Thrombus - 2012

Lessons learnt from root-cause analysis of hospital-acquired thrombosis
Huw Rowswell
pp 1-3
Hospital-acquired thrombosis refers to any venous thromboembolism event (either deep vein thrombosis or pulmonary embolism) where there is an association with a hospital stay. HAT has been defined as any event arising following an inpatient stay within the preceding 90 days, or one that is diagnosed during a patient stay, but that was not present on admission. The NHS standard contract for acute services gives a requirement for trusts to undertake and report a root-cause analysis on all confirmed cases of HAT. This was strengthened by the Commissioning for Quality and Innovation payment framework introducing a financial incentive around risk assessment from 2010.

Comment: Non-pharmacological stroke reduction in AF
Peter Rose
pp 2-2
The non-pharmacological management of atrial fibrillation to reduce stroke risk has gone largely unnoticed with the advent of the new oral anticoagulant era. Information on the long-term outcome for patients treated with left atrial appendage occlusion, compared with warfarin, continues to be updated. In principle, occlusion of the LAA, which is where more than 90% of clots arise in non-valvular patients, represents an alternative approach to reduce AF stroke risk, particularly for patients at bleeding risk with oral anticoagulants.

Thrombosis research in advanced disease
Sarah McLean
pp 4-6
It is recognised that venous thromboembolism is a common complication of malignancy. The relative risk of VTE is increased approximately fourfold in patients with cancer, compared with age and sex-matched controls without cancer. This risk increases with age, metastases, and prolonged immobilisation. Furthermore, cancer patients experience higher rates of recurrence of VTE and more bleeding complications in comparison with those without malignancy, and these risks appear to increase with disease progression.

Point-of-care D-dimer testing in clinical practice
Chris Gardiner
pp 7-9
The diagnosis of suspected venous thromboembolism is challenging because the symptoms are non-specific. Consequently, only 15–25% of patients with suspected VTE will have the diagnosis confirmed by objective imaging, with a prevalence of under 10% reported. Clearly, it is neither practical nor affordable to refer all patients with suspected VTE for imaging, so D-dimer measurement is commonly used to improve the cost-effectiveness of diagnosis. D-dimer is a degradation product of cross-linked fibrin, which is usually raised in the blood of patients with VTE. However, D-dimer is frequently raised in other, non-VTE, conditions, including malignancy, sepsis, inflammation, trauma and surgery.

Venous thromboembolism and maternal mortality
Hannah Sims and David Perry
pp 10-11
Maternal mortality is a rare event in the UK, and its prevalence has reduced over the last 30 years through an increasing medical awareness of the complications associated with pregnancy. To date, there have been eight reports, following confidential enquiries into maternal deaths, carried out by the Centre for Maternal and Child Enquiries. This has led to an increased awareness of women’s health in pregnancy and, more recently, through the Royal College of Obstetricians and Gynaecologists, to the introduction of guidance on how to implement change in everyday practice.

Practicalities of switching between warfarin and other coumarins
Sarah Bond
pp 12-13
Warfarin is currently the oral anticoagulant of choice throughout the UK, and has been for over 60 years. However, there are two other ‘old’ oral anticoagulants that are infrequently used alternatives to warfarin – acenocoumarol and phenindione. The ‘new’ oral anticoagulants – the direct thrombin inhibitor dabigatran, and the direct factor Xa inhibitor rivaroxoban – have licences for thromboprophylaxis after orthopaedic surgery and now for prevention of stroke in patients with atrial fibrillation and, in the case of rivaroxaban, also for the treatment of deep vein thrombosis and pulmonary embolism. These drugs are likely to provide a viable alternative to warfarin in the future.

FAQs: Why don’t INR measurements agree?
Ian Jennings
pp 15-15
The international normalised ratio is determined from the equation below, where PT is the prothombin time (with a commercial thromboplastin reagent), the MNPT is the mean normal prothrombin time (average PT time of 20 or more normal subjects), and the international sensitivity index is the slope of the line obtained when PTs of normal and warfarinised patients measured with the commercial thromboplastin are plotted against the PTs measured on the same samples with a ‘gold standard’ international reference preparation.

Thrombus was previously supported by Bayer from 2014 to 2016, by Boehringer Ingelheim from 2009 to 2013, by sanofi-aventis from 2007 to 2008 and by Leo Pharma from 1998 to 2006.

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ISSN 1369-8117 (Print) ISSN 2045-7855 (Online)