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Managing Thromboembolism in Pregnancy

Thromboembolism is a leading cause of maternal morbidity and mortality in the United States. The risk of venous thromboembolism (VTE) is increased four-fold during pregnancy and another five-fold for 6 weeks following delivery. The increased VTE risk for these women is mainly attributed to pregnancy because it puts the body in an increased thrombogenic state, but physiologic factors, such as an enlarged uterus and compressed blood vessels at the time of childbirth, also play a role. Other risk factors include having a prior VTE, family history of thrombosis, smoking, high blood pressure, obesity, and operative delivery. The consequences of VTE during pregnancy can be severe and often stem from a failure in diagnosis rather than inadequate therapy. An updated practice bulletin from the American College of Obstetricians & Gynecologists (ACOG) was published in the September 2011 issue of Obstetrics & Gynecology to provide clinicians with updated information on the risk factors, diagnosis, management, and prevention of VTE. “This document places more emphasis on the acquired risk factors for VTE during pregnancy,” says Andra H. James, MD, who helped develop the bulletin. “The recommendations explain how to monitor women for thromboembolic events, address certain risk factors, and treat suspected or acute cases of VTE. The hope is that maternal deaths can be reduced if more clinicians adopt the recommendations provided in the bulletin.” New Recommendations to Manage VTE A major recommendation offered in the ACOG update is the use of compression ultrasonography of the proximal veins when signs or symptoms are suggestive of new onset DVT (Figure). Use of compression ultrasonography will indicate if treatment should be started or surveillance...

Resuming Blood Thinner Use After a GI Bleed

Among patients with a warfarin-associated index gastrointestinal (GI) bleeding event, the decision to not resume warfarin within 90 days appears to be associated with higher risks for thrombosis and mortality. A cohort study demonstrated that resuming warfarin did not significantly increase the risk for recurrent GI bleeding. Abstract: Archives of Internal Medicine, September 2012...

Tailoring Antiplatelet Treatment

Important advances have occurred in our understanding of the platelets’ role in arterial thrombosis. These advances have enabled the development of new antiplatelet therapies. Clinical trials have demonstrated the benefit of antiplatelet therapy in a diverse range of cardiovascular diseases (CVD), including acute myocardial infarction, unstable angina, and ischemic stroke. The market for antiplatelet therapies has grown in recent years for several reasons, including the: Aging population. Global increase in CVD incidence due to diabetes. Increased understanding of the role of antiplatelet therapy in the prevention and treatment of CVDs. Prasugrel and ticagrelor are two antiplatelet agents that have been recently approved by the FDA for use in conjunction with aspirin to treat patients with acute coronary artery syndromes. In phase III trials, these agents have been shown to significantly reduce adverse cardiovascular events when compared with clopidogrel therapy. These additions to the antiplatelet therapy class can make it more challenging for clinicians to decide on what is most appropriate and beneficial for their patients. There is no longer just one option for antiplatelet therapy. Clinicians must now consider the optimal antiplatelet therapy for each patient depending on their presentation, bleeding risk, and cost. Personalizing Approaches in Antiplatelet Treatment The unpredictable response to clopidogrel reported nearly a decade ago introduced us to the field of personalized antiplatelet therapy based on genetic and platelet function testing. The CYP2C19 loss-of-function allele is a major independent predictor of the pharmacodynamic and clinical response to clopidogrel in PCI patients. Guidelines and FDA recommendations suggest that patients who are poor metabolizers, according to CYP2C19 testing, should be switched to an alternate antiplatelet therapy. Genetic...
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