxis. Regarding the DOAC, they should be administered in fixed-dose regimens in the obese sub-population. Given the increasing prevalence of obesity and the associated increased risk of VTE, further studies are needed to establish the safety and efficacy of anticoagulation dosing regimens.

Dose escalation of low molecular weight heparin in patients with recurrent cancer-associated thrombosis.

INTRODUCTION: Patients with cancer-associated thrombosis are at a high risk of developing recurrent events despite anticoagulant therapy. Escalation of the dose of low molecular weight heparin (LMWH) has been suggested as a potential treatment option to manage these patients. We sought to confirm the benefit and risk of this management strategy in patients with recurrent cancer-associated thrombosis. MATERIAL AND METHODS: A retrospective cohort study of consecutive cancer outpatients seen for management of a symptomatic recurrent cancer-associated thrombosis while on anticoagulation was undertaken. Objectively confirmed episodes of recurrent thrombosis were treated with either dose escalation of LMWH or initiation of therapeutic dose of LMWH in patients already anticoagulated with LMWH or vitamin K antagonist (VKA) respectively. Included patients were followed for a minimum of 3 months after the index recurrent event. RESULTS: Fifty-five cancer patients with a recurrent venous thromboembolism (VTE) despite anticoagulation were included. At the time of the recurrence, 89% of patients were on LMWH. The median time between the initial cancer-associated thrombosis to the index recurrent event was 2.3 months (range 0.1 to 30.4 months). Four patients (7.3%; 95% CI: 2.0 to 17.6%) had a second recurrent VTE during the 3-month follow-up period. Three patients (5.5%; 95% CI 1.1 to 15.1%) had major bleeding complications after dose escalation of LMWH. There were no recurrent fatal VTE or major bleeding episodes. CONCLUSION: Escalating the dose of LMWH seems effective and safe for managing patients with recurrent cancer-associated thrombosis despite anticoagulant therapy.