The importance of appropriate prophylaxis for the prevention of venous thromboembolism in at-risk medical patients.

BACKGROUND: Venous thromboembolism (VTE), which encompasses both deep-vein thrombosis and pulmonary embolism, is a significant healthcare problem, leading to considerable morbidity, mortality and resource utilisation. AIMS: This review discusses the adherence to VTE guideline recommendations and the available clinical evidence on the appropriate type, dose and duration of VTE prophylaxis. METHODS: A literature survey was conducted using Pub Med and EMBASE to identify publications related to appropriate thromboprophylaxis in medically ill patients at risk of VTE. RESULTS: Despite evidence from clinical trials and national guidelines, VTE prophylaxis in medically ill patients remains underutilised. The use of unfractionated heparin three-times-daily, low-molecular-weight heparin once-daily and fondaparinux once-daily has demonstrated effectiveness in clinical trials of medically ill patients. However, controversy exists about the use of unfractionated heparin twice-daily, and fondaparinux has not yet received US Food and Drug Administration approval for VTE prophylaxis in medically ill patients. CONCLUSION: It is important for clinicians to have an understanding of the evidence-based literature when selecting an appropriate drug, at the appropriate dose, for the appropriate duration for VTE prophylaxis in medically ill patients. VTE prophylaxis in medically ill patients is cost-effective, and drugs that are expensive may still be cost-effective when considering improved efficacy and/or safety. Recently, the underutilisation of VTE prophylaxis has led to the involvement of government and other regulatory agencies in an attempt to increase appropriate VTE prophylaxis in US hospitals and improve the clinical and economic outcomes in medical patients at risk of VTE.

Are hospitals delivering appropriate VTE prevention? The venous thromboembolism study to assess the rate of thromboprophylaxis (VTE start).

The 7th conference of the American College of Chest Physicians (ACCP7) provides recommendations on the type, dose, and duration of thromboprophylaxis in hospitalized patients at risk of venous thromboembolism (VTE), but the extent to which hospitals follow these criteria has not been well studied. Discharge and billing records for patients admitted to any of 16 acute-care hospitals from January 2005 to December 2006 were obtained. Patients 18 years or older who had an inpatient stay >or=2 days and no apparent contraindications for thromboprophylaxis were grouped into the categories of critical care, surgery and medically ill before being assessed for additional VTE risk factors based on the diagnostic criteria outlined in ACCP7. For patients at risk, the recommended type (mechanical or pharmacologic), dose, and duration of thromboprophylaxis was identified based on the guidelines and compared to the regimen actually received, if any. Among the 258,556 hospitalized patients, 68,278 (26.4%) were determined to be at risk of VTE without apparent contraindications for thromboprophylaxis. The proportions of patients who received the appropriate type, dose, and duration of thromboprophylaxis were 10.5, 9.8, and 17.9% for critical care, medical, and surgical patients, respectively. Of those at risk, 36.8% received no thromboprophylaxis and an additional 50.2% received thromboprophylaxis deemed inappropriate for one or more reasons. The implementation of ACCP7 guidelines for type, dosage, and duration of thromboprophylaxis is low in patients at risk of VTE. There is a need for physicians and health systems to improve awareness and implementation of recommended thromboprophylaxis.

Advancing the battle against acute ischemic syndromes: a focus on the GP IIb-IIIa inhibitors.

Platelet aggregation and thrombus formation, resulting from disruption of a coronary artery plaque, play a critical role in the pathology of acute coronary syndromes. Currently, aspirin and heparin are administered to decrease platelet aggregation. The discovery of the platelet integrin receptor alpha(IIb)beta3, also known as the platelet glycoprotein (GP) IIb-IIIa receptor, is a breakthrough in antiplatelet therapy. The GP IIb-IIIa receptor is responsible for the crucial binding of fibrinogen to platelets, leading to cross-links between platelets and further platelet aggregation. Since the introduction of abciximab, the first GP IIb-IIIa-receptor antagonist, several other nonantibody agents have been studied for use in percutaneous transluminal coronary angioplasty and also in stent placement, treatment of unstable angina, and myocardial infarction.