The treatment of acute deep vein thrombosis has been the subject of much research aimed at delineat ing the safest and most effective approach to diagnosis and treatment. Studies regarding long-term treatment have been limited by the narrow scope of laboratory and clinical analyses of many patients. In this study of 100 patients with a history of deep vein thrombosis, treated on an outpatient basis by a diverse group of clinicians, follow-up data were retrieved in order to determine the outcomes of various approaches to acute and long-term care. Among individuals followed for > 1 year, in only two patients (2%) was death attributable to a thrombotic event related to the etiology of the first episode of deep vein thrombosis. Most deceased patients succumbed to unrelated causes (11%). Among the 77 survivors, most (52%) received long-term antiplatelet therapy. All individ uals with a plasma coagulation defect, whether inherited or acquired, received anticoagulation with either heparin or warfarin. Since the long-term clinical outcome of most patients with deep vein thrombosis is dependent upon the underlying factor predisposing to thrombosis, the most important treatment decision is to select the therapy most likely to provide benefit without causing hemorrhage. An tiplatelet therapy, heparin, or warfarin may be chosen as appropriate for the individual patient.
Haemorrhagic complications of thrombolytic therapy for myocardial infarction are common. A 68 year old man presented with a myocardial infarction and was started on tissue plasminogen activator. Soon after he experienced rectal bleeding and a barium enema showed a small carcinoma in the colon, which was treated surgically. It is important that gastrointestinal bleeding secondary to thrombolysis is always investigated for an underlying cause.
The adverse consequences of thrombosis are per haps nowhere more evident than in clinical cardiology. Throm bosis and hemostasis are primary issues in the management of patients with atrial fibrillation, prosthetic heart valves, severe left ventricular dysfunction, and coronary artery disease. Clini cal trials have defined a crucial role for anticoagulation with warfarin in patients with atrial fibrillation to reduce the inci dence of stroke. Anticoagulation with warfarin and aspirin in combination offers significant protection from systemic emboli in patients with mechanical prosthetic valves, without a sub stantial increased risk of hemorrhage. The risk of systemic emboli may also be reduced by anticoagulation in patients with severe left ventricular dysfunction. Disturbance of the normal balance of hemostasis is a major factor in the pathophysiology of coronary artery disease. Antiplatelet therapy, antithrombin agents, anticoagulants, and fibrinolytic agents have been used to prevent and treat acute coronary thrombosis and to prevent reocclusion following thrombolysis and interventional therapy. Guidelines are presented for antithrombotic therapy in the prac tice of clinical cardiology. Key Words: Thrombosis— Cardiology—Coronary artery disease—Atrial fibrillation— Valvular heart disease.
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