BMJ
2001;322:1212-1213 ( 19 May )
Thomas Schwarz
Department of Internal Medicine, Division of Vascular Medicine,
University Hospital "Carl Gustav Carus", D-01307 Dresden, Germany
Correspondence to: T Schwarz [log in to unmask]
|
Methods
and results |
Between 1 November 1998 and 15 August 1999 all
patients presenting to the vascular diagnostics unit of the University Hospital
Dresden, Germany, as outpatients with acute deep vein thrombosis in
the leg were prospectively evaluated regarding eligibilty for home
treatment. We defined acute deep vein thrombosis as non-compressible deep
veins on ultrasonography (UM9 HDI, linear array 4-7 MHz, ATL,
Bothell, Washington, DC) and symptoms that had been present for less
than two weeks. Written informed consent was obtained from all patients.
On the day of diagnosis patients were started on oral
anticoagulation with phenprocoumon (adjusted to a target international normalised
ratio of 2-3) and the low molecular weight heparin nadroparin
(90 IU/kg body weight twice daily) until a therapeutic ratio
was achieved. All patients received class II compression stockings.
At presentation, the decision regarding hospital admission was based
on medical reasons, home care situation, patients' and general
practitioners' rejection of outpatient treatment, and hospital
service logistics. The 95% confidence intervals were calculated
according to the Wilson procedure.
We assessed recurrent venous thromboembolism (verified by sonography,
ventilation-perfusion scan, or pulmonary angiography), major
bleeding, and death at clinical follow up of patients treated at
home. Assessments were at three and six days and two, four, and
12 weeks after initiation of treatment. The study was approved by
the local ethics committee.
A total of 117 consecutive outpatients (48 men,
69 women) were diagnosed as having acute deep vein thrombosis. Of these,
92 received home treatmentthat is, they were not admitted at all. The median
(range) age was 62.0 (19-95) years. Three patients were
admitted to hospital for medical reasons; 11 because of the home
care situation; and 11 for reasons of hospital service logistics (table).
At the 12 week follow up of the 92 patients, eight had died
(six from cancer and two from chronic heart failure; three had
recurrent thrombosis; and four had developed minor bleeding. No
clinical pulmonary embolism or major bleeding occurred. Safety and
efficacy figures are similar to those previously published.5
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|
Comment |
Most outpatients presenting with acute deep vein thrombosis do not
need to be admitted to hospital. The proportion who do require
admission depends mainly on factors to do with infrastructure rather
than medical reasons. In our study, only 3% of patients were
admitted for medical reasons, and in 9% admission was because medication
and international normalised ratio could not be monitored. Even
these patients could have been treated as outpatients if adequate
professional care had been available at home. No serious complications
were noted in patients treated in an outpatient setting. Another 9%
of our patients presented in the emergency room and were already
being treated for deep vein thrombosis suspected on clinical grounds
alone. They were admitted until ultrasound examination could be
performed.
|
Acknowledgments |
We thank Roswitha Frommhold of the
nursing staff for excellent patient care and Harry R Büller, Amsterdam, for his
helpful criticism.
Contributors: TS and SMS had the original idea for the study,
recruited a large number of patients, created the trial database, analysed the
data, and wrote the paper. BS conducted statistical analysis and recruited
patients. UH advised on data collection and analysed the data. JB recruited
patients for the study. HES revised the final version of the manuscript and is
the guarantor of the paper. All authors approved the final version of the
paper.
|
Footnotes |
Funding: Sanofi-synthelabo, Berlin, and medi-Bayreuth, Bayreuth.
Competing interests: None declared.
|
References |
1. |
Dolovich LR, Ginsberg JS, Douketis JD,
Holbrook AM, Cheah G. A meta-analysis comparing low-molecular-weight heparins
with unfractionated heparin in the treatment of venous thromboembolism. Arch Int Med 2000; 160: 181-188 |
2. |
Schellong SM, Schwarz T, Kropp J,
Prescher Y, Beuthien B, Daniel WG. Bed rest in deep vein thrombosis and the
incidence of pulmonary embolism. Thromb
Haemost 1999; 82(suppl): 127-129 |
3. |
Koopman MM, Prandoni P, Piovella F, Ockelford
PA, Brandjes DPM, van der Meer J, et al. Treatment of venous thrombosis with
intravenous unfractionated heparin administered in the hospital as compared
with subcutaneous low-molecular-weight heparin administered at home. N Engl J Med 1996; 334: 682-687 |
4. |
Levine M, Gent M, Hirsh J, Leclerc J,
Anderson D, Weitz J, et al. A comparison of low-molecular-weight heparin
administered primarily at home with unfractionated heparin administered in
the hospital for proximal deep-vein thrombosis. N Engl J Med 1996; 334: 677-681 |
5. |
Lensing WA, Prandoni P, Prins MH, Büller
HR. Deep-vein thrombosis. Lancet
1999; 353: 479-485 |
(Accepted 16 January 2001)
Edward E.
Rylander, M.D.
Diplomat American
Board of Family Practice.
Diplomat American
Board of Palliative Medicine.