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Current management of venous thromboembolic disease
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the pedestrian on where to look before crossing the street; but I don’t remember seeing any of these in Oxford.
0 CURRENT MANAGEMENT OF VENOUS THROMBOEMBOLIC DISEASE. McCann RL, Sabiston DC. Br J Surg. 1989;76:113-14. This paper reviews current management of venous thromboembolic disease, as the management still remains controversial. Surgical thrombectomy, which had been abandoned because of the high rate of rethrombosis, has had a resurgence and is recommended for severe iliofemoral venous thrombosis causing phlegmasia cerulea dolens or phlegmasia alba dolens. For the management of acute pulmonary emboli, treatment with heparin cuts mortality in half (30% to 15%) compared to no treatment. Since heparin prevents extension of existing clot but only a small amount of clot lysis occurs, fibrinolytic therapy has been recommended by some for extensive venous thrombosis not requiring immediate surgical decompression. However, fibrinolytic therapy is associated with a 2.9 times greater incidence of bleeding complications than with herparin. While fibrinolytic agents have been shown to improve clot lysis, they have not been shown to improve mortality or improve pulmonary function either early or late over heparin use alone. With the increased incidence of bleeding complications with fibrinolytic agents, they are recommended only for patients with hemodynamic compromise but who do not require immediate [Paul Howes, MD] surgical embolectomy. Editor’s Note: It will be interesting to follow the management of peripheral thrombophlebitis with fibrinolytic therapy, and to see if this would diminish the incidence of pulmonary emboli as well as the need for long-term anticoagulation.
?? HEPATIC TRAUMA; RISK FACTORS INFLUENCING OUTCOME. Pretre R, Mentha B, Huber 0, Meyer P, Vogel J, Rohner A. Br J Surg. 1988;75:520-4. This is a retrospective analysis of factors affecting outcome in 99 patients who underwent laparotomy for hepatic trauma between 1977 and 1986. Blunt trauma accounted for 88% of cases and was associated with a 36% mortality. Eleven patients had penetrating trauma, 7 stab wounds, and 4 gunshot wounds, for which mortality was 14% and 50%, respectively. The number of organ systems involved had a linear relationship to mortality. Mortality was 5% when only the abdomen was injured, 25% with 1 other system involved, 45% with 2 other systems, 79% with 3 other systems, and 100% when 4 other systems were involved. Preoperative shock was present in 66% of patients who went to die compared with 27% of survivors, reflecting an increase in mortality from 20% to 58 % . Mortality was greater in those greater than 50 years of age compared to those younger, 63% compared with 30%. Six of the 35 deaths were due solely to hepatic injuries. [Paul Howes, MD]
The Journal of Emergency Medicine
0 MULTICENTER TRIAL OF INTRAVENOUS ANISOYLATED PLASMINOGEN STREPTOKINASE ACTIVATOR COMPLEX (APSAC) IN ACUTE MYOCARDIAL INFARCTION. Bassand JP, Machecourt J, Cassagnes J, et al. JACC. 1989;13:988-97. Within 5 hours of onset of symptoms 231 patients with first acute myocardial infarction were randomly allocated to treatment with anisoylated plasminogen streptokinase activated complex (APSAC), 30 units over 5 minutes, or to conventional heparin therapy, 5,000 units in a bolus injection. Heparin was reintroduced in both groups 4 hours after initial therapy at a dosage of 500 II-l/kg/day. Both groups were similar in age, location of infarction, functional class, and time of randomization. Coronary arteriography and thallium computed tomography were performed before hospital discharge. The patency rate of infarct-related artery was 77% in the APSAC group and 36% in the heparin group (PcO.001). Left ventricular ejection fraction determined from contrast angiography was significantly higher in the APSAC group than in the heparin group. This was true for the entire study group (0.53 +0.13 versus 0.47 hO.12, P=.OO2) as well as for the subgroups of patients with anterior and inferior wall infarction. At 3 weeks the difference remained significant for the anterior myocardial infarction subgroup. A significant 3 1% reduction in infarct size was found in the APSAC group. By the end of a 3-week follow-up period, seven APSAC patients and six heparin patients had died. The authors conclude that early infusion of APSAC in acute myocardial infarction produced a high early patency rate, significant limitation of infarct size, and significant preservation of left ventricular systolic function, mainly in anterior wall infarction. [Napoleon Knight, MD]
0 QUANTITATIVE RADIONUCLIDE ASSESSMENT OF REGIONAL VENTRICULAR FUNCTION AFTER THROMBOLYTIC THERAPY FOR ACUTE MYOCARDIAL INFARCTION; RESULTS OF PHASE I THROMBOLYSIS IN MYOCARDIAL INFARCTION (TIMI) TRIAL. Wackers FJ, Temn ML, Kayden DS, Braunwald E, Zaret BL et al. JACC. 1989;13:998-1005. The thrombolysis in myocardial infarction (TIMI) trial has been in progress since August 1984. Phase I, completed in February 1989, was conducted to establish the relative thrombolytic attributes of intravenous recombinant type plasminogen activator (rt-pa) in comparison with intravenous streptokinase. Coronary angiographic evidence of infarct-related vessel patency was used as the primary study end point. In the TIM1 phase I trial, it was demonstrated that significantly greater recanalization occurred after treatment with rt-pa than with streptokinase. In this trial, 290 patients with acute myocardial infarction were randomized to either rt-pa or streptokinase (IV). At discharge, 229 patients had radionuclide ventriculograms for assessment of global and regional left ventricular ejection fraction. Among these 229 patients, 185 had totally occluded infarct-related arteries. angiographic reperfusion of the infarct-related artery occurred in 69% of patients treated with
the pedestrian on where to look before crossing the street; but I don’t remember seeing any of these in Oxford.
0 CURRENT MANAGEMENT OF VENOUS THROMBOEMBOLIC DISEASE. McCann RL, Sabiston DC. Br J Surg. 1989;76:113-14. This paper reviews current management of venous thromboembolic disease, as the management still remains controversial. Surgical thrombectomy, which had been abandoned because of the high rate of rethrombosis, has had a resurgence and is recommended for severe iliofemoral venous thrombosis causing phlegmasia cerulea dolens or phlegmasia alba dolens. For the management of acute pulmonary emboli, treatment with heparin cuts mortality in half (30% to 15%) compared to no treatment. Since heparin prevents extension of existing clot but only a small amount of clot lysis occurs, fibrinolytic therapy has been recommended by some for extensive venous thrombosis not requiring immediate surgical decompression. However, fibrinolytic therapy is associated with a 2.9 times greater incidence of bleeding complications than with herparin. While fibrinolytic agents have been shown to improve clot lysis, they have not been shown to improve mortality or improve pulmonary function either early or late over heparin use alone. With the increased incidence of bleeding complications with fibrinolytic agents, they are recommended only for patients with hemodynamic compromise but who do not require immediate [Paul Howes, MD] surgical embolectomy. Editor’s Note: It will be interesting to follow the management of peripheral thrombophlebitis with fibrinolytic therapy, and to see if this would diminish the incidence of pulmonary emboli as well as the need for long-term anticoagulation.
?? HEPATIC TRAUMA; RISK FACTORS INFLUENCING OUTCOME. Pretre R, Mentha B, Huber 0, Meyer P, Vogel J, Rohner A. Br J Surg. 1988;75:520-4. This is a retrospective analysis of factors affecting outcome in 99 patients who underwent laparotomy for hepatic trauma between 1977 and 1986. Blunt trauma accounted for 88% of cases and was associated with a 36% mortality. Eleven patients had penetrating trauma, 7 stab wounds, and 4 gunshot wounds, for which mortality was 14% and 50%, respectively. The number of organ systems involved had a linear relationship to mortality. Mortality was 5% when only the abdomen was injured, 25% with 1 other system involved, 45% with 2 other systems, 79% with 3 other systems, and 100% when 4 other systems were involved. Preoperative shock was present in 66% of patients who went to die compared with 27% of survivors, reflecting an increase in mortality from 20% to 58 % . Mortality was greater in those greater than 50 years of age compared to those younger, 63% compared with 30%. Six of the 35 deaths were due solely to hepatic injuries. [Paul Howes, MD]
The Journal of Emergency Medicine
0 MULTICENTER TRIAL OF INTRAVENOUS ANISOYLATED PLASMINOGEN STREPTOKINASE ACTIVATOR COMPLEX (APSAC) IN ACUTE MYOCARDIAL INFARCTION. Bassand JP, Machecourt J, Cassagnes J, et al. JACC. 1989;13:988-97. Within 5 hours of onset of symptoms 231 patients with first acute myocardial infarction were randomly allocated to treatment with anisoylated plasminogen streptokinase activated complex (APSAC), 30 units over 5 minutes, or to conventional heparin therapy, 5,000 units in a bolus injection. Heparin was reintroduced in both groups 4 hours after initial therapy at a dosage of 500 II-l/kg/day. Both groups were similar in age, location of infarction, functional class, and time of randomization. Coronary arteriography and thallium computed tomography were performed before hospital discharge. The patency rate of infarct-related artery was 77% in the APSAC group and 36% in the heparin group (PcO.001). Left ventricular ejection fraction determined from contrast angiography was significantly higher in the APSAC group than in the heparin group. This was true for the entire study group (0.53 +0.13 versus 0.47 hO.12, P=.OO2) as well as for the subgroups of patients with anterior and inferior wall infarction. At 3 weeks the difference remained significant for the anterior myocardial infarction subgroup. A significant 3 1% reduction in infarct size was found in the APSAC group. By the end of a 3-week follow-up period, seven APSAC patients and six heparin patients had died. The authors conclude that early infusion of APSAC in acute myocardial infarction produced a high early patency rate, significant limitation of infarct size, and significant preservation of left ventricular systolic function, mainly in anterior wall infarction. [Napoleon Knight, MD]
0 QUANTITATIVE RADIONUCLIDE ASSESSMENT OF REGIONAL VENTRICULAR FUNCTION AFTER THROMBOLYTIC THERAPY FOR ACUTE MYOCARDIAL INFARCTION; RESULTS OF PHASE I THROMBOLYSIS IN MYOCARDIAL INFARCTION (TIMI) TRIAL. Wackers FJ, Temn ML, Kayden DS, Braunwald E, Zaret BL et al. JACC. 1989;13:998-1005. The thrombolysis in myocardial infarction (TIMI) trial has been in progress since August 1984. Phase I, completed in February 1989, was conducted to establish the relative thrombolytic attributes of intravenous recombinant type plasminogen activator (rt-pa) in comparison with intravenous streptokinase. Coronary angiographic evidence of infarct-related vessel patency was used as the primary study end point. In the TIM1 phase I trial, it was demonstrated that significantly greater recanalization occurred after treatment with rt-pa than with streptokinase. In this trial, 290 patients with acute myocardial infarction were randomized to either rt-pa or streptokinase (IV). At discharge, 229 patients had radionuclide ventriculograms for assessment of global and regional left ventricular ejection fraction. Among these 229 patients, 185 had totally occluded infarct-related arteries. angiographic reperfusion of the infarct-related artery occurred in 69% of patients treated with