prescription-medicine-bi

Cardiovascular

Cardiovascular disease, including heart disease and stroke, is a major global health concern and the leading cause of death and disability worldwide. At Boehringer Ingelheim we address unmet medical need by providing innovative treatments that improve the care of patients suffering from a range of cardiovascular conditions including irregular heart beats (atrial fibrillation), stroke, blood clots in deep veins or lungs (deep vein thrombosis or pulmonary embolism), high blood pressure (hypertension) or heart attack (myocardial infarction).

Deep Vein Thrombosis (DVT) is a serious but usually treatable medical condition. DVT occurs when a blood clot forms within a deep vein in a leg, thigh or even the arm. If part of the clot breaks off and travels to the lung, it can cause a potentially life-threatening condition known as pulmonary embolism (PE) which is the most serious complication of DVT. It is essential that patients with DVT or PE are quickly diagnosed and then treated to prevent clot growth and future clot formation.

Venous thromboembolism treatment (VTE) is common, with DVT and PE estimated to be the third most prevalent cardiovascular disorders after coronary heart disease and stroke.1Over 750,000 DVT and PE events are estimated to occur annually in six major EU countries (France, Germany, Italy, Spain, Sweden, UK)2  and over 900,000 events in the US.3 Although venous thromboembolism is both treatable and preventable, 40 percent of people who experience a DVT or PE will have a recurrent event within 10 years of the first event.4 Pulmonary embolism is a serious complication of DVT5  and the leading cause of preventable death in hospital.5,6  Those who survive may be left with permanent damage to the affected lung and other vital organs, and are at risk of complications such as chronic thromboembolic pulmonary hypertension (CTEPH)6,7. 

Prevention of venous thromboembolic events in patients who have undergone orthopaedic surgery

Patients undergoing major orthopedic surgery, such as total hip (THR) or total knee (TKR) joint replacement procedures, are at high risk of venous thromboembolism (VTE) and bleeding. Postoperative VTE, such as deep vein thrombosis (DVT) or pulmonary embolism (PE), results in significant mortality, morbidity, and health-care resource expenditure. 

Without thromboprophylaxis, the incidence of asymptomatic DVT has been reported to be 40–60%, with approximately 5–10% of deaths among hospitalized patients being associated with PE. Mild and moderate renal impairment has been shown to be associated with an increased risk of unprovoked and provoked VTE in the general population.

Major orthopaedic surgery causes trauma. Hip replacement surgery results in damage to blood vessels around the operation site, enhanced local and systemic activation of the coagulation cascade, reduced blood flow for several weeks, and suppression of fibrinolysis. Increased coagulant activity, combined with impaired venous hemodynamics, increases the risk of VTE. 

The risk of VTE following hip replacement surgery may be compounded by:

  • Factors related to the patient (age, inherited procoagulant conditions resulting in blood abnormalities) or clinical factors (malignancy).
  • Oral contraceptives or hormone replacement therapy, which also increases the risk of thrombosis.

 

References

  1. Goldhaber SZ. Pulmonary embolism thrombolysis: a clarion call for international collaboration. J Am Coll Cardiol 1992;19:246–247..
  2. Cohen AT, et al. Venous thromboembolism (VTE) in Europe. Thromb Haemost 2007;98:756-764.
  3. Roger VL. et al. Heart disease and stroke statistics—2012 update: A report from the American Heart Association. Circulation 2012;125(1):e2-e220.
  4. Prandoni P. et al. The risk of recurrent venous thromboembolism after discontinuing anticoagulation in patients with acute proximal deep vein thrombosis or pulmonary embolism. A prospective cohort study in 1,626 patients. Haematologica 2007;92(02):199–205.
  5. Heit JA, et al. Predictors of survival after deep vein thrombosis and pulmonary embolism. Arch Intern Med 1999;159:445-453.
  6. BMJ Best Practice. VTE Prophylaxis. Available at: http://bestpractice.bmj.com/best-practice/monograph/1087.html (link is external)
  7. Pengo V. et al. Incidence of chronic thromboembolic pulmonary hypertension after pulmonary embolism. N Engl J Med. 2004;350:2257-64.
  8. Pinjala, R. & ENDORSE-India investigators. Venous thromboembolism risk & prophylaxis in the acute hospital care setting (ENDORSE), a multinational cross-sectional study: results from the Indian subset data. Indian J. Med. Res. 136, 60–67 (2012).
  9. Lacut K, Le Gal G, Mottier D. Primary prevention of venous thromboembolism in elderly medical patients. Clin Interv Aging. 2008;3(3):399-411. doi:10.2147/cia.s832
  10. Kearon C and Aki EA. Duration of anticoagulant therapy for deep vein thrombosis and pulmonary embolism. Blood 2014;123:1794–1801.
  11. Gordon, Ronald J. MD, PhD*; Lombard, Frederick W. MBChB, FANZCA† Perioperative Venous Thromboembolism: A Review, Anesthesia & Analgesia: August 2017 - Volume 125 - Issue 2 - p 403-412
  12. Paul E Nilsson, MD, PhD, David Bergqvist, MD, PhD, Göran Benoni, MD, Ola Björgell, MD, Hans Fredin, MD, PhD, Urban Hedlund, MD, Sylvain Nicolas, and Göran Nylander, MD, PhD Orthopedics 1997;20(suppl):7-9: Published Online:February 02, 1997
  13. McNally MA, Mollan RAB. Total hip replacement, lower limb blood flow and venous thrombogenesis. J Bone Joint Surg. 1993;75-B:640-4. 
  14. Dahl OE, Andreassen G, Aspelin T, et al. Prolonged thromboprophylaxis following hip replacement surgery – Results of a double-blind, prospective, randomised, placebo-controlled study with dalteparin (Fragmin®). Thromb Haemost. 1997;77:26-31.
  15. Rosendaal FR. Risk factors in venous thrombotic disease. Thromb Haemost. 1999;82:610-9.