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Introduction Introduction
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Therapeutic anticoagulation for venous thromboembolism Therapeutic anticoagulation for venous thromboembolism
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Heparin Heparin
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Anticoagulation with unfractionated heparin Anticoagulation with unfractionated heparin
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Anticoagulation with LMWH Anticoagulation with LMWH
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Complications of heparin treatment Complications of heparin treatment
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Fondaparinux Fondaparinux
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Warfarin Warfarin
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Initiation and monitoring of anticoagulation with warfarin Initiation and monitoring of anticoagulation with warfarin
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Complications of warfarin treatment Complications of warfarin treatment
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New oral direct inhibitors of anticoagulation New oral direct inhibitors of anticoagulation
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Selecting an anticoagulant Selecting an anticoagulant
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Duration of anticoagulation after venous thromboembolism Duration of anticoagulation after venous thromboembolism
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Fibrinolysis for venous thromboembolism Fibrinolysis for venous thromboembolism
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Anticoagulation in particular clinical circumstances Anticoagulation in particular clinical circumstances
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Treatment of venous thromboembolism in pregnancy Treatment of venous thromboembolism in pregnancy
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Therapeutic anticoagulation for atrial fibrillation Therapeutic anticoagulation for atrial fibrillation
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Therapeutic anticoagulation in patients with prosthetic heart valves Therapeutic anticoagulation in patients with prosthetic heart valves
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Perioperative management of therapeutic anticoagulation Perioperative management of therapeutic anticoagulation
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Further reading Further reading
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16.16.2 Therapeutic anticoagulation
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Published:May 2010
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This version:October 2015
Updated in this version:
Update:
Enhanced discussion of indications for and use of oral direct inhibitors of thrombin and factor Xa.
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Extract
Essentials
Introduction
The main indications for therapeutic anticoagulation are venous thromboembolism (VTE)—(deep vein thrombosis (DVT) and pulmonary embolism, (PE) (see Chapter 16.16.1) and the prevention of stroke in patients with atrial fibrillation or mechanical heart valves. Oral vitamin K antagonists (in the United Kingdom, mostly warfarin) have been the mainstay of treatment, but the new oral direct inhibitors of thrombin or factor Xa are being increasingly used to treat VTE and to prevent stroke in atrial fibrillation. When warfarin is used in acute venous thromboembolism, initial anticoagulation with heparin is required because warfarin takes time to become effective.
Therapeutic anticoagulation for venous thromboembolism
DVT and PE are aspects of the same disease—VTE. Forty per cent of patients with DVT without clinical evidence of PE have evidence of emboli on lung scanning. The principles of therapeutic anticoagulation are the same for both. In proximal DVT and PE, this has involved immediate anticoagulation with heparin followed by a period of anticoagulation with warfarin (or other oral vitamin K antagonist). Distal DVT can be managed in the same way, but an alternative strategy is to use serial noninvasive testing (e.g. ultrasonography), which only reliably detects proximal thrombosis, to ensure that suspected distal thrombosis does not extend above the knee, withholding treatment if it does not.
Update:
Enhanced discussion of indications for and use of oral direct inhibitors of thrombin and factor Xa.
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