Thrombus - 2013

Diagnosing VTE: the challenges of implementing NICE guidance
Hamish Lyall
pp 1-4
In 2012, the National Institute for Health and Care Excellence (NICE) published Clinical Guideline (CG) 144 on the management of venous thromboembolic diseases and the role of thrombophilia testing. This article will review some of the practical issues and controversies that may arise when implementing the diagnostic pathways recommended in the NICE guideline. Suspected venous thromboembolism (VTE) is a frequent reason for referral to hospital. Traditionally, patients with suspected VTE were admitted to hospital for clinical assessment followed by diagnostic imaging. However, in the past 15 years there has been increasing use of outpatient services. These use predefined algorithms combining clinical assessment, clinical probability scores, laboratory tests (D-dimer) and different imaging modalities. The diagnostic pathway for VTE is now a complex multidisciplinary process. It requires integration of clinical, laboratory and radiology services in a timely manner. Increasingly, pathways also involve primary care.
Comment: Myths about reversal of warfarin
Peter Rose
pp 2-2
It is surprising that reversal of anticoagulation due to vitamin K antagonists continues to present a significant clinical problem within our routine services. Despite ample evidence for the efficacy of vitamin K and, in life-threatening situations, prothrombin complex concentrate (PCC) for the reversal of warfarin treatment, there remains confusion around their administration and, in particular, how quickly to act to reverse treatment. Unfortunately, there are several myths that pervade the thinking of many clinicians in this area. This was recently highlighted to me around the management of a patient with a retroperitoneal bleed and haemoglobin level of 50 g/l on warfarin for a mechanical mitral valve.
A review of the new oral direct inhibitors in the management of DVT and PE
Charlotte A Bradbury
pp 5-9
The mainstay of management of deep vein thrombosis (DVT) and pulmonary embolism (PE) is anticoagulation. Until recently, anticoagulation options were limited to vitamin K antagonists (VKAs), combined with parenteral heparin initiation. Although subcutaneous low molecular weight heparin (LMWH) is markedly more convenient than unfractionated heparin and has enabled those stable enough to be treated as outpatients, it still requires injections and sharps disposal, which some patients find difficult. In addition, warfarin has its own set of problems, including significant variability of anticoagulant effect, which requires monitoring and/or dose adjustments, as well as numerous interactions with drugs, alcohol and diet. However, its advantages include familiarity, reversibility, a good understanding of routine coagulation tests (international normalised ratio [INR]) and safety in renal dysfunction. The oral direct inhibitors (ODIs) have a fast onset of action and do not require monitoring or dose adjustments, as they have predictable pharmacokinetics. However, they cannot be reversed in an emergency and are excreted renally (to a variable extent) and, therefore, should be used with caution in renal impairment.
Venous thromboembolism in children
Tim Nokes
pp 10-11
There are very few clinical trials informing the investigation and management of venous thromboembolism (VTE) in children. Therefore, much of the current practice is extrapolated from adult experience. However, there are significant age-dependent differences in epidemiology, haemostasis, and safety and efficacy of anticoagulation between the two age groups. The annual incidence of VTE in children is significantly lower than in adults, at about one in 100,000, with a prevalence of 5.3 per 10,000 hospital admissions, according to the Canadian national registry, and others. Registry data are being used to gain experience of treating VTE in children.
The National VTE Prevention Programme - an update
Helen Morrison
pp 12-13
NHS England’s National Venous Thromboembolism (VTE) Prevention Programme, widely acknowledged as the most comprehensive of any healthcare system in the world, has developed progressively in recent years through the collaboration of clinical experts, NHS leaders and dedicated healthcare professionals. Its aim is to ensure that strategies for VTE prevention are fully integrated into routine patient care. To date, the focus of the programme has been on risk assessment, enabling appropriate prophylaxis to be prescribed and, as a result, outcomes improved. A number of measures have been successfully introduced into the system that have undoubtedly driven change – but there is still much to do.
Outpatient warfarin loading: proposal for a new age-related normogram in older patients with DVT
Nalini Sethia, Julie Blundell, Rachel Mainnie, Andrew McSoreley and Joanna Morton
pp 14-15
At present, warfarin remains a commonly used anticoagulant for the treatment of venous thromboembolism (VTE). Patients with VTE require parenteral anticoagulation until oral anticoagulation is established. For such patients, the time it takes to reach stable anticoagulation is therefore an important factor. Warfarin has a narrow therapeutic index and the dose required varies depending on genetic and environmental factors. Over-anticoagulation may lead to a potentially life-threatening haemorrhage and under-anticoagulation increases the risk of further thrombosis and can delay the patient’s discharge to primary care management.

Thrombus is funded by an unrestricted educational grant from Bayer HealthCare, with no editorial input into the contents of this journal.

Thrombus was previously supported 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)