https://www.chpso.org/sites/main/files/file-attachments/chest-2008-geerts-381s-453s.pdf

Prevention of Venous Thromboembolism* American College of Chest Physicians Evidence- Based Clinical Practice Guidelines (8th Edition)

Recurrent venous thromboembolism and bleeding complications during anticoagulant treatment in patients with cancer and venous thrombosis.

background Chronic thromboembolic pulmonary hypertension (CTPH) is associated with considerable morbidity and mortality. Its incidence after pulmonary embolism and associated risk factors are not well documented. methods We conducted a prospective, long-term, follow-up study to assess the incidence of symptomatic CTPH in consecutive patients with an acute episode of pulmonary embolism but without prior venous thromboembolism. Patients with unexplained persistent dyspnea during follow-up underwent transthoracic echocardiography and, if supportive findings were present, ventilation–perfusion lung scanning and pulmonary angiography. CTPH was considered to be present if systolic and mean pulmonary-artery pressures exceeded 40 mm Hg and 25 mm Hg, respectively; pulmonary-capillary wedge pressure was normal; and there was angiographic evidence of disease. results The cumulative incidence of symptomatic CTPH was 1.0 percent (95 percent confidence interval, 0.0 to 2.4) at six months, 3.1 percent (95 percent confidence interval, 0.7 to 5.5) at one year, and 3.8 percent (95 percent confidence interval, 1.1 to 6.5) at two years. No cases occurred after two years among the patients with more than two years of follow-up data. The following increased the risk of CTPH: a previous pulmonary embolism (odds ratio, 19.0), younger age (odds ratio, 1.79 per decade), a larger perfusion defect (odds ratio, 2.22 per decile decrement in perfusion), and idiopathic pulmonary embolism at presentation (odds ratio, 5.70). conclusions CTPH is a relatively common, serious complication of pulmonary embolism. Diagnostic and therapeutic strategies for the early identification and prevention of CTPH are needed.

Incidence of chronic thromboembolic pulmonary hypertension after pulmonary embolism.

https://www.armv-paca.org/index.php/mediatheque-full/recommandations-1/mtev-1/accp-2008-1/145-the-perioperative-management-antithrombotic-pdf-1/file

The perioperative management of antithrombotic therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition).

Objective To determine the efficacy and safety of the anticoagulant fondaparinux in older acute medical inpatients at moderate to high risk of venous thromboembolism.

Design Double blind randomised placebo controlled trial.

Setting 35 centres in eight countries.

Participants 849 medical patients aged 60 or more admitted to hospital for congestive heart failure, acute respiratory illness in the presence of chronic lung disease, or acute infectious or inflammatory disease and expected to remain in bed for at least four days.

Interventions 2.5 mg fondaparinux or placebo subcutaneously once daily for six to 14 days.

Outcome measure The primary efficacy outcome was venous thromboembolism detected by routine bilateral venography along with symptomatic venous thromboembolism up to day 15. Secondary outcomes were bleeding and death. Patients were followed up at one month.

Results 425 patients in the fondaparinux group and 414 patients in the placebo group were evaluable for safety analysis (10 were not treated). 644 patients (75.9%) were available for the primary efficacy analysis. Venous thrombembolism was detected in 5.6% (18/321) of patients treated with fondaparinux and 10.5% (34/323) of patients given placebo, a relative risk reduction of 46.7% (95% confidence interval 7.7% to 69.3%). Symptomatic venous thromboembolism occurred in five patients in the placebo group and none in the fondaparinux group (P = 0.029). Major bleeding occurred in one patient (0.2%) in each group. At the end of follow-up, 14 patients in the fondaparinux group (3.3%) and 25 in the placebo group (6.0%) had died.

Conclusion Fondaparinux is effective in the prevention of asymptomatic and symptomatic venous thromboembolic events in older acute medical patients. The frequency of major bleeding was similar for both fondaparinux and placebo treated patients.

https://www.bmj.com/content/bmj/332/7537/325.full.pdf

Efficacy and safety of fondaparinux for the prevention of venous thromboembolism in older acute medical patients: randomised placebo controlled trial

example is the largest recorded food related outbreak of paratyphoid, which occurred in Birmingham early this year and was successfully dealt with under the present control of infection arrangements. Another example is the outbreak Qf legionnaires' disease in London which Dr Cunningham and her colleagues had to deal witlY. One shudders to think what would have happened if the government had accepted the Acheson recommendations when the report was published. Control of infection has progressed since the major outbreaks of salmonella food poisoning at the Stanley Royd Hospital, Wakefield, and of legionnaires' disease in Stafford. Several models of good practice are now available in the provinces, including Birmingham. Health authorities in London would do well to adopt these practices, which emphasise the important role of local authorities in respect ofcommunicable disease and the link with the medical officer for environmental health in his role as proper officer. The models rely on the effective use of available resources. This is not the time to impose an unnecessary financial commitment on the National Health Service. Besides, historical evidence suggests that the health service would not be able to cope with the demands of the organisation of the nationwide control of infection services outside the National Health Service. No other Western country has abandoned the system built on local authority medical officers of health for controlling infection. It is time that we returned to it. S S BAKHSHI

A. A. Connolly

Papers

Deep vein thrombosis.