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In this clinical trial, rivaroxaban, an oral factor Xa inhibitor, was effective in the initial and continued treatment of symptomatic venous thromboembolism; it may become part of the treatment armamentarium for this common clinical problem. Acute venous thromboembolism (i.e., deep-vein thrombosis [DVT] or pulmonary embolism) is a common disorder with an annual incidence of approximately 1 or 2 cases per 1000 persons in the general population. 1 , 2 Short-term treatment is effective, with the risk of recurrent disease — the major complication — reduced from an estimated 25% to about 3% during the first 6 to 12 months of therapy. 3 The risk of recurrence remains after treatment ends and can reach 5 to 10% during the first year. 4 , 5 Standard treatment for acute venous thromboembolism is limited by the need for parenteral heparin initially, with overlapping . . .

The long-acting factor X inhibitor idraparinux was compared with a standard antithrombotic regimen in two randomized trials, one for the treatment of deep venous thrombosis (DVT Study) and the other for the treatment of pulmonary embolism (PE Study). In the DVT Study, idraparinux was not inferior to standard therapy. In the PE Study, idraparinux was less efficacious than standard therapy. For the treatment of deep venous thrombosis, idraparinux was not inferior to standard therapy. For the treatment of pulmonary embolism, idraparinux was less efficacious than standard therapy. The standard treatment for both deep venous thrombosis and pulmonary embolism is an initial course of unfractionated heparin or low-molecular-weight heparin, followed by a vitamin K antagonist for 3 to 12 months. 1 , 2 This therapy is effective but requires laboratory monitoring and dose adjustments. Idraparinux (Sanofi-Aventis) is a novel synthetic pentasaccharide that inhibits activated factor X and differs from fondaparinux in its substantially longer half-life. Initial clinical experience suggests that a fixed dose given subcutaneously once weekly is effective and causes less bleeding than vitamin K antagonists in the treatment of venous thromboembolism. 3 , 4 In two studies in patients presenting . . .

The current standard initial therapies for deep venous thrombosis are low-molecular-weight heparin and unfractionated heparin. In a dose-ranging study of patients with symptomatic deep venous thrombosis, fondaparinux had efficacy and a safety profile similar to those of low-molecular-weight heparin (dalteparin). To evaluate whether fondaparinux has efficacy and safety similar to those of enoxaparin in patients with deep venous thrombosis. Randomized, double-blind study. 154 centers worldwide. 2205 patients with acute symptomatic deep venous thrombosis. Fondaparinux, 7.5 mg (5.0 mg in patients weighing <50 kg and 10.0 mg in patients weighing >100 kg) subcutaneously once daily, or enoxaparin, 1 mg/kg of body weight, subcutaneously twice daily for at least 5 days and until vitamin K antagonists induced an international normalized ratio greater than 2.0. The primary efficacy outcome was the 3-month incidence of symptomatic recurrent venous thromboembolic complications. The main safety outcomes were major bleeding during initial treatment and death. An independent, blinded committee adjudicated all outcomes. 43 (3.9%) of 1098 patients randomly assigned to fondaparinux had recurrent thromboembolic events compared with 45 (4.1%) of 1107 patients randomly assigned to enoxaparin (absolute difference, -0.15 percentage point [95% CI, -1.8 to 1.5 percentage points]). Major bleeding occurred in 1.1% of patients receiving fondaparinux and 1.2% of patients receiving enoxaparin. Mortality rates were 3.8% and 3.0%, respectively. Follow-up was incomplete in 0.4% of fondaparinux-treated patients and 1.0% of enoxaparin-treated patients. Once-daily subcutaneous fondaparinux was at least as effective (not inferior) and safe as twice-daily, body weight-adjusted enoxaparin in the initial treatment of patients with symptomatic deep venous thrombosis.

The high risk of recurrent venous thromboembolism in patients with idiopathic venous thrombosis or pulmonary embolism is reason for extended thromboprophylaxis in selected patients. Although 6 months of prophylaxis with idraparinux after the initial 6 months of treatment with an anticoagulant was effective in preventing recurrent thromboembolism, its use caused an excess of major, clinically significant hemorrhagic episodes. Although extended prophylaxis with idraparinux was effective in preventing recurrent thromboembolism, its use caused an excess of major, clinically significant hemorrhagic episodes. Patients who have had venous thromboembolism have a risk of recurrence of approximately 30% during the first 8 years after the initial episode. 1 – 3 Most of these events occur during the first 6 to 12 months after the first event. Vitamin K antagonists are highly effective in reducing the risk of recurrence, 4 – 6 but their use requires close laboratory monitoring and dose adjustments to reduce the risk of bleeding. For these reasons, vitamin K antagonists are often discontinued before the recommended period of prophylaxis for idiopathic venous thromboembolism (6 to 12 months). 7 However, the risks and benefits of extending prophylaxis . . .

Venous thromboembolism is a common, life-threatening complication in patients undergoing elective neurosurgery. An average incidence of deep-vein thrombosis of 24 percent was found among 474 untreated control patients included in eight studies on the prevention of venous thromboembolism in elective (scheduled) neurosurgery. 1 – 8 Pulmonary embolism has been reported to occur in 1.5 to 5 percent of patients undergoing neurosurgery, with a mortality rate ranging from 9 percent to 50 percent. 9 The optimal strategy for prophylaxis against venous thromboembolism in elective neurosurgery is unclear. Physical methods, including intermittent-pneumatic-compression devices and compression stockings, 1 , 2 , 4 – 6 , 8 have been preferred to anticoagulant . . .

In 1998 the term economy class syndrome was coined to describe the association between travel and thrombosis. A fair risk estimate, however, has not been done. We report the results of a prospective study, in which we kept the effect of bias to a minimum. We compared travel history in 788 patients with venous thrombosis with that of controls with similar symptoms but in whom the disease had been excluded. For air travel alone, the odds ratio was 1·0 (95% CI 0·3–3·0); also, no association was recorded for other methods of transportation. We have shown that, there is no increased risk of deep vein thrombosis among travellers.

Abstract Objective: To evaluate the safety of withholding anticoagulant treatment from patients with clinically suspected deep vein thrombosis but normal findings on compression ultrasonography. Design: Compression ultrasonography was done with a simplified diagnostic procedure limited to the common femoral vein in the groin and the popliteal vein extending down to the trifurcation of the calf veins. Patients with normal ultrasonography findings at presentation were retested 1 week later. Main outcome measure: The incidence of venous thromboembolic complications during follow up for 6 months in patients in whom anticoagulant treatment was withheld on the basis of normal results on two ultrasonography tests 1 week apart. Setting: University research centres in four hospitals. Results: A total of 1702 patients were included in the study. Abnormal results on compression ultrasonography at presentation or at 1 week were found in 400 and 12 patients, respectively, for a prevalence of deep vein thrombosis of 24%. None of the patients were lost to follow up. Venous thromboembolic complications during the week of serial testing occurred in a single patient and in eight patients during 6 months' follow up, resulting in a cumulative rate of venous thromboembolic complications of 0.7% (95% confidence interval 0.3% to 1.2%). The mean number of extra hospital visits and additional tests required per initially referred patient was 0.8. Conclusion: It is safe to withhold anticoagulant treatment from patients with clinically suspected deep vein thrombosis who have a normal result on compression ultrasonography at the time of presentation and at 1 week. Key messages Clinical diagnosis of suspected deep vein thrombosis is notoriously unreliable and objective diagnostic tests are indicated to confirm or refute the presence of this condition Ultrasonography with vein compressibility of the common femoral and popliteal vein is the non-invasive test of choice for the diagnostic management of patients with suspected deep vein thrombosis It is safe to withhold anticoagulant treatment from patients with suspected deep vein thrombosis who have normal results on compression ultrasonography on presentation and on a single repeat test 1 week later With the simplified compression ultrasound strategy the number of repeat tests can be safely reduced to a single test performed a week after presentation Most patients with deep vein thrombosis can be identified at presentation, making this strategy convenient to patients and less costly

Objective To investigate the efficacy of using a rapid plasma D-dimer test as an adjunct to compression ultrasound for diagnosing clinically suspected deep vein thrombosis. Design D-dimer concentrations were determined in all patients with a normal ultrasonogram at presentation. Repeat ultrasonography was performed 1 week later only in patients with abnormal D-dimer test results. Main outcome measure Patients with normal ultrasonograms were not treated with anticoagulants and were followed for 3 months for thromboembolic complications. Setting University research and affiliated centres. Subjects 946 patients with clinically suspected deep vein thrombosis. Results Ultrasonograms were abnormal at presentation in 260 (27.5%) patients. Of the remaining 686 patients tested for D-dimer, 88 (12.8%) had abnormal concentrations. During follow up venous thromboembolic complications occurred in one of the 598 patients who were not treated with anticoagulants and who had an initial normal ultrasonogram and D-dimer concentration, whereas thromboembolic complications occurred in two of the 83 untreated patients who had abnormal D-dimer concentrations but a normal repeat ultrasonogram. The cumulative incidence of venous thromboembolic complications during follow up was 0.4% (95% confidence interval 0% to 0.9%). The rapid plasma D-dimer test used as an adjunct to compression ultrasonography resulted in a reduction in the mean number of repeat ultrasound examinations and additional hospital visits from 0.7 to 0.1 per patient. Conclusions Testing for D-dimer as an adjunct to a normal baseline ultrasound examination decreased the number of subsequent ultrasound examinations considerably without any increased risk of venous thromboembolic complications in patients not receiving anticoagulants. The use of ultrasound and testing for D-dimer enabled treatment decisions to be made at the time of presentation in most patients.

Anticoagulant treatment for deep-vein thrombosis aims to prevent pulmonary embolism and recurrent thrombosis and also to avoid excessive bleeding. 1 In addition, both the effect of therapy on the patients' well-being and the cost of therapy are factors to be weighed in determining the optimal treatment. It is current practice to treat acute venous thrombosis with intravenous standard (unfractionated) heparin for at least five days in a dose adjusted to lengthen the activated partial-thromboplastin time into a desired range. 2 - 5 Oral anticoagulant therapy is started concomitantly and continued for at least three months. 6 This approach is effective, but it suffers from . . .