A Comparison of Low-Molecular-Weight Heparin Administered Primarily at Home with Unfractionated Heparin Administered in the Hospital for Proximal Deep-Vein Thrombosis

Levine, Mark; Gent, Michael; Hirsh, Jack; Leclerc, Jacques; Anderson, David R.; Weitz, Jeffrey I.; Ginsberg, Jeffrey S.; Turpie, Alexander G.G.; Demers, Christine; Kovacs, Michael J.; Geerts, William; Kassis, J; Desjardins, Louis; Cusson, Jean R.; Cruickshank, Moira; Powers, Peter; Brien, William; Haley, Susan L.; Willan, Andrew R.

doi:10.1056/nejm199603143341101

Cited by 1,136 publications

(661 citation statements)

References 21 publications

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“…In this cohort of postarthroplasty patients, the incidence of major bleeding complications (10%) was substantially higher than the rates reported for nonsurgical patients, which are 0% to 5% [5,20,22,35]. This difference highlights the unique risks inherent to anticoagulation treatment in patients who have undergone procedures, which include substantial soft tissue dissection and osteotomies.…”

Section: Discussionmentioning

confidence: 63%

High Incidence of Complications From Enoxaparin Treatment After Arthroplasty

Neviaser

Chang

Lyman

et al. 2010

Clinical Orthopaedics &Amp; Related Research

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Pulmonary embolism (PE) complicates 1% to 10% of total joint arthroplasties and generally requires immediate anticoagulation. Low-molecular-weight heparins have supplanted unfractionated heparin as the treatment of choice for PE and hold a 1A recommendation from the American College of Chest Physicians for this indication. However, the complications of enoxaparin treatment begun in close proximity to arthroplasty surgery are not well described. We examined the records of 135 patients who underwent total joint arthroplasty, experienced an in-hospital PE, and received treatment with enoxaparin at therapeutic doses (1 mg/kg body weight). The type and frequency of complications were determined and classified as major or minor. Twenty-seven percent of patients experienced minor complications and 10% experienced major complications. The incidence of major bleeding was substantially higher than rates reported for nonsurgical patients. The overall complication rate of enoxaparin treatment is similar to the rate of complications reported for unfractionated heparin treatment in this setting, but the complications are less severe.

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Section: Discussionmentioning

confidence: 63%

High Incidence of Complications From Enoxaparin Treatment After Arthroplasty

Neviaser

Chang

Lyman

et al. 2010

Clinical Orthopaedics &Amp; Related Research

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“…Moreover, two major RCTs have also established that the outpatient administration of LMWH is as safe as unfractionated heparin administered in hospital for the treatment of DVT [42][43][44]. For these reasons, outpatient treatment of patients with DVT, with or without asymptomatic PE, has become common practice worldwide.…”

Section: Discussionmentioning

confidence: 99%

Outpatient treatment and early discharge of symptomatic pulmonary embolism: a systematic review

Squizzato¹,

Galli²,

Dentali³

et al. 2009

European Respiratory Journal

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The published literature regarding the safety of outpatient treatment of symptomatic pulmonary embolism (PE) was systematically summarised.A literature search was performed using the PubMed and EMBASE databases. Studies in which patients had symptomatic PE and the antithrombotic treatment was administered completely at home or the patients were discharged early were selected. A scoring system was used to divide studies into three quality categories. Short-and long-term outcomes were extracted: all-cause mortality, death from PE or from major haemorrhage, recurrent venous thromboembolism, and major bleeding.Eleven observational studies were included. No randomised controlled studies were identified. No study fulfilled the criteria for high quality. A total of 928 patients with symptomatic PE were treated completely as outpatients or discharged early; haemodynamic instability and hypoxia were the main exclusion criteria. No patient died during the first 7 days of antithrombotic treatment.Outpatient treatment of symptomatic PE is not based on high-quality evidence. Although the published data suggest that certain subgroups of haemodynamically and respiratorily stable patients may be safely treated at home when a well-defined management programme is applied, further studies are warranted for a short-term prognostic risk stratification of this PE subgroup.

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“…Patients with acute deep vein thrombus (DVT) can safely be treated as outpatients [1][2][3][4]. Outpatient treatment of DVT is recommended with grade 1B evidence in the most recent American College of Chest Physicians (ACCP) guidelines [5].…”

Section: Introductionmentioning

confidence: 99%

Outpatient treatment of symptomatic pulmonary embolism: A systematic review and meta-analysis

Piran

Gal

Wells

et al. 2013

Thrombosis Research

134

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Background: Patients with acute deep vein thrombus (DVT) can safely be treated as outpatients. However the role of outpatient treatment in patients diagnosed with a pulmonary embolism (PE) is controversial. We sought to determine the safety of outpatient management of patients with acute symptomatic PE. Materials and Methods: A systematic literature search strategy was conducted using MEDLINE, EMBASE, the Cochrane Register of Controlled Trials and all EBM Reviews. Pooled proportions for the different outcomes were calculated. Results: A total of 1258 patients were included in the systematic review. The rate of recurrent venous thromboembolism (VTE) in patients with PE managed as outpatients was 1.47% (95% CI: 0.47 to 3.0%; I 2 : 65.4%) during the 3 month follow-up period. The rate of fatal PE was 0.47% (95% CI: 0.16 to 1.0%; I 2 : 0%). The rates of major bleeding and fatal intracranial hemorrhage were 0.81% (95% CI: 0.37 to 1.42%; I 2 : 0%) and 0.29% (95% CI: 0.06 to 0.68%; I 2 : 0%), respectively. The overall 3 month mortality rate was 1.58% (95% CI: 0.71 to 2.80%; I 2 : 45%). The event rates were similar if employing risk stratification models versus using clinical gestalt to select appropriate patients for outpatient management. Conclusions: Independent of the risk stratification methods used, the rate of adverse events associated with outpatient PE treatment seems low. Based on our systematic review and pooled meta-analysis, low-risk patients with acute PE can safely be treated as outpatients if home circumstances are adequate.

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A Comparison of Low-Molecular-Weight Heparin Administered Primarily at Home with Unfractionated Heparin Administered in the Hospital for Proximal Deep-Vein Thrombosis

Abstract: Low-molecular-weight heparin can be used safely and effectively to treat patients with proximal deep-vein thrombosis at home.

Cited by 1,136 publications

References 21 publications

High Incidence of Complications From Enoxaparin Treatment After Arthroplasty

High Incidence of Complications From Enoxaparin Treatment After Arthroplasty

Outpatient treatment and early discharge of symptomatic pulmonary embolism: a systematic review

Outpatient treatment of symptomatic pulmonary embolism: A systematic review and meta-analysis

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