Sent 6/24/07 SK Kakkos, G Geroulakos, J Caprini, AN Nicolaides, G Stansby. Combined intermittent pneumatic leg compression and pharmacological prophylaxis for prevention of venous thromboembolism in high risk patients. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD005258. DOI: 10.1002/14651858.CD005258. Protocol. (PVD)
The “Goldhaber 2001” reference about the high
incidence of venous thromboembolism (VTE) arising in hospitalized patients
being due to failed rather than omitted prophylaxis was an
opinion piece.1 In 2000, Goldhaber and colleagues reported on a retrospective analysis
of about 80,000 hospitalized patients, in which they looked for the
development of VTE during the index hospitalization and up to 30 days after
discharge. Of the 384 VTE cases found, 201 had received prophylaxis and 183 had
not. Twelve of the 13 fatal pulmonary emboli (FPE) cases occurred in patients
receiving anticoagulant prophylaxis.2 At my request, Dr.
Goldhaber told me the anticoagulation prophylaxis status of the 20 patients who
died with PE contributing to death and those dying of causes unrelated to PE.
However, I am not at liberty to publish the number.
Goldhaber’s study provides evidence that will never be found in RCTs with n < 20,000 (i.e., all reported RCTs): anticoagulant prophylaxis very likely increases the risk of death. A possible mechanism is rebound hypercoagulation.
To confirm or refute the hypothesis that anticoagulant prophylaxis in hospitalized patients increases FPE and death, researchers in other hospitals should repeat Goldhaber’s retrospective analysis of VTE, FPE, and total mortality outcomes in patients with and without anticoagulants.
1. Goldhaber SZ. Prophylaxis of Venous Thrombosis. Current Treatment Options in Cardiovascular Medicine. 2001;3:225-235.
2. Goldhaber SZ, Dunn K, MacDougall RC. New Onset of Venous Thromboembolism Among Hospitalized Patients at Brigham and Women’s Hospital Is Caused More Often by Prophylaxis Failure Than by Withholding Treatment. Chest. 2000;118:1680-1684.