Rivaroxaban vs placebo for extended antithrombotic prophylaxis after laparoscopic surgery for colorectal cancer.

The clinical benefit of extended prophylaxis for venous thromboembolism (VTE) after laparoscopic surgery for cancer is unclear. The efficacy and safety of direct oral anticoagulants for this indication are unexplored. PROphylaxis of venous thromboembolism after LAParoscopic Surgery for colorectal cancer Study II (PROLAPS II) was a randomized, double-blind, placebo-controlled, investigator-initiated, superiority study aimed at assessing the efficacy and safety of extended prophylaxis with rivaroxaban after laparoscopic surgery for colorectal cancer. Consecutive patients who had laparoscopic surgery for colorectal cancer were randomized to receive rivaroxaban (10 mg once daily) or a placebo to be started at 7 ± 2 days after surgery and given for the subsequent 3 weeks. All patients received antithrombotic prophylaxis with low-molecular-weight heparin from surgery to randomization. The primary study outcome was the composite of symptomatic objectively confirmed VTE, asymptomatic ultrasonography-detected deep vein thrombosis (DVT), or VTE-related death at 28 ± 2 days after surgery. The primary safety outcome was major bleeding. Patient recruitment was prematurely closed due to study drug expiry after the inclusion of 582 of the 646 planned patients. A primary study outcome event occurred in 11 of 282 patients in the placebo group compared with 3 of 287 in the rivaroxaban group (3.9 vs 1.0%; odds ratio, 0.26; 95% confidence interval [CI], 0.07-0.94; log-rank P = .032). Major bleeding occurred in none of the patients in the placebo group and 2 patients in the rivaroxaban group (incidence rate 0.7%; 95% CI, 0-1.0). Oral rivaroxaban was more effective than placebo for extended prevention of VTE after laparoscopic surgery for colorectal cancer without an increase in major bleeding. This trial was registered at www.clinicaltrials.gov as #NCT03055026.

Diagnostic management of acute pulmonary embolism: a prediction model based on a patient data meta-analysis.

AIMS: Risk stratification is used for decisions regarding need for imaging in patients with clinically suspected acute pulmonary embolism (PE). The aim was to develop a clinical prediction model that provides an individualized, accurate probability estimate for the presence of acute PE in patients with suspected disease based on readily available clinical items and D-dimer concentrations. METHODS AND RESULTS: An individual patient data meta-analysis was performed based on sixteen cross-sectional or prospective studies with data from 28 305 adult patients with clinically suspected PE from various clinical settings, including primary care, emergency care, hospitalized and nursing home patients. A multilevel logistic regression model was built and validated including ten a priori defined objective candidate predictors to predict objectively confirmed PE at baseline or venous thromboembolism (VTE) during follow-up of 30 to 90 days. Multiple imputation was used for missing data. Backward elimination was performed with a P-value <0.10. Discrimination (c-statistic with 95% confidence intervals [CI] and prediction intervals [PI]) and calibration (outcome:expected [O:E] ratio and calibration plot) were evaluated based on internal-external cross-validation. The accuracy of the model was subsequently compared with algorithms based on the Wells score and D-dimer testing. The final model included age (in years), sex, previous VTE, recent surgery or immobilization, haemoptysis, cancer, clinical signs of deep vein thrombosis, inpatient status, D-dimer (in µg/L), and an interaction term between age and D-dimer. The pooled c-statistic was 0.87 (95% CI, 0.85-0.89; 95% PI, 0.77-0.93) and overall calibration was very good (pooled O:E ratio, 0.99; 95% CI, 0.87-1.14; 95% PI, 0.55-1.79). The model slightly overestimated VTE probability in the lower range of estimated probabilities. Discrimination of the current model in the validation data sets was better than that of the Wells score combined with a D-dimer threshold based on age (c-statistic 0.73; 95% CI, 0.70-0.75) or structured clinical pretest probability (c-statistic 0.79; 95% CI, 0.76-0.81). CONCLUSION: The present model provides an absolute, individualized probability of PE presence in a broad population of patients with suspected PE, with very good discrimination and calibration. Its clinical utility needs to be evaluated in a prospective management or impact study. REGISTRATION: PROSPERO ID 89366.

Management of isolated distal deep vein thrombosis.

Isolated distal deep vein thrombosis (DVT) represents up to 50% of all lower limb DVT in ultrasound series and is a frequent medical condition, which management is not well established. Data arising from registries and non-randomized studies suggest that most distal DVTs do not extend to the proximal veins and have an uneventful follow-up when left untreated. This data had some impact on international recommendations like the American College of Chest Physicians (ACCP), whose last version stated that ultrasound surveillance might be an option for selected low-risk patients. However, robust data arising from randomized studies are scarce. Indeed, only seven randomized trials assessing the need for anticoagulation for calf DVT have been published. Many of these trials had an open-label design and were affected by methodological limitations. When considering randomized placebo-controlled trials, one included low-risk patients and was hampered by a limited statistical power (CACTUS study). Nevertheless, data from this trial tend to confirm that the use of therapeutic anticoagulation in low-risk patients with symptomatic calf DVT is not superior to placebo in reducing VTE but is associated with a higher risk of bleeding. A second randomized placebo-controlled trial did not assess the necessity of anticoagulant treatment but rather the long-term risk of recurrence and compared 6 weeks versus 12 weeks of treatment with rivaroxaban (RIDTS study). Finally, the last available randomized trial compared a 3-month versus a 12-month edoxaban treatment in patients with cancer and mainly asymptomatic distal DVT, detected by systematic compression ultrasonography. Overall, available data suggest that the use of therapeutic anticoagulation in low-risk patients with symptomatic calf DVT is not superior to placebo in reducing VTE. High risk patients (previous VTE, active cancer, inpatients) might benefit from a course of anticoagulant treatment. However, the optimal anticoagulant intensity and duration are uncertain and further studies are needed.

[Angiology and hemostasis: what's new in 2023]. / Angiologie et hémostase: ce qui a changé en 2023.

We discuss four topics among the angiology and hemostasis studies of importance in 2023. The BASIL-2 study provides new data for the management of chronic limb-threatening ischemia by comparing surgical and endovascular treatment. The new classification of antiphospholipid antibody (aPL) syndrome integrates new clinical elements and gives a different weight among the isotype and titer of aPL. Concizumab, an antibody targeting the tissue factor pathway inhibitor, broadens the therapeutic arsenal for hemophilia A and B as evidenced by the results of the EXPLORER 7 study. The PREVENT-CLOT and CASTING study focus on the prevention of thrombosis after trauma, by testing the role of aspirin or the lack of thromboprophylaxis, respectively.

Parmi les sujets d'angiologie et d'hémostase qui ont marqué l'année 2023, quatre ont retenu notre attention. L'étude BASIL-2 apporte de nouvelles données pour la prise en charge de l'ischémie critique des membres inférieurs en comparant les traitements chirurgical et endovasculaire. La nouvelle classification du syndrome des anticorps antiphospholipides (aPL) intègre de nouveaux items cliniques et donne un poids différent aux isotypes et titres des aPL. Le concizumab, un anticorps ciblant l'inhibiteur de la voie du facteur tissulaire, vient élargir l'arsenal thérapeutique pour les hémophilies A et B comme en témoignent les résultats de l'étude EXPLORER 7. Les études PREVENT-CLOT et CASTING s'intéressent à la prévention de la thrombose après traumatisme, en testant la place de l'aspirine ou l'absence de thromboprophylaxie.

Mortality rate related to peripheral arterial disease: A retrospective analysis of epidemiological data (years 2008-2019).

BACKGROUND AND AIMS: Peripheral arterial disease (PAD) is one of the most prevalent cardiovascular diseases with more than 230 million people being affected worldwide. As highlighted by the recent European Society of Cardiology guidelines, data on the epidemiology of PAD is urgently needed. METHODS AND RESULTS: We accessed the vital registration data of the Veneto region (Northern Italy, approximately five millions inhabitants) covering the period 2008-2019. We computed annual age-standardized rates for PAD reported as the underlying cause of death (UCOD) or as one of multiple causes of death (MCOD). Age-adjusted odds ratios (OR) served to study the association between PAD and cardiovascular comorbidities. The age-standardized mortality rate for PAD as MCOD slightly declined from 19.6 to 17.8 in men and from 10.8 to 9.1 deaths per 100,000 population-years in women. The age-standardized PAD-specific mortality rate (UCOD) remained stable: 3.1 to 3.7 per 100,000 person-years in women (Average Annual Percent Change 1.3, 95% CI -0.8; 3.4%) and 4.4 to 4.3 per 100,000 person-years (Average Annual Percent Change -0.2, 95% CI -3.6; 3.4%) in men. PAD contributed to 1.6% of all deaths recorded in the region. Ischemic heart disease, diabetes mellitus and neoplasms were the most prevalent UCOD among PAD patients. PAD was associated with diabetes mellitus (OR 3.79, 95%CI 3.55-4.06) and chronic kidney diseases (OR 2.73, 95%CI 2.51-2.97) in men, and with atrial fibrillation (OR 2.26, 95%CI 2.10-2.44) in women. CONCLUSION: PAD remains a substantial cause of death in the general population of this high-income region of Western Europe with marked sex-specific differences.

Risk for Recurrent Venous Thromboembolism in Patients With Subsegmental Pulmonary Embolism Managed Without Anticoagulation : A Multicenter Prospective Cohort Study.

BACKGROUND: The incidence of pulmonary embolism has been increasing, but its case-fatality rate is decreasing, suggesting a lesser severity of illness. The clinical importance of patients with pulmonary embolism isolated to the subsegmental vessels is unknown. OBJECTIVE: To determine the rate of recurrent venous thromboembolism in patients with subsegmental pulmonary embolism managed without anticoagulation. DESIGN: Multicenter prospective cohort study. (ClinicalTrials.gov: NCT01455818). SETTING: Eighteen sites between February 2011 and February 2021. PATIENTS: Patients with isolated subsegmental pulmonary embolism. INTERVENTION: At diagnosis, patients underwent bilateral lower-extremity venous ultrasonography, which was repeated 1 week later if results were negative. Patients without deep venous thrombosis did not receive anticoagulant therapy. MEASUREMENTS: The primary outcome was recurrent venous thromboembolism during the 90-day follow-up period. RESULTS: Recruitment was stopped prematurely because the predefined stopping rule was met after 292 of a projected 300 patients were enrolled. Of the 266 patients included in the primary analysis, the primary outcome occurred in 8 patients, for a cumulative incidence of 3.1% (95% CI, 1.6% to 6.1%) over the 90-day follow-up. The incidence of recurrent venous thromboembolism was 2.1% (CI, 0.8% to 5.5%) and 5.7% (CI, 2.2% to 14.4%) over the 90-day follow-up in patients with single and multiple isolated subsegmental pulmonary embolism, respectively. No patients had a fatal recurrent pulmonary embolism. LIMITATION: The study was restricted to patients with low-risk subsegmental pulmonary embolism. CONCLUSION: Overall, patients with subsegmental pulmonary embolism who did not have proximal deep venous thrombosis had a higher-than-expected rate of recurrent venous thromboembolism. PRIMARY FUNDING SOURCE: Heart and Stroke Foundation of Canada and French Ministry of Health Programme Hospitalier de Recherche Clinique.

Safety and Efficiency of Diagnostic Strategies for Ruling Out Pulmonary Embolism in Clinically Relevant Patient Subgroups : A Systematic Review and Individual-Patient Data Meta-analysis.

BACKGROUND: How diagnostic strategies for suspected pulmonary embolism (PE) perform in relevant patient subgroups defined by sex, age, cancer, and previous venous thromboembolism (VTE) is unknown. PURPOSE: To evaluate the safety and efficiency of the Wells and revised Geneva scores combined with fixed and adapted D-dimer thresholds, as well as the YEARS algorithm, for ruling out acute PE in these subgroups. DATA SOURCES: MEDLINE from 1 January 1995 until 1 January 2021. STUDY SELECTION: 16 studies assessing at least 1 diagnostic strategy. DATA EXTRACTION: Individual-patient data from 20 553 patients. DATA SYNTHESIS: Safety was defined as the diagnostic failure rate (the predicted 3-month VTE incidence after exclusion of PE without imaging at baseline). Efficiency was defined as the proportion of individuals classified by the strategy as "PE considered excluded" without imaging tests. Across all strategies, efficiency was highest in patients younger than 40 years (47% to 68%) and lowest in patients aged 80 years or older (6.0% to 23%) or patients with cancer (9.6% to 26%). However, efficiency improved considerably in these subgroups when pretest probability-dependent D-dimer thresholds were applied. Predicted failure rates were highest for strategies with adapted D-dimer thresholds, with failure rates varying between 2% and 4% in the predefined patient subgroups. LIMITATIONS: Between-study differences in scoring predictor items and D-dimer assays, as well as the presence of differential verification bias, in particular for classifying fatal events and subsegmental PE cases, all of which may have led to an overestimation of the predicted failure rates of adapted D-dimer thresholds. CONCLUSION: Overall, all strategies showed acceptable safety, with pretest probability-dependent D-dimer thresholds having not only the highest efficiency but also the highest predicted failure rate. From an efficiency perspective, this individual-patient data meta-analysis supports application of adapted D-dimer thresholds. PRIMARY FUNDING SOURCE: Dutch Research Council. (PROSPERO: CRD42018089366).

A Framework for the Development of Living Practice Guidelines in Health Care.

BACKGROUND: Living practice guidelines are increasingly being used to ensure that recommendations are responsive to rapidly emerging evidence. OBJECTIVE: To develop a framework that characterizes the processes of development of living practice guidelines in health care. DESIGN: First, 3 background reviews were conducted: a scoping review of methods papers, a review of handbooks of guideline-producing organizations, and an analytic review of selected living practice guidelines. Second, the core team drafted the first version of the framework. Finally, the core team refined the framework through an online survey and online discussions with a multidisciplinary international group of stakeholders. SETTING: International. PARTICIPANTS: Multidisciplinary group of 51 persons who have experience with guidelines. MEASUREMENTS: Not applicable. RESULTS: A major principle of the framework is that the unit of update in a living guideline is the individual recommendation. In addition to providing definitions, the framework addresses several processes. The planning process should address the organization's adoption of the living methodology as well as each specific guideline project. The production process consists of initiation, maintenance, and retirement phases. The reporting should cover the evidence surveillance time stamp, the outcome of reassessment of the body of evidence (when applicable), and the outcome of revisiting a recommendation (when applicable). The dissemination process may necessitate the use of different venues, including one for formal publication. LIMITATION: This study does not provide detailed or practical guidance for how the described concepts would be best implemented. CONCLUSION: The framework will help guideline developers in planning, producing, reporting, and disseminating living guideline projects. It will also help research methodologists study the processes of living guidelines. PRIMARY FUNDING SOURCE: None.

[Angiology and hemostasis : what's new in 2022]. / Angiologie et hémostase : ce qui a changé en 2022.

In this article, we have selected four topics that particularly caught our attention during the year 2022, and which are related to anticoagulation, its bleeding complications, and hemophilia. Thus, we discuss the issue of the treatment with rivaroxaban of atrial fibrillation associated with rheumatic valvulopathy, which has been studied in a randomized trial, the intensity of thromboprophylaxis in COVID outpatients and inpatients, and the bleeding risk of anticoagulation in patients with cerebral tumors. Finally, recent data on gene therapy in severe hemophilia A, an upcoming treatment, are discussed.

Dans cet article, nous avons sélectionné 4 sujets qui ont particulièrement retenu notre attention durant l'année 2022, en lien avec l'anticoagulation, ses complications hémorragiques et l'hémophilie. Ainsi, nous abordons le traitement par rivaroxaban de la fibrillation atriale associée à une valvulopathie rhumatismale qui a fait l'objet d'une étude randomisée, l'intensité de la thromboprophylaxie chez les patients hospitalisés ou traités en ambulatoire avec un Covid dont les données se sont bien étoffées, le risque associé à l'anticoagulation chez les patients avec une néoplasie cérébrale et, finalement, la thérapie génique dans l'hémophilie A sévère qui devrait apparaître sur le marché très prochainement.

[Deep vein thrombosis: new developments and recommendations for the primary care physician]. / Thrombose veineuse profonde : nouveautés et recommandations pour le médecin de premier recours.

The management of deep vein thrombosis is becoming more specific in terms of diagnostic methods and drug treatments. The use of the dichotomous Wells' score is now established. The indications for direct oral anticoagulants have expanded. Prevention and management of the post-thrombotic syndrome are based on compression socks. Their use is individualized and needs repeated assessments in time. This article presents the latest developments and outlines principles involved in the management of superficial, distal and deep vein thrombosis in primary care.

La prise en charge de la thrombose veineuse profonde se précise en termes de méthode diagnostique et de traitements médicamenteux. L'utilisation du score de Wells dichotomique s'est imposée et les indications des anticoagulants oraux se sont élargies. Le port de bas de compression pour la prévention et la prise en charge du syndrome post-thrombotique est maintenant individualisé et basé sur une évaluation répétée dans le temps. Cet article présente ces dernières nouveautés et expose les éléments nécessaires à la prise en charge des thromboses superficielles, distales et profondes en médecine de premier recours.

Ruling out pulmonary embolism across different healthcare settings: A systematic review and individual patient data meta-analysis.

BACKGROUND: The challenging clinical dilemma of detecting pulmonary embolism (PE) in suspected patients is encountered in a variety of healthcare settings. We hypothesized that the optimal diagnostic approach to detect these patients in terms of safety and efficiency depends on underlying PE prevalence, case mix, and physician experience, overall reflected by the type of setting where patients are initially assessed. The objective of this study was to assess the capability of ruling out PE by available diagnostic strategies across all possible settings. METHODS AND FINDINGS: We performed a literature search (MEDLINE) followed by an individual patient data (IPD) meta-analysis (MA; 23 studies), including patients from self-referral emergency care (n = 12,612), primary healthcare clinics (n = 3,174), referred secondary care (n = 17,052), and hospitalized or nursing home patients (n = 2,410). Multilevel logistic regression was performed to evaluate diagnostic performance of the Wells and revised Geneva rules, both using fixed and adapted D-dimer thresholds to age or pretest probability (PTP), for the YEARS algorithm and for the Pulmonary Embolism Rule-out Criteria (PERC). All strategies were tested separately in each healthcare setting. Following studies done in this field, the primary diagnostic metrices estimated from the models were the "failure rate" of each strategy-i.e., the proportion of missed PE among patients categorized as "PE excluded" and "efficiency"-defined as the proportion of patients categorized as "PE excluded" among all patients. In self-referral emergency care, the PERC algorithm excludes PE in 21% of suspected patients at a failure rate of 1.12% (95% confidence interval [CI] 0.74 to 1.70), whereas this increases to 6.01% (4.09 to 8.75) in referred patients to secondary care at an efficiency of 10%. In patients from primary healthcare and those referred to secondary care, strategies adjusting D-dimer to PTP are the most efficient (range: 43% to 62%) at a failure rate ranging between 0.25% and 3.06%, with higher failure rates observed in patients referred to secondary care. For this latter setting, strategies adjusting D-dimer to age are associated with a lower failure rate ranging between 0.65% and 0.81%, yet are also less efficient (range: 33% and 35%). For all strategies, failure rates are highest in hospitalized or nursing home patients, ranging between 1.68% and 5.13%, at an efficiency ranging between 15% and 30%. The main limitation of the primary analyses was that the diagnostic performance of each strategy was compared in different sets of studies since the availability of items used in each diagnostic strategy differed across included studies; however, sensitivity analyses suggested that the findings were robust. CONCLUSIONS: The capability of safely and efficiently ruling out PE of available diagnostic strategies differs for different healthcare settings. The findings of this IPD MA help in determining the optimum diagnostic strategies for ruling out PE per healthcare setting, balancing the trade-off between failure rate and efficiency of each strategy.

[Sub-segmental pulmonary embolism: what to do?] / Embolie pulmonaire sous-segmentaire : que faire ?

The advent of computed tomodensitometry has led to an increase in the incidence rate of subsegmental pulmonary embolism. The clinical implications of this category of pulmonary embolism remain unclear up to now, to the point that some experts question the indication for therapeutic anticoagulation. The purpose of this article is to review the existing literature regarding the management of subsegmental pulmonary embolism and to propose a pragmatic approach regarding the indication for therapeutic anticoagulation.

L'apparition de la tomodensitométrie a mené à une augmentation du taux d'incidence des embolies pulmonaires sous-segmentaires. Les implications cliniques de cette catégorie d'embolie pulmonaire demeurent à ce jour encore incertaines, à tel point que certains experts se questionnent sur l'indication à une anticoagulation thérapeutique. Le but de cet article est de revoir la littérature existant pour la prise en charge des embolies pulmonaires sous-segmentaires et de proposer une approche pragmatique concernant l'indication à une anticoagulation thérapeutique.

[Hospital mechanical thromboprophylaxis]. / Thromboprophylaxie mécanique hospitalière.

Mechanical thromboprophylaxis is an important part of hospital prevention of venous thromboembolism. It comprises graduated compression stockings and intermittent pneumatic compression. In this review, we summarize its physiological effect on venous hemodynamics, recent clinical studies that offer contrasting results, and discuss its utility in contemporary clinical practice. Mechanical thromboprophylaxis is currently suggested in patients at high thrombotic and hemorrhagic risk, favoring intermittent pneumatic compression, but does not seem useful in addition to pharmacological thromboprophylaxis.

La thromboprophylaxie mécanique est une composante importante de la prévention hospitalière de la maladie thromboembolique veineuse. Elle comprend la compression graduée par bas ou chaussettes et la compression pneumatique intermittente (CPIn). Dans cet article, nous résumons son effet veineux physiologique et revenons sur les études cliniques récentes qui offrent des résultats contrastés. Enfin, nous discutons de sa place en clinique contemporaine. La thromboprophylaxie mécanique est actuellement suggérée chez des patients à hauts risques thrombotique et hémorragique, en privilégiant la compression pneumatique intermittente, mais ne semble pas utile en plus d'une thromboprophylaxie pharmacologique.

[Selected highlights in angiology and haemostasis for the year 2021]. / Angiologie-hémostase - Année 2021 : morceaux choisis.

Several topics among those that marked the year 2021 are discussed in this article. Factor XI represents an original target for new anticoagulants, and the first results of a phase 2 study of prophylaxis after knee replacement surgery are very promising. A real-life study confirms that the pulmonary embolism exclusion strategy using an age-adjusted D-dimer cut-off is safe and increases the diagnostic yield. Several studies of tranexamic acid provide further insight into the indications for its use and highlight some potential risks. Finally, the concerns regarding a potential risk of increased mortality related to paclitaxel-eluting technology used in lower limb revascularisation are questioned by the results of the latest trials.

Plusieurs sujets parmi ceux qui ont marqué l'année 2021 sont abordés dans cet article. Le facteur XI représente une cible originale pour de nouveaux anticoagulants et les premiers résultats d'une étude de phase 2 dans la prophylaxie après chirurgie du genou sont très prometteurs. Une étude de vie réelle confirme que la stratégie d'exclusion de l'embolie pulmonaire en utilisant un seuil de D-dimères adapté à l'âge est sûre et augmente le rendement diagnostique. Plusieurs études concernant l'acide tranexamique permettent de mieux cerner les indications de son utilisation et soulignent quelques risques potentiels. Finalement, les données récentes remettent en cause le risque de surmortalité liée à la technologie à élution au paclitaxel utilisée dans les interventions endovasculaires des membres inférieurs rapporté précédemment.

Proximal deep vein thrombosis and pulmonary embolism in COVID-19 patients: a systematic review and meta-analysis.

BACKGROUND: COVID-19 appears to be associated with a high risk of venous thromboembolism (VTE). We aimed to systematically review and meta-analyze the risk of clinically relevant VTE in patients hospitalized for COVID-19. METHODS: This meta-analysis included original articles in English published from January 1st, 2020 to June 15th, 2020 in Pubmed/MEDLINE, Embase, Web of science, and Cochrane. Outcomes were major VTE, defined as any objectively diagnosed pulmonary embolism (PE) and/or proximal deep vein thrombosis (DVT). Primary analysis estimated the risk of VTE, stratified by acutely and critically ill inpatients. Secondary analyses explored the separate risk of proximal DVT and of PE; the risk of major VTE stratified by screening and by type of anticoagulation. RESULTS: In 33 studies (n = 4009 inpatients) with heterogeneous thrombotic risk factors, VTE incidence was 9% (95%CI 5-13%, I2 = 92.5) overall, and 21% (95%CI 14-28%, I2 = 87.6%) for patients hospitalized in the ICU. Proximal lower limb DVT incidence was 3% (95%CI 1-5%, I2 = 87.0%) and 8% (95%CI 3-14%, I2 = 87.6%), respectively. PE incidence was 8% (95%CI 4-13%, I2 = 92.1%) and 17% (95%CI 11-25%, I2 = 89.3%), respectively. Screening and absence of anticoagulation were associated with a higher VTE incidence. When restricting to medically ill inpatients, the VTE incidence was 2% (95%CI 0-6%). CONCLUSIONS: The risk of major VTE among COVID-19 inpatients is high but varies greatly with severity of the disease. These findings reinforce the need for the use of thromboprophylaxis in all COVID-19 inpatients and for clinical trials testing different thromboprophylaxis regimens in subgroups of COVID-19 inpatients. TRIAL REGISTRATION: The review protocol was registered in PROSPERO International Prospective Register of Systematic Reviews ( CRD42020193369 ).

[Towards new indications for direct oral anticoagulants]. / Angiologie-hémostase - Vers de nouvelles indications des anticoagulants oraux directs.

Direct oral anticoagulants (DOAC) represent commonly prescribed drugs in everyday clinical practice for indications such as atrial fibrillation, prevention of venous thromboembolic disease (VTE) after major orthopaedic surgery, treatment of deep vein thrombosis and pulmonary embolism, and long term prevention of VTE recurrence. More recently, the efficacy of DOAC has been demonstrated in new clinical situations, such as heparin-induced thrombocytopenia, cancer-associated VTE and secondary prevention of cardiovascular events in patients with atherothrombotic arterial disease. This article's aims is to present the recent data on which these new indications are based.

Les anticoagulants oraux directs (ACOD) font actuellement partie des médicaments couramment prescrits en pratique clinique dans les indications telles que la fibrillation atriale, la prévention de la maladie thromboembolique veineuse (MTEV) après chirurgie orthopédique majeure, le traitement de la thrombose veineuse profonde et embolie pulmonaire et la prévention de la récidive de MTEV au long cours. Se sont récemment rajoutées de nouvelles situations cliniques dans lesquelles les ACOD ont fait la preuve de leur efficacité, telles que la thrombopénie induite par l'héparine, le traitement de la MTEV liée au cancer et la prévention secondaire des événements cardiovasculaires chez les patients avec maladie athéromateuse. Cet article a pour but de présenter les données récentes sur lesquelles sont basées ces nouvelles indications.

[Diagnosis and management of pulmonary embolism : some reflections on the latest ESC guidelines]. / Diagnostic et prise en charge de l'embolie pulmonaire - Quelques réflexions sur les dernières recommandations de l'European Society of Cardiology.

The latest recommendations from the European Society of Cardiology (ESC) on the diagnostic and therapeutic management of pulmonary embolism (PE) published this year provide an important update compared to the 2014 version. In terms of diagnosis, the use of the age-adjusted D-dimer cutoff is currently suggested, and a diagnostic algorithm for suspected PE during pregnancy is proposed. Detailed recommendations are provided for the initial orientation of patients with acute PE based on prognostic stratification criteria, as well as for clinical follow-up after PE. Finally, direct oral anticoagulants are included as therapeutic options for the treatment of cancer-associated thrombosis.

Les dernières recommandations de l'European Society of Cardiology sur la prise en charge diagnostique et thérapeutique de l'embolie pulmonaire (EP) publiées cette année apportent une mise à jour importante par rapport à la version 2014. Au niveau du diagnostic, l'adaptation du seuil de D-dimères à l'âge du patient est actuellement suggérée, et un algorithme diagnostique durant la grossesse est proposé. Des recommandations détaillées quant à l'orientation initiale des patients avec EP aiguë sont exposées en fonction de critères de stratification pronostique, de même que pour le suivi clinique après EP. Enfin, sur la base des dernières données à disposition, les anticoagulants oraux directs sont intégrés dans l'arsenal thérapeutique du traitement des thromboses associées au cancer.

[Evolution in the endovascular management of lower limb arteriopathy]. / Évolution dans la prise en charge endovasculaire de l'artériopathie des membres inférieurs.

Arteriopathy of the lower limbs is a frequent pathology. In the face of persistent invalidating claudication or critical ischemia, surgical or endovascular revascularization treatment is necessary. The aim of this article is to review the evolution of the endovascular therapeutic arsenal of the femoropopliteal segment, to present the new endovascular devices available and to give current recommendations for post-interventional antithrombotic treatment.

L'artériopathie des membres inférieurs est une pathologie fréquente. Face à une claudication invalidante persistante ou à une ischémie critique, un traitement de revascularisation chirurgicale ou endovasculaire est nécessaire. Cet article a pour but de revenir sur l'évolution de l'arsenal thérapeutique endovasculaire du segment fémoro-poplité, de présenter les nouveaux dispositifs endovasculaires disponibles et de faire part des recommandations actuelles du traitement antithrombotique postinterventionnel.

[Evolution of thromboprophylaxis after hip and knee arthroplasties]. / Évolution de la thromboprophylaxie après prothèses de hanche et de genou.

Venous thrombotic events frequently complicate major elective arthroplasties such as hip and knee replacements. The risk of proximal deep vein thrombosis and pulmonary embolism is estimated at 5 %. For decades, the use of low-dose heparins for up to 5 weeks post-surgery has helped to reduce the risk of thrombotic complications. In this narrative review, we describe the evidence supporting the use of direct oral anticoagulants (in Switzerland - rivaroxaban and apixaban), whose risk-benefit ratios appears superior to that of heparins, at a lower cost. Hybrid strategies combining a short-term anticoagulant followed by low-dose aspirin are also recommended for patients deemed at low thrombotic risk.

Les thromboses veineuses profondes proximales et les embolies pulmonaires sont des complications redoutées après des interventions électives majeures en chirurgie orthopédique (prothèses totales de la hanche et du genou), avec une incidence cumulée estimée à 5 %. Depuis des décennies, ce risque est réduit par l'utilisation d'héparine à dose préventive jusqu'à 5 semaines postopératoires. Dans cette revue narrative, nous décrivons les évidences motivant l'utilisation des anticoagulants oraux directs (rivaroxaban et apixaban en Suisse) qui semblent présenter un rapport bénéfice-risque supérieur aux héparines, à un coût moindre. Des stratégies hybrides comprenant un anticoagulant puis l'aspirine sont désormais également recommandées chez des patients considérés à bas risque thrombotique.

[Arteriofit: a supervised exercise training program, recommended as a first-line treatment in intermittent claudication]. / Artériofit : un programme recommandé en première intention pour le traitement de la claudication intermittente.

Lower extremities arterial disease (LEAD) is the third most common manifestation of atherosclerosis. The number of cardiovascular events in this population is similar to that of coronary artery disease. Management consists mainly of strict control of cardiovascular risk factors, optimal pharmacological treatment and supervised exercise training. Supervised exercise training is superior to other exercise modalities in terms of increased walking time, maximum walking distance, pain-free walking distance and quality of life scores. In association with revascularization, the benefits are enhanced. In Switzerland, federal programs have been created on this basis and exist in many cities. They are little known and yet essential.

L'insuffisance artérielle des membres inférieurs est la troisième manifestation la plus fréquente de l'athérosclérose. Le nombre d'événements cardiovasculaires dans cette population est similaire à celui des malades coronariens. La prise en charge consiste en un contrôle strict des facteurs de risque cardiovasculaires, un traitement pharmacologique optimal et l'entraînement supervisé à la marche. L'entraînement supervisé est supérieur aux autres modalités d'exercices en termes d'augmentation du temps de marche, de la distance maximale de marche, de la distance de marche sans douleur et des scores de qualité de vie. En association avec une revascularisation, les bénéfices sont majorés. En Suisse, des programmes fédéraux ont été créés sur ces bases et existent dans de nombreuses villes. Ils sont méconnus et pourtant essentiels.