Vitamin K antagonists versus low-molecular-weight heparin for the long term treatment of symptomatic venous thromboembolism

Injection Techniques to Reduce Adverse Effects of Subcutaneous Low-Molecular-Weight Heparin Among Patients With Cardiovascular Diseases: A Scoping Review

AIM(S)

To systematically review the existing literature and address the following research question: What are the most effective techniques used to minimise adverse effects resulting from subcutaneous injections of low-molecular-weight heparin among patients with cardiovascular diseases?

DESIGN

A scoping review.

METHODS

A comprehensive search was conducted across multiple databases, including CINAHL, PubMed, EMBASE and the Cochrane Library, from 1 February 2014 to 31 January 2024. Participants were aged 18 years or older, diagnosed with venous thromboembolism or arterial thromboembolism and had prescribed subcutaneous injections of low-molecular-weight heparin. The collected data were analysed following the Joanna Briggs Institute approach, and it was organised and categorised based on the main objectives of the review.

RESULTS

Twenty studies were eligible, including 1 best practice project, 7 randomised controlled trials and 9 quasi-experimental studies. The techniques under investigation encompassed various aspects, including the injection site, injection duration (e.g., 30 s vs. 10 s), injection method (e.g., needle insertion angle), duration of needle withdrawal after injection, pressure application time and cold pressure. Preliminary evidence suggests that techniques such as using the abdominal site and slower injection rates may help reduce adverse effects. However, the optimal parameters for injection duration, waiting time, pressure and cold application, including the duration of these applications, remain uncertain due to limitations in sample size and heterogeneity in interventions and outcome measures across the studies.

CONCLUSIONS

Ensuring the accurate administration of low-molecular-weight heparin is of utmost importance as it plays a critical role in decreasing mortality rates and minimising substantial healthcare costs linked to complications arising from incorrect administration. The findings from the current review have significantly contributed to strengthening the evidence base in this field, providing more robust and reliable information.

IMPLICATIONS FOR THE PROFESSION

This review emphasises the significance of implementing standardised subcutaneous injection techniques for low-molecular-weight heparin in patients with cardiovascular disease in order to reduce complications and enhance patient outcomes.

REPORTING METHOD

This study followed the applicable guidelines established by the PRISMA 2020 statement. The PRISMA checklist for systematic reviews was utilised for reporting purposes.

PATIENT OR PUBLIC CONTRIBUTION

There is no patient or public contribution to declare.

TRIAL REGISTRATION

OSF registries: osf.io/phk72.

Position Statement on In-hospital/Clinic Point-of-care Coagulation Testing for Anticoagulation Monitoring in Saudi Arabia

Objectives

Hospital overload is a persistent occurrence in daily practice. Interventions such as point-of-care testing (POCT) are needed to alleviate the pressure faced by healthcare providers and administrators.

Methods

An invited panel of experts from Saudi Arabia was formed under the auspices of the Saudi Heart Association in order to discuss local treatment gaps in the management of patients receiving anticoagulation therapy. This was done in a series of meetings, which resulted in the development of official recommendations for the implementation of POCT for anticoagulation monitoring in the country. Recommendations were based on a comprehensive literature review and international guidelines taking into consideration local clinical practice, clinical gaps, and treatment/testing availabilities.

Results

Vitamin K antagonist (VKA)-based anticoagulation therapy requires routine monitoring. POCT is a promising model of care for the monitoring of International Normalized Ratio (INR) in patients receiving oral anticoagulation in terms efficacy, safety and convenience. The availability of POC INR testing should not replace the use of standard laboratory anticoagulation monitoring. However, there are several indications for implementing POCTINR monitoring that was agreed upon by the expert panel. POCT for anticoagulation monitoring should primarily be used in the warfarin (or other VKA) monitoring clinic in order to ensure treatment efficiency, cost-effectiveness of care, patient satisfaction, and quality of life improvement. The expert panel detailed the requirements for the establishment of a warfarin (or other VKA) monitoring clinic in terms of organization, safety, quality control, and other logistic and technical considerations. The limitations of POCT should be recognized and recommendations on best practices should be strictly followed. Core laboratory confirmation should be sought for patients with higher INR results (>4.7) on POCT. Proper training, quality control, and regulatory oversight are also critical for preserving the accuracy and reliability of POCT results.

Conclusions

POCT enables more rapid clinical decision-making in the process of diagnosis (rule-in or rule-out), treatment choice and monitoring, and prognosis, as well as operational decision-making and resource utilization. POCT thus can fulfill an important role in clinical practice, particularly for patients receiving VKAs.

TILE pilot trial study protocol: Tinzaparin Lead-in to Prevent the Post-Thrombotic syndrome study protocol

INTRODUCTION

The post-thrombotic syndrome (PTS) is a form of chronic venous insufficiency due to a prior ipsilateral deep venous thrombosis (DVT). This is a frequent complication that develops in 20%-50% of patients after a proximal DVT and is associated with significant healthcare, economic and societal consequences. In the absence of effective and well-tolerated treatment options for established PTS, effective preventative measures are needed. Anticoagulation itself reduces the risk of PTS, and low-molecular-weight heparin may reduce this further through anti-inflammatory properties targeting the initial acute inflammatory phase of DVT.

METHODS AND ANALYSIS

The Tinzaparin Lead-In to Prevent the Post-Thrombotic syndrome pilot trial is an investigator-initiated, multicentre, open-label assessor-blinded trial that will randomise patients with first acute symptomatic common femoral or iliac DVT to receive either a 3-week lead-in course of tinzaparin, followed by rivaroxaban (experimental arm) or rivaroxaban alone (control arm). Its primary objectives are to assess: (1) proportion of PTS at 6 months using the Villalta scale and (2) study feasibility, which consists of (a) the proportion of screened patients eligible for the study, (2) the proportion of eligible patients recruited and (c) the proportion of recruited patients adherent to treatment (defined as at least 80% of drug taken). This study will determine the feasibility of a subsequent larger definitive trial. Secondary outcomes include change of quality of life scores, PTS severity, global improvement, patient satisfaction, bleeding, recurrent venous thromboembolism, leg pain, death and lost to follow-up. Target recruitment will be a total of 60 participants, recruited at 5-6 centres.

ETHICS AND DISSEMINATION

Primary ethics approval was received from the Sunnybrook Health Sciences Center Research Ethics Board (approval ID 3315). Results of the study will be disseminated via peer-reviewed presentation at scientific conferences and open access publication.

TRIAL REGISTRATION NUMBER

NCT04794569.

Iliocaval Reconstruction: Review of Technique, Challenges, and Outcomes

Iliocaval thrombosis is a major source of morbidity for patients, with a range of clinical presentations, including recurrent lower extremity deep venous thrombosis and postthrombotic syndrome. Endovascular reconstruction of chronic iliocaval occlusion has been demonstrated to be a technically feasible procedure that provides long-lasting symptom relief in combination with antithrombotic therapy and close clinical monitoring. Herein, we describe the etiologies of iliocaval thrombosis, patient assessment, patient management prior to and after intervention, procedural techniques, and patient outcomes.

Is alteration in single drug anticoagulant/antiplatelet regimen necessary in patients who need minor oral surgery? A systematic review with meta-analysis

OBJECTIVE

This study aimed to systematically review literature about the effect of alteration of the pharmacological regimen in adult patients using anticoagulants or antiplatelets who need minor oral surgery.

MATERIAL AND METHODS

A search strategy was performed in three databases-PubMed-Medline, Scopus, and Embase-and included randomized clinical trials (either parallel or crossover), involving individuals under anticoagulant or antiplatelet therapy who underwent oral surgeries. Studies comprised two groups: those who stopped their medication prior to the dental procedure (control) or those who did not (test). Meta-analyses were conducted for the pooled risk ratio (RR) between the groups. Subgroup analyses were performed for anticoagulant and antiplatelet therapies.

RESULTS

Thirteen studies were included. It was found that patients who did not stop therapy had 157% higher intraoperative bleeding occurrences (95%CI: 1.40-4.71). In the subgroup analysis, warfarinazed patients showed significantly higher occurrences of intraoperative bleeding when compared with the control (RR: 1.79; 95%CI: 1.00-3.21). Conversely, there was no statistically significant difference in postoperative bleeding between the groups (RR: 0.81; 95%CI: 0.54-1.22; p = 0.42).

CONCLUSION

Minor oral surgeries can be safely performed in patients under antiplatelets or anticoagulants without drug regimen modification. Because these patients tend to bleed more during procedures, use of local hemostatic measures is strongly advised.

CLINICAL RELEVANCE

Management of patients under antiplatelet or anticoagulant drugs is still challenging in clinical practice. However, clinicians may perform minor oral surgeries safely without changing the pharmacological regimen. Use of local hemostatic measures is strongly advised during these procedures.