Clinical and Safety Outcomes Associated With Treatment of Acute Venous Thromboembolism: A Systematic Review and Meta-Analysis

Perspective:

This network systematic review and meta-analysis describes the outcomes and safety of treatment for acute venous thromboembolism (VTE) in almost 45,000 patients. The following are seven key points to remember:

1. Use of unfractionated heparin (UFH) plus warfarin was associated with a higher risk of recurrent VTE (hazard ratio [HR], 1.42; 95% confidence interval [CI], 1.15-1.79) compared to use of low molecular weight heparin (LMWH) plus warfarin for initial therapy.

2. In the first 3 months of treatment for an acute VTE, use of UFH plus warfarin was associated with recurrence in 1.84% (95% CI, 1.33-2.51%) of patients, compared to 1.30% (95% CI, 1.02-1.62%) for the LMWH plus warfarin-treated group.

3. Rivaroxaban use was associated with a lower risk of bleeding (HR, 0.55; 95% CI, 0.35-0.89) and fewer major bleeding events in the first 3 months (HR, 0.49%; 95% CI, 0.29-0.85%) compared to LMWH plus warfarin.

4. Apixaban use was associated with a lower risk of bleeding (HR, 0.31; 95% CI, 0.15-0.62) and fewer major bleeding events in the first 3 months (HR, 0.28%; 95% CI, 0.14-0.50%) compared to LMWH plus warfarin.

5. There was no difference in the risk of recurrent VTE or major bleeding when comparing LMWH plus warfarin to fondaparinux plus warfarin, LMWH plus dabigatran, LMWH plus edoxaban, or LMWH therapy alone.

  1. There was also no statistically significant difference when stratified by treatment for deep vein thrombosis (DVT) or pulmonary embolism (PE).

  2. Comparing the effectiveness of individual strategies for patients with cancer-associated VTE was not assessed in this analysis. Similarly, the effect of different treatment strategies based on the provoked nature of a VTE was not assessed in this analysis.

6. Despite the data suggesting use of UFH plus warfarin to be inferior to LMWH plus warfarin, certain clinical situations (e.g., patients with severe renal dysfunction) might necessitate the use of the UFH strategy.

7. Use of oral anticoagulation only with either rivaroxaban or apixaban appears to be equally efficacious in prevention of recurrent VTE with the advantage of lower bleeding risk when compared to most of the other treatment strategies.

Clinical Topics: Anticoagulation Management, Pulmonary Hypertension and Venous Thromboembolism, Vascular Medicine, Anticoagulation Management and Venothromboembolism

Keywords: Neoplasms, Heparin, Low-Molecular-Weight, Pulmonary Embolism, Warfarin, Venous Thromboembolism, Venous Thrombosis


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