1 / 25

Indicazioni e modalità di prevenzione secondaria

Indicazioni e modalità di prevenzione secondaria. Gualtiero Palareti U.O. di Angiologia e Malattie della Coagulazione “Marino Golinelli” Policlinico S. Orsola-Malpighi Bologna. Recurren t events account for 19-25% of total events. EPI-GETBO study, T&H 2000 Cohen et al., T&H 2007.

irma
Download Presentation

Indicazioni e modalità di prevenzione secondaria

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Indicazioni e modalità di prevenzione secondaria Gualtiero Palareti U.O. di Angiologia e Malattie della Coagulazione“Marino Golinelli”Policlinico S. Orsola-Malpighi Bologna

  2. Recurrent events account for 19-25% of total events EPI-GETBO study, T&H 2000 Cohen et al., T&H 2007

  3. To avoid recurrences is a main target of prolonged treatment Which is the optimal duration of anticoagulation?

  4. VKAs are highly effective in preventing recurrences; however, their protective effect is present only during treatment

  5. Agnelli et al., NEJM 2001: WODIT study

  6. Risks of VTE and of its treatment • Recurrences= 17,5% (at 2 y); 24,6% (at 5 y); about 30% (at 10 y) • Oral anticoagulation (INR > 2.0) is highly effective with a risk reduction 90% • Major bleeding during anticoagulation = 1-2%fatal 0,25% (ISCOAT study, Lancet 1996)

  7. Factors influencing the risk of recurrence

  8. Type of 1st event and quality of its treatment - distance from 1st event - idiopathic/removed or persisting trigger factor - proximal or isolated distal - PE or DVT only - at least 3 m. anticoagulation (2.0-3.0 INR)

  9. Patient characteristics/comorbidities - males > females - thrombophilia - BMI - active cancer (metastatic, chemotherapy) - chronic inflammatory dis. - residual vein thrombus - signs of hypercoagulability (D-dimer, Thrombin generation assays)

  10. Circulation 2010

  11. Prandoni et al., Haematologica 2007

  12. Arch Intern Med 2010 Annualized recurrence rates at 24 months: 3.3% pt-y in 2268 pts with a transient risk factor, 0.7% pt-y in 248 pts with a surgical factor, 4.2% pt-y in 509 pts with a non-surgical factor. 7.4% pt-y in the same studies after unprovoked VTE The rate ratio at 24 months for a non-surgical vs a surgical factor = 3.0 for unprovoked vs a non-surgical factor = 1.8

  13. Does the clinical presentation and extent of VTE predict likelihood and type of recurrence? A patient level meta-analysis (Baglin et al., JTH in press) 5-year cumulative rate of recurrent VTE in 2,554 patients = 22.6% In PE = 22.0% and recurrence as PE = 10.6% In proximal DVT = 26.4% and recurrence as PE = 3.6% Recurr. as PE in PE vs proximal DVT proximal DVT = HR, 3.1 Recurr. in proximal vs distal DVT = HR, 4.8

  14. Duration of anticoagulation: What do the guidelines recommend?

  15. ACCP 2008: Duration of AnticoagulationShort-term treatment Treatment with a VKA for 3 months in pts with: Proximal DVT secondary to a transient (reversible) factor(Grade 1A) Isolated distal DVT (Grade 2B)

  16. ACCP 2008 Duration of AnticoagulationLong-term treatment - Second episode of unprovoked VTE(Grade 1A) - DVT and cancer: LMWH for the first 3 to 6 monthsof long-term anticoagulant therapy (Grade 1A),indefinitelyor until the cancer is resolved (Grade 1C) - Antiphospholipid Syndrome

  17. ACCP 2008 Duration of AnticoagulationUnprovoked proximal DVT - VKA for at least 3 months (Grade 1A) - After 3 months, all patients should be evaluated for the risk-benefit ratio of long-term therapy (Grade 1C) - For patients in whom risk factors forbleeding are absent and for whom good anticoagulantmonitoring is achievable, we recommendlong-term treatment (Grade 1A)

  18. Possible strategies after a first period of full anticoagulation in pts with a first unprovoked VTE Indefinite full anticoagulation with VKA (2-3 INR), or NOAC (in the next future) VKA anticoagulation with lower INR range To identify subgroups of patients at high/low risk (to prolong or stop anticoagulation) To give effective drugs but safer than VKA (less bleeding)

  19. 2009

  20. 2010

  21. 2010

  22. 2010

  23. The DULCIS study(D-dimer and ULtrasonography in Combination Italian Study) A management study to optimize the duration of anticoagulation after a 1st VTE Executive Committee Gualtiero Palareti (Bologna), Vittorio Pengo (Padova), Paolo Prandoni (Padova) (gualtiero.palareti@unibo.it)

  24. DULCIS study: main features • Unprovoked 1st VTE after > 3 mo. AC • At least 1 y AC if residual trombus • D-d repeatedly tested during the first 3 m after AC is stopped • Sex- and age-specific D-d cut-off values established with various commercial D-d assays • AC resumed if D-d > cut-off within the first 3 m. • 2 y follow-up

More Related