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Anticoagulation therapy for serious blood clots during pregnancy

Pregnant women are more susceptible than non‐pregnant women to forming blood clots in their veins (venous thrombosis). When these clots occur in the deep leg veins, the clot can break up and fragments (emboli) move to the lungs where they may block the blood flow to the lungs (pulmonary embolism). This can have serious consequences. Anticoagulants are used to treat clots and are given to pregnant women with increased susceptibility to clotting. These medications thin the blood to reduce the risk of the further thrombosis and reduce the risk of pulmonary embolism. An important complication of treatment is haemorrhage. During pregnancy heparin is the most common anticoagulant used, either the older unfractionated heparin (UFH) or the newer low molecular weight heparin (LMWH). Neither of these cross the placenta, and both have been shown to be safe during pregnancy, whereas there are concerns that warfarin may affect the fetus. LMWH has been shown to be more effective than UFH outside pregnancy.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2010

Heparins and some mechanical pumping devices may help prevent blood clots forming in the legs after surgery for hip fracture

Patients with hip fracture may develop blood clots (thrombosis) in their legs. Some of these blood clots may travel to the lungs and cause a blockage (embolism), which can be fatal. Various drugs and physical devices are sometimes used to try and prevent these complications. This review of randomised trials found that both heparins and mechanical pumping devices significantly decrease the incidence of deep vein thrombosis. There was not enough evidence to conclude about the effect on lung (pulmonary) embolism, mortality or possible side effects for either heparin or mechanical methods.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2008

Blood thinners to prevent blood clots in people with cancer and central venous catheters

A central venous catheter (CVC) is a tube that is inserted into a large vein to give fluids or drugs. CVC placement increases the risk of blood clots in people with cancer. This systematic review evaluated the efficacy and safety of blood thinning agents (anticoagulants) in people with cancer.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2014

Anticoagulants compared with anti‐inflammatory drugs or placebo for treating people who have venous blood clots

A blood clot can block a venous blood vessel to cause what is known as a thromboembolism. This most often occurs in a leg (deep vein thrombosis) or in the lungs (pulmonary embolism), which can be fatal. Once formed, a blood clot in a leg can increase in size or can move to the lungs and the recommended treatment is to give drugs that thin the blood (anticoagulants). These include heparins and drugs that inhibit the action of vitamin K (warfarin, phenprocoumon, and acenocoumarol). The possible harms caused by anticoagulants include bleeding in the gut or brain and anticoagulant‐induced clotting. The review authors made a thorough search of the medical literature looking for controlled studies on people with blood clots in their veins comparing blood thinning drugs (anticoagulants) with drugs to reduce inflammation (non‐steroidal anti‐inflammatory drugs) or dummy treatment (placebo). Only two small studies with a total of 113 participants treated over three months were identified, which gave inconclusive results. Since the use of anticoagulants is widely accepted in clinical practice, designing and implementing other similar studies would not be ethical.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2008

Central venous access sites to prevent venous blood clots, blood vessel narrowing, and infection

Central venous access (CVA) involves a large bore catheter inserted in a vein in the neck, upper chest or groin (femoral) area to give drugs that cannot be given by mouth or via a conventional needle (cannula or tube in the arm). CVA is widely used. However, its thrombotic (causing a blood clot) and infectious complications can be life‐threatening and involve high‐cost therapy. Research has revealed that the risk of catheter‐related complications varies according to the sites of central venous catheter (CVC) insertion. It would be helpful to find the preferred site of insertion to minimize the risk of catheter‐related complications. This review examined whether there was any evidence to show that CVA through any one site (neck, upper chest, or femoral area) is better than the other. Four studies were identified comparing data from 1513 participants. For the purpose of this review, three comparisons were evaluated: 1) internal jugular versus subclavian CVA routes; 2) femoral versus subclavian CVA routes; and 3) femoral versus internal jugular CVA routes. We compared short‐term and long‐term catheter insertion. We defined long‐term as for more than one month and short‐term as for less than one month, according to the Food and Drug Administration (FDA). No randomized controlled trial was found comparing all three CVA routes and reporting the complications of venous stenosis.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2012

Vitamin K antagonists or low‐molecular‐weight heparin for the long term treatment of symptomatic blood clots

Blood clots (venous thromboembolism) sometimes cause blockages in veins after surgery, bed rest, or spontaneously. These clots can be fatal when they travel to the lungs. Vitamin K antagonists are effective in preventing renewed blood clot formation, by thinning the blood. Low‐molecular‐weight heparins (LMWHs) are drugs that also thin the blood but they are expensive and are used for pregnant women or people who are at greater risk of major bleeding and cannot take vitamin K antagonists. This systematic review of 15 trials with a combined total of 3197 patients found no statistically significant differences in the safety and effectiveness of LMWH compared with vitamin K antagonists. More research about the best way to treat blood clots in the veins in long term treatment is needed.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2012

Fixed daily dose of a low molecular weight heparin compared with an adjusted dose of unfractionated heparin for treating blood clots in the deep veins

Venous thromboembolism (VTE) is a condition in which a blood clot forms in the deep veins of the leg or pelvis (DVT) or the clot travels in the blood and blocks a blood vessel in the lungs (pulmonary embolism (PE)). The chances of getting a VTE can be increased if people have risk factors such as previous clots, prolonged periods of immobility (such as travelling on aeroplanes or bed rest), cancer, exposure to oestrogens (pregnancy, oral contraceptives or hormone replacement therapy), trauma and blood disorders such as thrombophilia (abnormal blood clotting). People with a VTE are treated with an anticoagulant, which prevents further clots from forming. Heparin is an anticoagulant and comes in two forms: low molecular weight heparin (LMWH) or unfractionated heparin (UFH). UFH is an older drug and is given either intravenously or by injection. When administering UFH, clinicians have to monitor blood‐clotting factors carefully and adjust the dose, because of the variability of its effect. LMWH is given by subcutaneous injection once or twice a day and does not need to be monitored as closely as UFH.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2017

Drugs to break down blood clots for people with sudden onset peripheral arterial occlusion

Acute reduction in blood flow to a limb can be caused by a blood clot blocking an artery or a vascular graft. If not treated promptly this condition, known as peripheral arterial occlusion, can result in amputation or be life threatening. Infusion of clot‐busting drugs can restore blood flow by dissolving the clot (thrombolysis). This review found some evidence from five randomized controlled trials, involving a total of 687 patients that suggested local infusion of a drug into the affected artery is more effective than infusion into a vein, and is also associated with a lower risk of unwanted bleeding. No particular drug was more effective in preventing limb loss or death than another. The drugs investigated were streptokinase, urokinase, recombinant tissue plasminogen activator and pro‐urokinase. More research is needed to confirm these findings. All of the findings of this review came from small studies that involved people with peripheral arterial ischaemia of differing severity.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2014

Preventing death from blood clots, the formation of blood clots and blood clots in the lungs in people who have had physical trauma

Thromboembolism (unwanted clotting of the blood) is a frequent complication in people who have experienced physical trauma and is also an important cause of death. The type of trauma, association with vascular injuries, and prolonged hospital bed rest are known risk factors for the development of deep vein thrombus (clot in veins of lower extremities) that can travel (embolize) to the lungs and cause death. Because of this it is usually recommended that people who have had major trauma are given mechanical or pharmacological treatments to prevent their blood forming unwanted blood clots. Mechanical interventions can include compression stockings, an air‐filled plastic tube that presses around the leg, a metal blood clot filter placed inside a vein; pharmaceutical drugs include unfractionated heparin, low weight molecular heparin, anticoagulants (e.g. warfarin), antiplatelet drugs (e.g. aspirin) and others. Sixteen studies involving 3,005 people are included in this review. We did not find strong evidence that either mechanical or pharmacological interventions reduce death or clots travelling to the lungs, but we found some evidence that they can prevent clots from forming in the legs.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2013

What are blood clots and what causes them?

When we injure ourselves and start to bleed, our bodies make sure that the bleeding soon stops by forming a clump of blood (a blood clot) that closes the wound. Sometimes blood clots form in the bloodstream even though there are no external injuries. This can lead to thrombosis, a heart attack or stroke.

Informed Health Online [Internet] - Institute for Quality and Efficiency in Health Care (IQWiG).

Version: December 27, 2016

Deep vein thrombosis (DVT): Leg in a cast: When does it make sense to use injections for blood clot prevention?

If someone has their leg in a plaster cast or brace and can’t move it for a long period of time, they are at increased risk of deep vein thrombosis. Injections to prevent blood clots are then recommended. In all other cases, getting back on your feet again as soon as possible is enough.

Informed Health Online [Internet] - Institute for Quality and Efficiency in Health Care (IQWiG).

Version: March 23, 2017

Blood thinners for the initial treatment of blood clots in patients with cancer

Patients with cancer are at an increased risk of blood clots. The blood thinner (anticoagulant) administered in the first few days can consist of unfractionated heparin (infused intravenously) or low molecular weight heparin (injected subcutaneously once or twice per day). These two blood thinners may have different effectiveness and safety profiles.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2015

There is not enough evidence to determine if anticoagulants safely prevent blood clots in patients with chronic heart failure who are in normal heart rhythm

Blood clots (thromboembolism) in the lungs, legs and brain (ischaemic stroke) contribute to disability and the death of patients with heart failure. Although anticoagulants such as warfarin are of proven benefit in patients in certain subgroups of patients with heart failure, such as those with atrial fibrillation, there is little evidence that warfarin works well in the wider heart failure population. There may also be serious side effects such as bleeding (causing ulcers and haemorrhagic stroke). At present there are no data to recommend the routine use of anticoagulants to prevent thromboembolism in patients with heart failure who are in normal heart rhythm.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2014

Fibrinogen depleting agents may help to remove blood clots in acute ischaemic stroke

Fibrinogen depleting agents are promising but unproven for acute ischaemic stroke. Most strokes are due to a blood clot blocking an artery in the brain. Fibrinogen depleting agents may help remove the blood clot to restore the blood supply to the brain and so improve the chance of making a recovery from the stroke. Fibrinogen depleting agents also reduce blood thickness (or viscosity), which also helps to improve blood flow to the brain. However, these agents can also cause serious bleeding in the brain. Evidence from this updated review, which includes eight trials involving 5701 participants, indicates that there is currently not sufficient evidence to support the routine use of fibrinogen depleting agents for the treatment of acute ischaemic stroke. Further trials are needed to determine reliably whether there is worthwhile benefit, and if so, which categories of patients are most likely to benefit.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2013

Oral anticoagulation plus an antiplatelet drug is better than anticoagulants alone for reducing death or blood clots after heart valve replacement

After heart valve replacement oral anticoagulation (a blood thinner) is frequently used to keep blood clots from forming on the valve. These blood clots can block the flow of blood through the valve or break off and cause a stroke. Blood thinners, such as coumadin, reduce the risk of these outcomes and require careful monitoring. Drugs that affect the platelets, such as aspirin, are not effective alone but may add benefit to the blood thinners. This updated review of 13 trials found that oral anticoagulation and antiplatelet drugs were more effective than anticoagulation alone. The addition of antiplatelet drugs to anticoagulants increases the risk of bleeding by about 50%. Low‐dose aspirin (less than 100 mg daily) may be associated with the lowest risk of bleeding. However, in general the quality of the included trials tended to be low, possibly reflecting the era when the majority of the trials were conducted (1970s and 1980s when trial methodology was less advanced).

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2013

Prolonged administration of low molecular weight heparin lowers the number of blood clots in the lower limbs after operation in the abdomen or pelvis

Patients subjected to major surgery of the abdomen are at considerable risk of developing blood clots in the veins of the lower limbs. These clots may detach and develop clots in the lungs and cause sudden death. Clots in the limbs may impaire the venous function leading to a life‐long tendency to swollen legs and leg ulceration. In order to avoid these complications patients are often offered protective medicine during the first week after surgery, but patients are probably at risk of developing clots up to one month after surgery. This review suggests that prophylaxis should be administered for at least one month after surgery.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2009

Prevention of blood clots in non‐hospitalised cancer patients receiving chemotherapy

Cancer patients are more likely than people without cancer to develop blood clots in their veins (known as venous thromboembolism). Chemotherapy further increases this risk. Yet a number of factors specific to the cancer, such as the bleeding tendency at the site of the cancer, or a relative decrease in the number of platelets in the blood (thrombocytopenia) caused by chemotherapy can increase the likelihood that cancer patients will have bleeding complications with medicines used to prevent and treat blood clots (anticoagulants). This systematic review looked at the effectiveness and safety of anticoagulants when used to prevent blood clots in cancer patients receiving chemotherapy.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2017

Blood thinners for the long‐term treatment of blood clots in patients with cancer

Patients with cancer are at an increased risk of developing blood clots and might respond differently to blood thinners (anticoagulants) compared with patients without cancer.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2014

Preventing Blood Clots After Hip or Knee Replacement Surgery or Surgery for a Broken Hip: A Review of the Research for Adults

This summary covers what research says about the possible benefits and side effects of treatments to help prevent a blood clot after hip or knee surgery. Treatment options include medicines that thin your blood and devices that increase blood flow in your legs (leg or foot coverings that inflate and deflate or elastic stockings). This summary can help you discuss these options with your doctor.

Comparative Effectiveness Review Summary Guides for Consumers [Internet] - Agency for Healthcare Research and Quality (US).

Version: August 30, 2012

Once versus twice daily injections of low molecular weight heparin for the initial treatment of blood clots in the veins

Blood clots in the veins (venous thromboembolism (VTE)) can develop spontaneously or after surgery or bed rest. Venous thromboembolism can be life threatening if clots travel to the lungs. Blood‐thinning drugs such as heparin are used to dissolve clots. Low molecular weight heparin (LMWH) can be given by injection, enabling people to leave hospital. The usual treatment is two injections a day, but once a day would be more convenient. This review included five studies with a combined total of 1508 participants. The combined data showed no statistically significant difference in recurrent VTE between the once daily and twice daily treatment regimens. A comparison of major bleeding events, improvement of the blood clot size and death also showed no statistically significant difference between the two treatment regimens. None of the five included studies reported information on post‐thrombotic syndrome (ongoing swelling of the affected leg, pain, and skin changes). One daily injection with LMWH is therefore as effective and safe as twice daily injections.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2015

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