COMMENTARY

Readers' Responses to the Article Entitled "Anticoagulation Therapy for Venous Thromboembolism"

Robert Hoyt, MD; Allen Markowicz, MD, MBA; R. G. (Jerry) Sarsfield, MD, FRCSC

Disclosures

January 03, 2005

To the Editor,

I take issue with several statements and conclusions made by Cundiff.[1] He states, "because no placebo-controlled trials of low-molecular-weight heparins or thrombolytic drugs in VTE have been done, their efficacy and safety are not scientifically supported." In the September 2004 Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy: Prevention of Venous Thromboembolism, they cite 6 placebo-controlled studies.[2] Specifically, in the MEDENOX study, deep vein thrombosis (DVT) was detected in 14.9% of general medical patients on placebo and 5.5% of patients on 40 mg of enoxaparin. In the PREVENT Thromboprophylaxis Study, 5% of the patients on placebo and 2.8% of the patients on dalteparin developed symptomatic venous thromboemboli (VTE), sudden death, and/or DVT. Two patients developed fatal pulmonary emboli (PE) in the placebo group and none in the dalteparin group. In this study, the rate of major bleeding occurred in .5% of the patients on dalteparin and .2% of the patients on placebo. This is in contrast with Cundiff's statement that the rate of major bleeding with anticoagulant use varies from 1% to 33%.

I also do not agree with the conclusion that "Fatal PE occur primarily as an agonal event of terminally ill people." Fatal PE can occur in young people with spinal cord injuries or patients with acquired or inherited thrombophilia with few other risk factors.

Although it is true that studies have not shown a decrease in mortality for prophylaxed hospitalized medical patients, failure to offer treatment with a bad resultant outcome is a frequent cause of lawsuits today.

Prevention of VTE has gained the national spotlight. One of the 4 key areas that the HealthGrades Study emphasized to reduce unnecessary US deaths was the prevention of postoperative PE.[3] The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the National Quality Forum are currently working to develop performance measures for the prevention of DVTs.[4] It is just a matter time before DVT prevention is mandated by JCAHO for hospitalized patients.

Until better studies and therapies are available, most of us will choose the current recommendations put forth by the Seventh ACCP Conference.

Robert Hoyt, MD

Pensacola Naval Hospital, Pensacola, Florida

  1. Cundiff D. Anticoagulation therapy for venous thromboembolism. Medscape General Medicine. 2004;6(3). Available at: http://www.medscape.com/viewarticle/487577 Accessed December 16, 2004.

  2. Geerts W. Prevention of venous thromboembolism: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126(suppl):338-400.

  3. HealthGrades Quality Study. Patient safety in American hospitals July 2004. Available at: Accessed December 16, 2004.

  4. Joint Commission on Accreditation of Healthcare Organizations. Joint Commission, National Quality Forum to work on deep vein thrombosis prevention and care project. Available at: www.jcaho.org/news+room/news+release+archives/jcaho_092704.htm Accessed December 16, 2004.

To the Editor,

You will also find the same data rigor deficit regarding the basis of antibiotic prophylaxis for cardiac valve disease surrounding dental or surgical interventions. But what does one do? Not to do either is virtually certain to result in an adverse liability decision if a maloccurence takes place, regardless of this data, or even causality. The practitioner is left with continuing the custom unless an authoritative guideline comes out to the contrary. I believe that the National Institutes of Health (NIH) should have a special mission to do studies like these,[1] if they could even get by a human clinical trial-experimentation committee review. Another role the NIH should take on is doing double-blind, randomized, controlled trials within classes to tell us whether or not there is a difference in outcomes, such as between lisinopril and ramipril.

Allen Markowicz, MD, MBA (Toledo, Ohio)

  1. Cundiff D. Anticoagulation therapy for venous thromboembolism. Medscape General Medicine. 2004;6(3). Available at: http://www.medscape.com/viewarticle/487577 Accessed September 9, 2004.

To say that thrombolytics are ineffective for the treatment of DVT, with the purpose of lowering postphlebitic syndrome, may be true,[1] but to base that on the studies quoted in this article is inappropriate. Only low-dose streptokinase studies were quoted, and some of the other studies have been questioned for years (especially Kakkar's data). One would really have to look at the data with urokinase.

Otherwise, the article was an interesting assault on a sacred cow... much needed.

R. G. (Jerry) Sarsfield, MD, FRCSC

  1. Cundiff D. Anticoagulation therapy for venous thromboembolism. Medscape General Medicine. 2004;6(3). Available at: http://www.medscape.com/viewarticle/487577 Accessed December 16, 2004.

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