Treatment of established deep vein thrombosis: a review of the therapeutic armamentarium.
Although it has never been evaluated by an appropriately designed clinical trial, there is a strong impression that acute symptoms of deep vein thrombosis (DVT) and pulmonary embolism (PE) are improved by heparin treatment. The first experimental evidence showing that anticoagulants were effective in reducing mortality from PE came in landmark study by Barritt and Jordon in Lancet in 1960. In 1986, Hull et al demonstrated that failure to attain an adequate anticoagulant effect with heparin in patients with proximal vein thrombosis is associated with a high rate of recurrence. Current practice favors admission to the hospital of patients with venous thromboembolism to be treated with intravenous (IV) heparin for at least 4-5 days, overlapped with initiation of warfarin. Four randomized trials evaluating continuous intravenous (CIV) vs. subcutaneous (SQ) heparin administration in the treatment of DVT found no significant differences in the observed rates of clinically important events. Thus, SQ route heparin is as efficacious and would allow treatment at home. Low molecular weight heparins, when released by the FDA for this indication, will make this more feasible.
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