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New blood clot guidelines for pregnant women
June 25, 2008Blood clot recommendations highlight challenges for pediatric and pre-surgery populations
New evidence-based guidelines address the prevention and management of thrombosis in key patient populations and reinforce recommendations related to the routine use of preventive therapies. Published as a supplement in the June issue of CHEST, the peer-reviewed journal of the American College of Chest Physicians (ACCP), Antithrombotic and Thrombolytic Therapy: ACCP Evidence-Based Clinical Practice Guidelines, Eighth Edition was developed by an international panel of 90 experts and includes more than 700 of the most comprehensive recommendations related to the prevention, treatment, and long-term management of thrombotic disorders. The guidelines include chapters on the challenges in preventing and treating thrombosis in pregnant women and children, and on managing peri- and postoperative patients, while also reinforcing previous guidelines related to the routine use of preventive therapies, including aspirin.
"For years, clinicians have faced challenges in preventing and managing thrombosis in women who are pregnant or patients who require surgery," said guidelines panel chair Jack Hirsh, MD, FCCP, Henderson Research Center, Hamilton, ON, Canada. "The new guidelines address many troublesome issues in antithrombotic therapy and provide clinicians with a variety of options for care in special patient groups." Antithrombotic and thrombolytic therapies are used to prevent and treat thrombosis or blood clotting that arises in arteries, veins, and the heart.
PREGNANT WOMEN
The new ACCP guidelines address challenging issues facing women who are pregnant or wish to become pregnant while undergoing long-term antithrombotic therapy. Pregnant women taking vitamin K antagonists (VKA), such as the anticoagulant warfarin, have an increased risk for birth defects and miscarriage and are, therefore, advised to stop taking VKAs before 6 weeks of fetal gestation. However, some pregnant women with certain types of mechanical heart valves may be continued on VKA therapy because of concerns about the effectiveness of alternative anticoagulants in preventing stroke and valve thrombosis. For other women taking VKAs who become pregnant, the guidelines recommend substituting low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH). The guidelines recommend two options for doing this: (1) continuing VKA but performing frequent pregnancy tests to determine when pregnancy has been achieved, followed by the substituion of LMWH or UFH as therapy; or (2) substituting VKAs with LMWH or UFH prior to conception. Although the second option eliminates the potential for fetal exposure to VKA, it provides additional challenges. LMWH and UFH are more expensive than VKAs and must be administered through a once- or twice-daily injection as opposed to a once daily oral dose of VKAs. In addition, long-term use of LMWH or UFH can be associated with osteoporosis.
"If women substitute heparin prior to pregnancy and have difficulties conceiving, they may find themselves taking the medication for a much longer timeframe than expected," said guideline coauthor Shannon Bates, MD, McMaster University and Henderson Research Centre, Hamilton, Ontario, Canada. "This is not only inconvenient but also increases treatment costs and may be associated with long-term risks for the mother."
CHILDREN
Recommendations related to childhood stroke, one of the top ten causes of death in children, and congenital heart disease have been substantially expanded since the previous guideline. Arterial ischemic stroke (AIS), usually caused by embolism or thrombosis, is difficult to diagnose in children because underlying health conditions are markedly different than those in adult stroke and up to 15% of children with AIS have no apparent risk factors. The guidelines recommend that children with AIS receive initial antithrombotic therapy until underlying causes can be determined, followed by maintenance therapy to prevent long-term recurrence. In addition, the newly expanded guidelines on the prevention and treatment of thrombosis related to congenital heart disease interventions include discussions of ventricular assist devices and prosthetic heart valves.
"Care for children with major cardiac problems has improved dramatically. Many children who previously died now survive, but thrombosis remains a major cause of secondary complications for these children," said Dr. Hirsh. "Effective antithrombotic therapy is critical if these children are to grow up as normal, healthy children."
PATIENTS UNDERGOING SURGERY
For the first time, the guidelines dedicate a full chapter to the perioperative management of patients on long-term antithrombotic therapy who require surgery or other invasive procedures. Most patients must temporarily stop receiving therapy just prior to undergoing surgery, as well as during surgery, in order to minimize surgery-related bleeding. However, stopping antithrombotic therapy can increase the risk of a thromboembolic event. To address this challenge, the guidelines recommend that the risk of a thromboembolic event during interruption of therapy is balanced against the risk for bleeding when antithrombotic therapy is discontinued just prior to surgery. The guidelines also recommend routine use of thromboprophylaxis for patients undergoing major general, gynecologic, or orthopedic surgeries and have been expanded to include bariatric and coronary artery bypass surgery.
GENERAL RECOMMENDATIONS
Overall, ACCP guidelines recommend thromboprophylaxis for most patients who are hospitalized; however, they do not recommend routine use of thromboprophylaxis for patient groups with a very low risk of venous thromboembolism. Low risk groups include patients undergoing laparoscopic surgery, knee arthroscopy, or those who take long airplane flights. For these patients, physicians can make decisions about thromboprophylaxis based on the individual patient's thrombosis risk. The guidelines continue to recommend against the use of aspirin alone as a means to prevent venous thromboembolism in any patient population because more effective methods are available.
American College of Chest Physicians
PREGNANT WOMEN
The new ACCP guidelines address challenging issues facing women who are pregnant or wish to become pregnant while undergoing long-term antithrombotic therapy. Pregnant women taking vitamin K antagonists (VKA), such as the anticoagulant warfarin, have an increased risk for birth defects and miscarriage and are, therefore, advised to stop taking VKAs before 6 weeks of fetal gestation. However, some pregnant women with certain types of mechanical heart valves may be continued on VKA therapy because of concerns about the effectiveness of alternative anticoagulants in preventing stroke and valve thrombosis. For other women taking VKAs who become pregnant, the guidelines recommend substituting low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH). The guidelines recommend two options for doing this: (1) continuing VKA but performing frequent pregnancy tests to determine when pregnancy has been achieved, followed by the substituion of LMWH or UFH as therapy; or (2) substituting VKAs with LMWH or UFH prior to conception. Although the second option eliminates the potential for fetal exposure to VKA, it provides additional challenges. LMWH and UFH are more expensive than VKAs and must be administered through a once- or twice-daily injection as opposed to a once daily oral dose of VKAs. In addition, long-term use of LMWH or UFH can be associated with osteoporosis.
"If women substitute heparin prior to pregnancy and have difficulties conceiving, they may find themselves taking the medication for a much longer timeframe than expected," said guideline coauthor Shannon Bates, MD, McMaster University and Henderson Research Centre, Hamilton, Ontario, Canada. "This is not only inconvenient but also increases treatment costs and may be associated with long-term risks for the mother."
CHILDREN
Recommendations related to childhood stroke, one of the top ten causes of death in children, and congenital heart disease have been substantially expanded since the previous guideline. Arterial ischemic stroke (AIS), usually caused by embolism or thrombosis, is difficult to diagnose in children because underlying health conditions are markedly different than those in adult stroke and up to 15% of children with AIS have no apparent risk factors. The guidelines recommend that children with AIS receive initial antithrombotic therapy until underlying causes can be determined, followed by maintenance therapy to prevent long-term recurrence. In addition, the newly expanded guidelines on the prevention and treatment of thrombosis related to congenital heart disease interventions include discussions of ventricular assist devices and prosthetic heart valves.
"Care for children with major cardiac problems has improved dramatically. Many children who previously died now survive, but thrombosis remains a major cause of secondary complications for these children," said Dr. Hirsh. "Effective antithrombotic therapy is critical if these children are to grow up as normal, healthy children."
PATIENTS UNDERGOING SURGERY
For the first time, the guidelines dedicate a full chapter to the perioperative management of patients on long-term antithrombotic therapy who require surgery or other invasive procedures. Most patients must temporarily stop receiving therapy just prior to undergoing surgery, as well as during surgery, in order to minimize surgery-related bleeding. However, stopping antithrombotic therapy can increase the risk of a thromboembolic event. To address this challenge, the guidelines recommend that the risk of a thromboembolic event during interruption of therapy is balanced against the risk for bleeding when antithrombotic therapy is discontinued just prior to surgery. The guidelines also recommend routine use of thromboprophylaxis for patients undergoing major general, gynecologic, or orthopedic surgeries and have been expanded to include bariatric and coronary artery bypass surgery.
GENERAL RECOMMENDATIONS
Overall, ACCP guidelines recommend thromboprophylaxis for most patients who are hospitalized; however, they do not recommend routine use of thromboprophylaxis for patient groups with a very low risk of venous thromboembolism. Low risk groups include patients undergoing laparoscopic surgery, knee arthroscopy, or those who take long airplane flights. For these patients, physicians can make decisions about thromboprophylaxis based on the individual patient's thrombosis risk. The guidelines continue to recommend against the use of aspirin alone as a means to prevent venous thromboembolism in any patient population because more effective methods are available.
American College of Chest Physicians
Thrombosis Current Events and Thrombosis News RSSClots traveling from lower veins may not be the cause of pulmonary embolism in trauma patients
A report from a team of Massachusetts General Hospital (MGH) physicians calls into question the longstanding belief that pulmonary embolism (PE) - the life-threatening blockage of a major blood vessel in the lungs - is caused in trauma patients by a blood clot traveling from vessels deep within the legs or lower torso.
Blood clots in lungs might not always originate in deep veins of legs and pelvis in trauma patients
Few trauma patients who develop potentially deadly blood clots in the lungs (pulmonary embolism) also have clots in the deep veins of their pelvis and legs (deep venous thrombosis), challenging commonly held beliefs about the association between the two conditions.
Drug-eluting stents better than bare-metal stents for heart attack patients
Late-breaking data from the landmark HORIZONS-AMI clinical trial, presented at the 21st annual Transcatheter Cardiovascular Therapeutics (TCT) scientific symposium, demonstrated that after two years, in heart attack patients, the use of a drug-eluting stent (paclitaxel) was safer and more effective than a bare-metal stent; and that the administration of the anticoagulant medication bivalirudin enhanced safety and efficacy compared to the use of heparin + GPIIb/IIIa inhibitors.
SPIRIT IV trial shows everolimus stent sets new standard for event-free survival
Late-breaking data from SPIRIT IV, a large-scale multi-center study of nearly 4,000 patients in the U.S., shows that an everolimus-eluting stent demonstrated enhanced safety and efficacy in the treatment of de novo native coronary artery lesions when compared to a paclitaxel-eluting stent, and showed that "low late loss" may be achieved with drug-eluting stents without sacrificing safety.
Few complications 1 year after aortic valve implantation
Research presented at the 21st annual Transcatheter Cardiovascular Therapeutics (TCT) scientific symposium, sponsored by the Cardiovascular Research Foundation (CRF), demonstrated an "exceptionally low" rate of complications one year after implantation of transcatheter aortic valve prostheses.
Image-guided treatment for deep venous thrombosis could improve patients' long-term outcomes
Deep Venous Thrombosis (DVT) is a serious condition that involves the formation of a blood clot inside of a deep vein usually in the legs. A patient with DVT is typically treated with anticoagulants (blood thinners) however researchers have found that image-guided interventional radiology procedures may play a more central role in the long-term treatment of DVT.
Results from the Kyoto heart study
The KYOTO HEART Study, which took place in Japan between January 2004 and January 2009, shows that the addition of valsartan to conventional antihypertensive treatment to improve blood pressure control is associated with an improved cardiovascular outcome in Japanese hypertensive patients at high risk of CVD events.
University of Maryland researchers identify gene variant linked to effectiveness of plavix
Researchers at the University of Maryland School of Medicine have identified a common gene variant carried by as many as a third of the general population that is believed to play a major role in determining why people do not respond to a popular anti-clotting medication, Plavix.
Study finds women slightly more likely to die than men in the 30 days following a heart attack
A new study from NYU School of Medicine found that women may have a slightly higher risk of death than men in the thirty days following an acute coronary syndrome (ACS), but that these differences appear to be attributable to factors such as severity and type of ACS.
Scientists Find New No-Needle Approach to Prevent Blood Clots
The dean of the University of Oklahoma College of Public Health and a team of scientists worldwide have found a better way to prevent deadly blood clots after joint replacement surgery - a major problem that results in thousands of unnecessary deaths each year. The research appears this week in the New England Journal of Medicine.
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