Long-term use of different doses of low-molecular-weight heparin versus vitamin K antagonists in the treatment of venous thromboembolism.

BACKGROUND: We evaluated whether the incidence of recurrent venous thromboembolic events (VTEs) during and after therapy differs for patients treated with full or reduced doses of low-molecular-weight heparin (LMWH) used long term compared with vitamin K antagonists (VKAs). METHODS: We identified randomized studies of long-term treatment with LMWH or VKA by searching MEDLINE, EMBASE, BIOSIS, and PASCAL. Seventeen studies were included, with 4,002 patients. RESULTS: In the assessment at 12 months of 1,957 patients without cancer, the recurrence rates of VTE in the LMWH/VKA groups were 8.3%/7.6% in the studies using full doses and 12.3%/12.1% in those using prophylactic doses. However, combined analysis after treatment to 1 year showed a nonsignificant (NS) trend to lower recurrent symptomatic VTE in favor of VKA (RR = 1.46, 95% CI 0.96-2.23). In 1,292 patients with cancer the recurrence rates of VTE in the LMWH/VKA groups were 6.5%/17.9% (p = 0.005) in the studies using full doses, 7.1%/13.4% (p = 0.002) in the studies using intermediate doses, and 14.3%/19.1% (p = NS) in the studies using prophylactic doses. Furthermore, the recurrences of VTE after discontinuation of treatment in the LMWH/VKA groups were 1.6%/9.5% (RR = 0.25, 95% CI 0.06-1.1) in 252 patients with full doses and 12%/7.4% (RR = 1.49, 95% CI 0.3-7.48) in 52 patients with prophylactic doses. In this population with cancer, the full-treatment LMWH regimen did not produce more major bleeding events than intermediate or prophylactic doses (5.1% vs. 6.3% or 8.1%, respectively). CONCLUSION: Full-dose LMWH for 3-6 months is as safe as intermediate and prophylactic doses for the long-term treatment of deep vein thrombosis. In patients with cancer it appears that there is an excess of VTE recurrence after treatment with prophylactic doses that does not occur with full therapeutic doses.

Early mobilisation in patients with acute deep vein thrombosis does not increase the risk of a symptomatic pulmonary embolism.

AIM: The purpose of the study was to determine if early mobilisation in patients with acute lower limb deep vein thrombosis (DVT) increases the incidence of symptomatic pulmonary embolism (PE) and to evaluate the predisposing factors for PE such as location of the thrombus and duration of symptoms. METHODS: The current study was a prospective randomised clinical trial. Between January 2005 and December 2007, 219 patients with acute lower limb DVT were enrolled in the study (118 males and 101 females); the mean age was 64.2 years. INCLUSION CRITERIA: <15 days of initial symptoms, life expectancy >1 year, no life-threatening clinical conditions, and signed informed consent. The patients were randomised into two groups. Group A, 105 patients (47.9%) were hospitalized and received 5 days of bed rest; Group B, 114 patients (52.1%) received care at home with early walking and compression stockings. The primary end point was the presence of symptomatic PE during the first 10 days of treatment. The relationships between the duration of symptoms, location of the thrombus, and symptomatic PE were also analysed. RESULTS: Five cases of symptomatic PE were detected (2.3%), three in Group B and two in Group A. There was no significant difference in the occurrence of new PE between the two groups (P=0.54). Likewise, no difference was detected based on the duration of symptoms (P=0.62) and the location of the thrombus (P=0.43). CONCLUSIONS: In acute DVT , early walking, thrombus location, and duration of the symptoms did not influence the incidence of symptomatic PE.

Diagnóstico de la hipertensión arterial renovascular mediante Eco-Doppler

Objetivo: valorar la fiabilidad del eco-Doppler en la detección de estenosis renales en pacientes con sospecha de hipertensión renovascular. Material y método: estudio prospectivo durante cuatro años de 91 arterias renales en 47 pacientes hipertensos (tres monorrenos) con sospecha de hipertensión arterial renovascular. Edad media: 56 años (r = 25-77); 22 varones y 25 mujeres. Parámetros valorados por dúplex: velocidad sistólica máxima (VSM) y velocidad diastólica final (VDF) en arteria renal, cociente renal-aórtico e índice de resistencia periférica. Análisis estadístico: curvas ROC y análisis multivariante para la obtención del mejor parámetro diagnóstico de estenosis > 60 por ciento. A todos los pacientes se les realizó arteriografía de ambas arterias renales. Resultados: mediante análisis multivariante únicamente la VSM > 180 cm/sg (p = 0,01) y el cociente renal-aórtico > 3 (p = 0,04) son predictivos de estenosis > 60 por ciento. Así hemos identificado 60 de 65 estenosis inferiores al 60 por ciento, 20 de 21 estenosis superiores al 60 por ciento, y 5 de 5 oclusiones (Kappa = 0,85) (p 180 cm/sg es el mejor parámetro para detectar estenosis > 60 por ciento (AU)