Prolonged acenocoumarol treatment in patients with venous thromboembolic disease from a rural area.To the Editor: The recent American College of Chest Physicians The American College of Chest Physicians (ACCP) is a medical organization consisting of physicians and non-physician specialists in the field of chest medicine, which includes pulmonology, thoracic surgery, and critical care medicine. conference has recommended more prolonged periods of anticoagulant anticoagulant (ăn'tēkōăg`yələnt), any of several substances that inhibit blood clot formation (see blood clotting). treatment in patients with venous thromboembolic thromboembolic
pertaining to or emanating from thromboembolism.
see thromboembolic colic. disease (VTD). (1) For example, it has suggested that patients with a first episode of idiopathic VTD be considered for indefinite anticoagulant treatment. (1) However, the incidence of major hemorrhage is higher in the clinical practice than in clinical trials. (2,3) We studied the outcomes in patients treated with acenocoumarol for more than 6 months in a series of consecutive outpatients with VTD from a rural Spanish area.
We conducted a prospective observational study of 94 consecutive outpatients diagnosed in a first-level hospital from a rural area of Extremadura (Spain) with venous thromboembolic disease (VTD), deep vein thrombosis A blood clot (thrombos) in a vein deep within the muscle, typically in the thigh or calf. It is caused by disease or the lack of activity such as sitting for hours at a computer screen. and/or pulmonary embolism. All patients were treated with low molecular weight heparin In medicine, low molecular weight heparin (LMWH) is a class of medication used as an anticoagulant in diseases that feature thrombosis, as well as for prophylaxis in situations that lead to a high risk of thrombosis. in the acute phase. As long-term treatment, 35 patients received acenocoumarol for more than 6 months, according to the attendant physician's criterion. Twenty patients (57.1%) had "idiopathic" VTD (nonassociated with "classical" risk factors: recent surgery, immobilization Immobilization Definition
Immobilization refers to the process of holding a joint or bone in place with a splint, cast, or brace. This is done to prevent an injured area from moving while it heals. and/or cancer). Sixteen patients (45.7%) had pulmonary thromboembolism, 13 (37.1%) proximal isolated deep vein thrombosis and 6 (17.1%) distal isolated deep vein thrombosis. The other characteristics of patients are shown in the Table. The median follow-up was 12.7 months (range 8-29 mo). No patient died and no patient had thromboembolic recurrence. One patient (2.8%) had a major hemorrhage (gastrointestinal hemorrhage after 14 months of acenocoumarol treatment).
The annual incidence of major hemorrhage associated with anticoagulant treatment in patients with VTD in clinical trials is usually lower than 4%. (2) In the clinical practice, this incidence may be higher. For example, an observational study of patients treated with oral anticoagulants Anticoagulants
Drugs that suppress, delay, or prevent blood clots. Anticoagulants are used to treat embolisms.
Mentioned in: Embolism, Heart Valve Replacement because of diverse indications reported an incidence of major hemorrhage (7%) in the first year. (3) Therefore, the recent recommendation of more prolonged anticoagulant treatments in patients with VTD (1) might not be applicable in the clinical practice.
In our study of outpatients with VTD treated with acenocoumarol for more than 6 months, there was no death and no thromboembolic recurrence and the frequency of major hemorrhage was about 3% after a mean follow-up of almost 13 months. We point out that most patients were elderly, and major hemorrhages associated with anticoagulant treatment may be more frequent in the elderly. (2) However, other risk factors for hemorrhage associated with anticoagulant treatment, such as cancer and chronic renal failure chronic renal failure Chronic kidney failure Nephrology A slow decline in renal function, which may be 2º to chronic HTN, DM, CHF, SLE, or sickle cell anemia and, if extreme, leads to ESRD, mandating kidney dialysis; an abrupt decline in renal function may be , (2,3) were infrequent in our study. Prolonging treatment for VTD with acenocoumarol for more than 6 months may be useful in outpatients with characteristics similar to the patients of this study. However, further studies in the clinical practice with a higher number of patients and other characteristics are necessary to confirm and to extend this recommendation.
Jose Maria Calvo-Romero, MD
Internal Medicine Service
Hospital Ciudad de Coria co·ri·a
Plural of corium. , Coria (Caceres)
Esther Maria Lima-Rodriguez, MD
Area de Salud de Coria (Caceres)
1. Buller HR, Agnelli G, Hull RD, et al. Antithrombotic therapy for venous thromboembolic disease: the Seventh ACCP ACCP American College of Chest Physicians
ACCP American College of Clinical Pharmacy
ACCP Army Correspondence Course Program
ACCP Atlantic Climate Change Program
ACCP Association of Caribbean Commissioners of Police
ACCP Assembly of Caribbean Community Parliamentarians Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126(3 Suppl):401S-428S.
2. Levine MN, Raskob G, Beyth RJ, et al. Hemorrhagic Hemorrhagic
A condition resulting in massive, difficult-to-control bleeding.
Mentioned in: Hantavirus Infections
pertaining to or characterized by hemorrhage. complications of anticoagulant treatment: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126(3 Suppl):287S-310S.
3. McMahan DA, Smith DM, Carey MA, et al. Risk of major hemorrhage for outpatients treated with warfarin warfarin (wôr`fərĭn), anticoagulant used to treat blood clots. In large doses it causes bleeding. Warfarin, mixed with bait, is used in rodent control.
Anticoagulant drug, marketed as Coumadin. . J Gen Intern Med 1998; 13:311-316.
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Table. Characteristics of study patients (n = 35) Age (mean, years) 72.7 Age (range, years) 46-88 Age >70 years 25 (71.4%) Sex male 19 (54.3%) Cancer 3 (8.6%) Chronic cardiopulmonary disease 10 (28.6%) Chronic renal failure* 3 (8.6%) Previous VTD 4 (11.4%) *Serum creatinine >1.5 mg/dL. VTD: venous thromboembolic disease.