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C0070: Treatment of DVT: Evaluation of Safety and Efficacy
POSTERS / Thrombosis Research 133S3 (2014) S35–S123
thrombocytopenia treatment was mandatory in 4 of them (firstline treatment in 1 case; second or third line in 3 cases). Regarding arterial thrombosis we found 4 coronary syndromes and 1 stroke. All five patients had cardiovascular risk factors and none of them was splenectomised or had antiphospholipid antibodies. The median platelet count at the time of TE was 65×109 /L. 1 patient was being treated for thrombocytopenia at the time of diagnosis; 2 patients required treatment to receive antithrombotic medication. In addition, 10 patients had arterial thrombosis before the diagnosis of ITP. All of them were receiving antiplatelet drugs. In 7 cases, immune thrombocytopenia treatment was required to maintain antithrombotic treatment. Conclusions: • In our series the rate of thrombosis in patients with ITP is 8%, with a predominance of venous vs arterial thrombosis. • Use of antithrombotic medication often creates a need for thrombocytopenia therapy in the absence of other criteria of treatment.
DEEP VEIN THROMBOSIS 2 C0070 TREATMENT OF DVT: EVALUATION OF SAFETY AND EFFICACY A. Vardanyan1 , R. Mumladze1 , A. Badanyan1 , L. Patrushev1 , E. Roitman1 , D. Dolidze1 , M. Shieh1 . 1 Russian Medical Academy of Postgraduate Education Health and Social Development, Barrikadnaya str., 2/1, 123995 Moscow, Russia Background: In the EU more than 680,000 cases of deep venous thrombosis (DVT) are reported annually. Treatment of VTE should combine clinical and economic practicality in the utilization of contemporary medications. The aim of our study is to analyze the efficacy and safety results of DVT treatment in our institution to determine optimal treatment regimens. Methods: Analysis of diagnosis & treatment of 159 patients treated for DVT at Botkin Hospital from Jan. 2012 to Nov. 2014 was performed. The study included 62 (38.9%) men and 97 (61.1%) women. Age ranged from 22 to 95 years. Ultrasound was used for initial and main diagnosis of DVT, as well as monitoring of treatment efficacy. In 50 patients (31.4%) with DVT, the following genetic studies were performed: FV Leiden mutation, G20210A (prothrombin gene), C10034T (g-fibrinogen gene), C677T (MTHFR gene), G1639A (VKORC 1 gene), and allelic variants CYP2C9*2 & *3 of the cytochrome P450 gene. A personalized approach of therapy, with consideration of individual risk factors and hereditary characteristics, was employed. Treatment involved transition from LMWH or UFH to warfarin with monitoring of INR. However in 23 (14.5%) of patients, there was difficulty in choosing the optimal dose of warfarin. In 20 (12.5%) patients with DVT, rivaroxaban was found to be an effective monotherapy. Results: DVT of the calf was diagnosed in 67 (42.1%) patients. Thrombosis of proximal deep veins was diagnosed in 92 (57.9%) patients. Patients with DVT showed signs of thrombinemia: increased concentrations of Soluble Fibrin Monomer Complex and D-dimer, and decreased activity of Antithrombin III. Genetic tests revealed: Heterozygous FV Leiden in 7 (14%), homozygous prothrombin mutation in 1 (2%), homozygous fibrinogen gene mutation in 5 (10%), homozygous MTHFR gene mutation in 5 (10%) patients. To determine warfarin dosage, we investigated the aforementioned alleles of cytochrome P450
S65
CYP2C9 and VKORC1 genes, which were found in 21 (42%) and 30 (60%) patients respectively. Satisfactory (good or moderate) restoration of venous blood-flow was noted following 3 weeks of anticoagulant therapy. Conclusions: In treatment of VTE, it is necessary to utilize a systematic approach, requiring use of appropriate antithrombotic therapy and monitoring its efficacy. Since the need for regular monitoring complicates therapy, when possible, rivaroxaban monotherapy may be considered as an option to simplify therapy. C0139 CT CHEST ANGIOGRAPHY SCAN REQUEST FOR THE DIAGNOSIS OF PULMONARY EMBOLISM IN EMERGENCY DEPARMENT P. Javier Marchena Yglesias1 . 1 Parc Sanitari Sant Joan de Deu, Barcelona, Spain Background: Pulmonary embolism (PE) is one component of venous thromboembolic disease with a high prevalence. In general population remains the third leading cause of outpatient cardiovascular death and the leading cause of hospital. Therefore, the diagnosis must be accurate and that sometimes is not easy. For diagnosis could be apply pre-test probability scores prior to conducting any imaging test. If they are moderate or high risk, the CT chest angiography scan is the imaging test of choice, leaving the pulmonary ventilation / perfusion as an alternative in case you cannot do it. To assess request of CT chest angiography scan to diagnosis or rule out PE, made from the emergency department, their suitability to the pretest probability scores and clinical characteristics outcomes. Methods: We reviewed the CT chest angiography scan requests from January to May 2013. Used demographic variables as well as the appropriateness of requests by pre-test probability scores, the patient’s clinical and accordingly the justification of the request. Results: A total of 340 CT chest angiography scan request for diagnosis of PE were performed in the study period (January– May 2013) throughout the hospital of which 135 (39%) were made from the Emergency Department. The mean age of the patients are 74.83±13.68 (33–97 years). 56% are male. Regarding risk factors for PE, 20% had cancer, 10.9% had had a previous VTE and 10.8% immobilization of more than 4 days. In 45% of cases did not have any risk factors. Only 18% of the patients underwent pre-test probability score, of which 16% achieved a result of intermediate probability. D-dimer was performed in 76% of patients with a positive result in 80% of cases. The main symptom to justify the request for the test image was dyspnea (38%), elevated D-dimer (17.8%), chest pain (14.5%), arterial blood gases (5.4%) alteration, syncope (5.4%), fever (3.2%) and others (6.4%). With the application of pre-test probability scores, the request were justified in 40% of them and only 27% of cases were positive to PE. After completion of the test 31% of the patients were discharged. Multivariate analysis of the data reveals that the confirmation of pulmonary embolism is associated with elevated levels of D-dimer >2000 (OR 1.70, 95% CI 1.51–1.91, p < 0.001) and the justification of the request based in intermediate and high levels of pre-test probability score (OR 2.69, 95% CI 2.55–2.83, p < 0.001). Conclusions: The number CT chest angiography scan request for the diagnosis of pulmonary embolism is high considering the low percentage of confirmatory diagnoses. Only 40% would be justified by objective criteria, with only 27% of confirmation. It should improve the performance of pre-test probability score to justify the requests and not based on D-dimer levels, which although high titers can make unfounded suspicion, may have alternative diagnoses.
thrombocytopenia treatment was mandatory in 4 of them (firstline treatment in 1 case; second or third line in 3 cases). Regarding arterial thrombosis we found 4 coronary syndromes and 1 stroke. All five patients had cardiovascular risk factors and none of them was splenectomised or had antiphospholipid antibodies. The median platelet count at the time of TE was 65×109 /L. 1 patient was being treated for thrombocytopenia at the time of diagnosis; 2 patients required treatment to receive antithrombotic medication. In addition, 10 patients had arterial thrombosis before the diagnosis of ITP. All of them were receiving antiplatelet drugs. In 7 cases, immune thrombocytopenia treatment was required to maintain antithrombotic treatment. Conclusions: • In our series the rate of thrombosis in patients with ITP is 8%, with a predominance of venous vs arterial thrombosis. • Use of antithrombotic medication often creates a need for thrombocytopenia therapy in the absence of other criteria of treatment.
DEEP VEIN THROMBOSIS 2 C0070 TREATMENT OF DVT: EVALUATION OF SAFETY AND EFFICACY A. Vardanyan1 , R. Mumladze1 , A. Badanyan1 , L. Patrushev1 , E. Roitman1 , D. Dolidze1 , M. Shieh1 . 1 Russian Medical Academy of Postgraduate Education Health and Social Development, Barrikadnaya str., 2/1, 123995 Moscow, Russia Background: In the EU more than 680,000 cases of deep venous thrombosis (DVT) are reported annually. Treatment of VTE should combine clinical and economic practicality in the utilization of contemporary medications. The aim of our study is to analyze the efficacy and safety results of DVT treatment in our institution to determine optimal treatment regimens. Methods: Analysis of diagnosis & treatment of 159 patients treated for DVT at Botkin Hospital from Jan. 2012 to Nov. 2014 was performed. The study included 62 (38.9%) men and 97 (61.1%) women. Age ranged from 22 to 95 years. Ultrasound was used for initial and main diagnosis of DVT, as well as monitoring of treatment efficacy. In 50 patients (31.4%) with DVT, the following genetic studies were performed: FV Leiden mutation, G20210A (prothrombin gene), C10034T (g-fibrinogen gene), C677T (MTHFR gene), G1639A (VKORC 1 gene), and allelic variants CYP2C9*2 & *3 of the cytochrome P450 gene. A personalized approach of therapy, with consideration of individual risk factors and hereditary characteristics, was employed. Treatment involved transition from LMWH or UFH to warfarin with monitoring of INR. However in 23 (14.5%) of patients, there was difficulty in choosing the optimal dose of warfarin. In 20 (12.5%) patients with DVT, rivaroxaban was found to be an effective monotherapy. Results: DVT of the calf was diagnosed in 67 (42.1%) patients. Thrombosis of proximal deep veins was diagnosed in 92 (57.9%) patients. Patients with DVT showed signs of thrombinemia: increased concentrations of Soluble Fibrin Monomer Complex and D-dimer, and decreased activity of Antithrombin III. Genetic tests revealed: Heterozygous FV Leiden in 7 (14%), homozygous prothrombin mutation in 1 (2%), homozygous fibrinogen gene mutation in 5 (10%), homozygous MTHFR gene mutation in 5 (10%) patients. To determine warfarin dosage, we investigated the aforementioned alleles of cytochrome P450
S65
CYP2C9 and VKORC1 genes, which were found in 21 (42%) and 30 (60%) patients respectively. Satisfactory (good or moderate) restoration of venous blood-flow was noted following 3 weeks of anticoagulant therapy. Conclusions: In treatment of VTE, it is necessary to utilize a systematic approach, requiring use of appropriate antithrombotic therapy and monitoring its efficacy. Since the need for regular monitoring complicates therapy, when possible, rivaroxaban monotherapy may be considered as an option to simplify therapy. C0139 CT CHEST ANGIOGRAPHY SCAN REQUEST FOR THE DIAGNOSIS OF PULMONARY EMBOLISM IN EMERGENCY DEPARMENT P. Javier Marchena Yglesias1 . 1 Parc Sanitari Sant Joan de Deu, Barcelona, Spain Background: Pulmonary embolism (PE) is one component of venous thromboembolic disease with a high prevalence. In general population remains the third leading cause of outpatient cardiovascular death and the leading cause of hospital. Therefore, the diagnosis must be accurate and that sometimes is not easy. For diagnosis could be apply pre-test probability scores prior to conducting any imaging test. If they are moderate or high risk, the CT chest angiography scan is the imaging test of choice, leaving the pulmonary ventilation / perfusion as an alternative in case you cannot do it. To assess request of CT chest angiography scan to diagnosis or rule out PE, made from the emergency department, their suitability to the pretest probability scores and clinical characteristics outcomes. Methods: We reviewed the CT chest angiography scan requests from January to May 2013. Used demographic variables as well as the appropriateness of requests by pre-test probability scores, the patient’s clinical and accordingly the justification of the request. Results: A total of 340 CT chest angiography scan request for diagnosis of PE were performed in the study period (January– May 2013) throughout the hospital of which 135 (39%) were made from the Emergency Department. The mean age of the patients are 74.83±13.68 (33–97 years). 56% are male. Regarding risk factors for PE, 20% had cancer, 10.9% had had a previous VTE and 10.8% immobilization of more than 4 days. In 45% of cases did not have any risk factors. Only 18% of the patients underwent pre-test probability score, of which 16% achieved a result of intermediate probability. D-dimer was performed in 76% of patients with a positive result in 80% of cases. The main symptom to justify the request for the test image was dyspnea (38%), elevated D-dimer (17.8%), chest pain (14.5%), arterial blood gases (5.4%) alteration, syncope (5.4%), fever (3.2%) and others (6.4%). With the application of pre-test probability scores, the request were justified in 40% of them and only 27% of cases were positive to PE. After completion of the test 31% of the patients were discharged. Multivariate analysis of the data reveals that the confirmation of pulmonary embolism is associated with elevated levels of D-dimer >2000 (OR 1.70, 95% CI 1.51–1.91, p < 0.001) and the justification of the request based in intermediate and high levels of pre-test probability score (OR 2.69, 95% CI 2.55–2.83, p < 0.001). Conclusions: The number CT chest angiography scan request for the diagnosis of pulmonary embolism is high considering the low percentage of confirmatory diagnoses. Only 40% would be justified by objective criteria, with only 27% of confirmation. It should improve the performance of pre-test probability score to justify the requests and not based on D-dimer levels, which although high titers can make unfounded suspicion, may have alternative diagnoses.