Update in the prevention and treatment of deep vein thrombosis and pulmonary embolism.

PURPOSE OF REVIEW

Thromboembolic events have a major impact on outcome of surgical and medical patients. This review is focused on standards and recent advances in antithrombotic strategies for prevention and therapy of venous thromboembolism and pulmonary embolism.

RECENT FINDINGS

Alert programs improve prophylactic strategies to prevent venous thromboembolism. Evidenced-based guidelines are available on antithrombotic and thrombolytic therapy outweighing the benefits, risks, burdens and costs. Selective factor Xa and direct thrombin inhibitors are at least as effective as low-molecular-weight heparin in prevention of venous thromboembolism and treatment of pulmonary embolism, but have fewer side effects and will not need routine monitoring. In high-risk orthopaedic patients but not in general surgery patients fondaparinux is superior to low-molecular-weight heparin in the prevention of thromboembolic disease. Ximelagatran, the first oral direct thrombin inhibitor, is as effective and well tolerated as warfarin. Long-term treatment is uncertain, however, because of elevation in alanine transaminase levels. In high-risk patients with contraindication for anticoagulation, retrievable vena cava filters may be an option to prevent pulmonary embolism. Permanent cava filters do not improve long-term survival and are associated with relevant side effects. Thrombolytics should be reserved for deep venous thrombosis complicated by limb gangrene and for life threatening pulmonary embolism.

SUMMARY

There is currently sufficient information based on guidelines available on preventive and therapeutic strategies for venous thromboembolism and pulmonary embolism. Antithrombotics are the therapeutic backbone. In high-risk orthopedic surgery and venous thromboembolism the new antithrombotics fondaparinux, idraparinux and ximelagatran are superior to standard treatment. Temporary caval filters may be a therapeutic option in high-risk patients with contraindication for antithrombotics.