Compression stockings, AF patients at risk, and ICH outcomes

Extended use of compression stockings lowers risk of post-thrombotic syndrome

Anna D. Garrett, PharmD, BCPSPost-thrombotic syndrome (PTS) is a common and long-term complication of deep venous thrombosis (DVT). The syndrome may develop in up to one-third of DVT patients, even when anticoagulation therapy is optimal. The majority of patients develop symptoms within the first year after a DVT diagnosis and most will experience them within two years post-diagnosis. The symptoms include skin changes, pain, vein dilation, and venous ulcers and often require costly medical intervention. Patients also report significant morbidity and impaired quality-of-life.   Preventive strategies include pharmacologic thromboprophylaxis and recent studies suggest that continuous use of elastic compression stockings (ECS) for 24 months may reduce by 50% the incidence of post-thrombotic syndrome. The collective data regarding the benefit of ECS, however, are conflicting, largely as result of low adherence rates in studies.

A new randomized controlled non-inferiority trial in the Netherlands studied the benefit of 12 months vs 24 months of ECS use. The primary outcome was the incidence of PTS 24 months after diagnosis of DVT, as assessed by the standardized PTS-specific Villalta scale in an intention-to-treat analysis. The main secondary outcome was quality-of-life based on results of the disease-specific VEINES-QOL/Sym questionnaire (http://bmccardiovascdisord.biomedcentral.com/articles/10.1186/s12872-015-0080-7).

Study participants (N=518) assessed to be ECS compliant and who had not experienced PTS one year after diagnosis of DCT were randomized to stop or continue ECS therapy for an additional 12 months. In the stop-ECS group, 51 of 256 patients (19.9%) developed PTS. In the continue-ECS group, 34 of 262 patients (13%) were affected. The absolute difference between groups was 6.9%. Non-inferiority was not achieved. Quality of life did not differ between the stop- and continue-ECS groups.

The authors concluded there was additional benefit (decreased risk of PTS) to wearing ECS for a second year after a diagnosis of DVT among motivated patients who were compliant with ECS use for one year.

Source: Mol GC, van de Ree MA, Klok FA et al. One versus two years of elastic compression stockings for prevention of post-thrombotic syndrome (OCTAVIA study): Randomised controlled trial. BMJ 2016;353:i2691.

One-third of AF patients at risk for stroke do not receive anticoagulation

Oral anticoagulation (OAC) is recommended over aspirin for stroke prevention in patients with atrial fibrillation (AF) who are at moderate-to-high risk of thromboembolism. A recent study showed that one in three AF patients at higher risk for thromboembolism might not receive recommended OAC therapy.

Using 2008–2012 data from a national cardiovascular care registry, researchers identified over 210,000 patients with AF known to be at moderate-to-high risk for thromboembolism based on a CHADS₂ score of ≥2. Overall, 38% of patients were treated with aspirin alone, while the rest received warfarin or non-vitamin K antagonist OAC (eg, dabigatran, rivaroxaban). Findings were similar in a secondary analysis using the more sensitive CHA₂DS₂-VASc risk score. Authors identified specific patient characteristics associated with use of aspirin over OAC.

Source: Hsu JC, Maddox TM, Kennedy K et al. Aspirin instead of oral anticoagulant prescription in atrial fibrillation patients at risk for stroke. J Am Coll Cardiol 2016;67: 2913-2923.

Anticoagulation after ICH improves long-term outcomes

Approximately one-half of patients who survive intracerebral hemorrhage (ICH) are at high risk for thromboembolism. A recent study Danish study demonstrated that the use of oral anticoagulant therapy (OAT) ICH is associated with a lower risk of death and thromboembolic events and carries no increased risk of major bleeding.

Using nationwide Danish medical registries, the investigators identified 6,369 patients between 2005 and 2013 who were at risk of thromboembolism in the first 30 days after hospitalization for ICH. Among these patients, 2,978 (47%) had an indication for OAT. During the follow-up, (median: 2.3 years), 1,281 (43%) died, 497 (17%) had a thromboembolic event, and 536 (18%) had major bleeding. Post-discharge treatment with OAT among patients with an indication for OAT was associated with a significantly lower risk of death and thromboembolic events and no increased risk of major bleeding. In contrast, among patients with an indication for antiplatelet inhibitors who were treated with these agents, no statistically significant improvement in clinical outcome was observed.

The authors concluded that post-discharge use of OAT was associated with a lower risk of all-cause mortality and thromboembolic events with no increased risk of major bleeding among patients surviving ICH. The decision of whether to use or avoid OAT depends on a thorough assessment of the individual patient’s thromboembolic and hemorrhagic risk and should reflect the patient’s preferences and informed choice.

Source: Ottosen TP, Grijota M, Hansen ML, et al. Use of antithrombotic therapy and long-term clinical outcome among patients surviving intracerebral hemorrhage. Stroke 2016;Jun 14:[Epub ahead of print].