Dataset Information

Bed rest versus early ambulation with standard anticoagulation in the management of deep vein thrombosis: a meta-analysis.

ABSTRACT:

Introduction

Bed rest has been considered as the cornerstone of management of deep vein thrombosis (DVT) for a long time, though it is not evidence-base, and there is growing evidence favoring early ambulation.

Methods

Electronic databases including Medline, PubMed, Cochrane Library and three Chinese databases were searched with key words of "deep vein thrombosis", "pulmonary embolism", "venous thrombosis", "bed rest", "immobilization", "mobilization" and "ambulation". We considered randomized controlled trials, prospective or retrospective cohort studies that compared the outcomes of acute DVT patients managed with early ambulation versus bed rest, in addition to standard anticoagulation. Meta-analysis pertaining to the incidence of new pulmonary embolism (PE), progression of DVT, and DVT related deaths were conducted, as well as the extent of remission of pain and edema.

Results

13 studies were included with a total of 3269 patients. Compared to bed rest, early ambulation was not associated with a higher incidence of new PE, progression of DVT, or DVT related deaths (RD -0.03, 95% CI -0.05? -0.02; Z = 1.24, p = 0.22; random effect model, Tau2 = 0.01). Moreover, if the patients suffered moderate or severe pain initially, early ambulation was related to a better outcome, with respect to remission of acute pain in the affected limb (SMD 0.42, 95%CI 0.09?0.74; Z = 2.52, p = 0.01; random effect model, Tau2 = 0.04). Meta-analysis of alleviation of edema cannot elicit a solid conclusion because of significant heterogeneity among the few studies.

Conclusions

Compared to bed rest, early ambulation of acute DVT patients with anticoagulation was not associated with a higher incidence of new PE, progression of DVT, and DVT related deaths. Furthermore, for the patients suffered moderate or severe pain initially, a better outcome can be seen in early ambulation group, regarding to the remission of acute pain in the affected limb.

SUBMITTER: Liu Z

PROVIDER: S-EPMC4393252 | biostudies-literature | 2015

REPOSITORIES: biostudies-literature

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Publications

Bed rest versus early ambulation with standard anticoagulation in the management of deep vein thrombosis: a meta-analysis.

Liu Zhenlei Z Tao Xixi X Chen Yuexin Y Fan Zhongjie Z Li Yongjun Y

PloS one 20150410 4

<h4>Introduction</h4>Bed rest has been considered as the cornerstone of management of deep vein thrombosis (DVT) for a long time, though it is not evidence-base, and there is growing evidence favoring early ambulation.<h4>Methods</h4>Electronic databases including Medline, PubMed, Cochrane Library and three Chinese databases were searched with key words of "deep vein thrombosis", "pulmonary embolism", "venous thrombosis", "bed rest", "immobilization", "mobilization" and "ambulation". We consider ...[more]

PMID: 25860350

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Project description:BackgroundIn patients with acute deep vein thrombosis (DVT), pharmacomechanical catheter-directed thrombolysis (PCDT) in conjunction with anticoagulation therapy is increasingly used with the goal of preventing postthrombotic syndrome. Long-term costs and cost-effectiveness of these 2 treatment strategies from the perspective of the US healthcare system have not been compared.Methods and resultsBetween 2009 and 2014, the ATTRACT trial (Acute Venous Thrombosis: Thrombus Removal With Adjunctive Catheter-Directed Thrombolysis) randomized 692 patients with acute proximal DVT to PCDT plus anticoagulation (n=337) or standard treatment with anticoagulation alone (n=355). Costs (2017 US dollars) were assessed over a 24-month follow-up period using a combination of resource-based costing, hospital bills, Medicare reimbursement rates, and the Drug Topics Red Book. Health state utilities were obtained from the Short Form-36. In-trial results and US life tables were used to develop a Markov cohort model to evaluate lifetime cost-effectiveness. For the PCDT group, mean costs of the initial procedure were $13 600; per-patient costs associated with the index hospitalization were $21 509 for PCDT and $3877 for standard care (difference=$17 632; 95% CI, $16 117-$19 243). The 24-month difference in costs was $20 045 (95% CI, $16 093-$24 120). Utility scores increased significantly between baseline and 6 months for both groups, with no significant differences between groups at any follow-up time point. Projected differences in lifetime costs of $16 740 and quality-adjusted life years (QALYs) of 0.08, yield an incremental cost-effectiveness ratio for PCDT of $222 041/QALY gained. In probabilistic sensitivity analysis, the probability that PCDT would achieve a lifetime incremental cost-effectiveness ratio <$50 000/QALY or <$150 000/QALY was 1% and 25%, respectively. For iliofemoral DVT, QALY gains with PCDT were greater, yielding an incremental cost-effectiveness ratio of $137 526/QALY; for femoral-popliteal DVT, standard therapy was an economically dominant strategy.ConclusionsWith an incremental cost-effectiveness ratio >$200 000/QALY gained, PCDT is not an economically attractive treatment for proximal DVT. PCDT may be of intermediate value in patients with iliofemoral DVT. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT00790335.

Project description:BackgroundIsolated distal deep vein thrombosis (IDDVT), a disease frequently detected in hospitalized patients, can progress to proximal deep vein thrombosis (PDVT) and pulmonary embolism (PE). Here, we evaluated the effects of anticoagulation in hospitalized IDDVT patients.MethodsWe conducted a retrospective study in our hospital and enrolled hospitalized IDDVT patients diagnosed by compression ultrasonography (CUS) from January to December 2020. Participants were divided into anticoagulation (AC) and non-anticoagulation (non-AC) groups. After propensity score matching (PSM), multivariate Cox regression analyses were performed to assess whether anticoagulation was associated with PDVT/PE, and all-cause mortality.ResultsA total of 426 IDDVT inpatients with CUS follow-up were screened from 1502 distal DVT patients and finally enrolled. The median age was 67 years with 51.4% males and 15.5% cancer patients. The median follow-up was 11.6 months. There were 288 and 138 patients treated with or without anticoagulants, respectively. Patients in the non-AC group had less body mass index and more comorbidities. Patients in the AC group were treated with rivaroxaban or dabigatran (52.1%), low molecular weight heparin (42.7%), and warfarin (5.2%). The PSM generated 111 pairs of well-matched IDDVT patients with or without anticoagulation. The Kaplan-Meier analysis demonstrated that neither the incidence of PDVT/PE (5.4% vs. 2.7%, log-rank p = 0.313) nor all-cause mortality (27.9% vs. 18.9%, log-rank p = 0.098) was significant different between groups. Anticoagulation was not associated with PDVT/PE and all-cause mortality in the multivariable Cox regression analyses using the matched cohorts. The main risk factors for all-cause mortality were age, malignancy history, BMI, sepsis, heart failure, and white blood cell (WBC) count.ConclusionsIn hospitalized IDDVT patients, the thrombosis extension rate to PDVT/PE was low. Anticoagulation did not reduce the incidence of thrombosis extension of IDDVT and was not associated with all-cause mortality.

Project description:To determine the optimum duration of oral anticoagulant therapy after an episode of deep vein thrombosis or pulmonary embolism, or both.Multicentre, prospective, randomised study with follow-up for one year.46 hospitals in United Kingdom.Patients aged > or =18 with deep vein thrombosis or pulmonary embolism, or both.Three (n=369) or six months (n=380) of anticoagulation with heparin for five days accompanied and followed by warfarin, with a target international normalised ratio of 2.0-3.5.Death from deep vein thrombosis or pulmonary embolism; failure to resolve, extension, recurrence of during treatment; recurrence after treatment; and major haemorrhage during treatment.In the patients allocated to three months' treatment two died from deep vein thrombosis or pulmonary embolism during or after treatment, compared with three in the six month group. During treatment deep vein thrombosis or pulmonary embolism failed to resolve, extended, or recurred in six patients in the three month group without fatal consequences, compared with 10 in the six month group. After treatment there were 23 non-fatal recurrences in the three month group and 16 in the six month group. Fatal and non-fatal deep vein thrombosis or pulmonary embolism during treatment, and after treatment thus occurred in 31(8%) of those who had received three months' anticoagulation compared with 29 (8%) of those who had received six months' (P=0.80, 95% confidence interval for difference -3.1% to 4.7%). There were no fatal haemorrhages during treatment but there were eight major haemorrhages in those treated for six months and none in those treated for three months (P=0.008, -3.5% to -0.7%). Thus 31 (8%) of the patients receiving three months' anticoagulation experienced adverse outcomes as a result of deep vein thrombosis or pulmonary embolism or its treatment compared with 35 (9%) of those receiving six months' (P=0.79, -4.9% to 3.2%).For patients in the UK with deep vein thrombosis or pulmonary embolism and no known risk factors for recurrence, there seems to be little, if any, advantage in increasing the duration of anticoagulation from three to six months. Any possible advantage would be small and would need to be judged against the increased risk of haemorrhage associated with the longer duration of treatment with warfarin.Clinical Trials NCT00365950 [ClinicalTrials.gov].

Project description:BackgroundDeep vein thrombosis (DVT) of the lower extremity (LE) might lead to pulmonary embolism (PE) and post-thrombolytic syndrome (PTS). Recently, percutaneous endovenous intervention (PEVI) has been advocated for early removal of thrombus clot and restoration of venous patency. This study aims to review the safety and efficacy outcomes of PEVI versus anticoagulation in the treatment of acute LE-DVT.MethodsWe searched the databases of PubMed, Embase, and the Cochrane Library for randomized controlled trials (RCTs) comparing catheter-directed thrombolysis (CDT) and/or pharmacomechanical thrombectomy (PMT) versus anticoagulation for acute proximal LE-DVT, published before August 2022. Efficacy outcomes were PTS and venous patency. Safety outcomes included recurrent thromboembolism, bleeding complications, and PE.ResultsOverall, 1,266 patients were included from 6 RCTs. The overall risk of bias was small due to enrolled high-quality RCTs. Compared to anticoagulation, PEVI moderately reduced PTS incidence [odds ratio (OR) 0.47, 95% confidence interval (CI) 0.23-0.99], obviously inhibited moderate-to-severe PTS (OR 0.60, 95% CI: 0.40-0.88), significantly decreased PE (OR 0.16, 95% CI: 0.05-0.48), and substantially increased venous patency (OR 7.95, 95% CI: 1.00-63.16). There was no significant difference in recurrent thromboembolism between PEVI and anticoagulation (OR 0.76, 95% CI: 0.34-1.73). Bleeding events did not differ statistically between PEVI and anticoagulation (OR 1.36, 95% CI: 0.87-2.11). We conducted single-arm meta-analysis of the PEVI or anticoagulation. Pooled proportion of PTS was less after PEVI (0.295, 95% CI: 0.123-0.505) than after anticoagulation (0.459, 95% CI: 0.306-0.616). Pooled proportion of moderate-to-severe PTS was lower after PEVI (0.098, 95% CI: 0.033-0.191) than after anticoagulation (0.183, 95% CI: 0.126-0.247). Pooled proportion of PE was smaller after PEVI (0.006, 95% CI: 0.00-0.020) as compared to anticoagulation (0.075, 95% CI: 0.038-0.122). Pooled proportion of recurrent thromboembolism was similar between PEVI (0.095, 95% CI: 0.054-0.146) and anticoagulation (0.124, 95% CI: 0.061-0.206). Pooled proportion of bleeding was not different statistically between PEVI (0.026, 95% CI: 0.00-0.131) and anticoagulation (0.008, 95% CI: 0.00-0.094).ConclusionsPEVI, consisting of PMT and/or CDT, is an extremely effective and feasible approach for patients with acute LE-DVT. In comparison to therapeutic anticoagulation, PEVI restores venous patency, inhibits the PTS development, reduces the PE occurrence, does not markedly increase the bleeding risk, but does not reduce recurrent thromboembolism.

Dataset Information

Bed rest versus early ambulation with standard anticoagulation in the management of deep vein thrombosis: a meta-analysis.

Introduction

Methods

Results

Conclusions

Publications

Bed rest versus early ambulation with standard anticoagulation in the management of deep vein thrombosis: a meta-analysis.

Similar Datasets

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