Thrombotic Complications of Antithrombotic Therapy: A Paradox with Implications for Clinical Practice
Authors: Gary E. Raskob
Journal: Annals of Internal Medicine (1997)

Editorials1 November 1997Thrombotic Complications of Antithrombotic Therapy: A Paradox with Implications for Clinical PracticeGary E. Raskob, MSc and James N. George, MDGary E. Raskob, MScUniversity of Oklahoma Health Sciences Center Oklahoma City, OK 73190 and James N. George, MDUniversity of Oklahoma Health Sciences Center Oklahoma City, OK 73190Author, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-127-9-199711010-00012 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Heparin and warfarin have been the standard therapy for thromboembolic disease for more than 50 years. During this time, the clinical indications for their use have expanded. Heparin is the standard initial therapy for acute venous thrombosis or pulmonary embolism; it is also widely used to treat acute coronary syndromes and prevent thrombosis during vascular surgery or angioplasty, ex vivo thrombi during cardiopulmonary bypass surgery and hemodialysis, and postoperative venous thromboembolism in high-risk patients. The use of warfarin has also expanded in recent years to include prevention of thromboembolic stroke in patients with atrial fibrillation, a condition that affects many ...References1. Hull R, Hirsh J, Jay R, Carter C, England C, Gent M, et al. Different intensities of oral anticoagulant therapy in the treatment of proximal-vein thrombosis. N Engl J Med. 1982; 307:1676-81. Google Scholar2. George J. Heparin-associated thrombocytopenia. In: Hull R, Pineo GF, eds. Disorders of Thrombosis. Philadelphia: WB Saunders; 1996; 359-73. Google Scholar3. Sallah S, Thomas DP, Roberts HR. Warfarin and heparin-induced skin necrosis and the purple toe syndrome: infrequent complications of anticoagulant treatment. Thromb Haemost. 1997; 78:785-90. Google Scholar4. Visentin G, Ford SE, Scott JP, Aster RH. Antibodies from patients with heparin-induced thrombocytopenia/thrombosis are specific for platelet factor 4 complexed with heparin or bound to endothelial cells. J Clin Invest. 1994; 93:81-8. Google Scholar5. Kelton JG, Smith JW, Warkentin TE, Hayward CP, Denomme GA, Horsewood P. Immunoglobulin G from patients with heparin-induced thrombocytopenia binds to a complex of heparin and platelet factor 4. Blood. 1994; 83:3232-9. Google Scholar6. Towne JB, Bernhard VM, Hussey C, Garancis JC. White clot syndrome. Peripheral vascular complications of heparin therapy. Arch Surg. 1979; 114:372-7. Google Scholar7. Warkentin TE, Levine MN, Hirsh, J, Horsewood P, Roberts RS, Gent M, et al. Heparin-induced thrombocytopenia in patients treated with low-molecular-weight heparin or unfractionated heparin. N Engl J Med. 1995; 332:1330-5. Google Scholar8. Warkentin TE, Elavathil LI, Hayward CP, Johnston MA, Russet JI, Kelton JG. The pathogenesis of venous limb gangrene associated with heparin-induced thrombocytopenia. Ann Intern Med. 1997; 127:804-12. Google Scholar9. Miletich J, Sherman L, Broze G Jr. Absence of thrombosis in subjects with heterozygous protein C deficiency. N Engl J Med. 1987; 317:991-6. Google Scholar10. Hull RD, Raskob GE, Rosenbloom D, Panju AA, Brill-Edwards P, Ginsberg JS, et al. Heparin for 5 days as compared with 10 days in the initial treatment of proximal venous thrombosis. N Engl J Med. 1990; 322:1260-4. Google Scholar11. Gallus A, Jackaman J, Tillett J, Mills W, Wycherley A. Safety and efficacy of warfarin started early after submassive venous thrombosis or pulmonary embolism. Lancet. 1986; 2:1293-6. Google Scholar12. Hull RD, Raskob GE, Pineo GF, Green D, Trowbridge AA, Elliott CG, et al. Subcutaneous low-molecular-weight heparin compared with continuous intravenous heparin in the treatment of proximal-vein thrombosis. N Engl J Med. 1992; 326:975-82. Google Scholar13. Levine M, Gent M, Hirsh J, Leclerc J, Anderson D, Weitz J, et al. A comparison of low-molecular-weight heparin administered primarily at home with unfractionated heparin administered in the hospital for proximal deep-vein thrombosis. N Engl J Med. 1996; 334:677-81. Google Scholar14. Koopman MM, Prandoni P, Piovella F, Ockelford PA, Brandjes DP, van der Meer J, et al. Treatment of venous thrombosis with intravenous unfractionated heparin administered in the hospital as compared with subcutaneous low-molecular-weight heparin administered at home. The Tasman Study Group. N Engl J Med. 1996; 334:682-7. Google Scholar15. Hull R, Delmore T, Genton E, Hirsh J, Gent M, Sackett D, et al. Warfarin sodium versus low-dose heparin in the long-term treatment of venous thrombosis. N Engl J Med. 1979; 301:855-8. Google Scholar16. Prandoni P, Lensing AW, Cogo A, Cuppini S, Villalta S, Carta M, et al. The long-term clinical course of acute deep venous thrombosis. Ann Intern Med. 1996; 125:1-7. Google Scholar17. Harrison L, Johnston M, Massicotte MP, Crowther M, Moffat K, Hirsh J. Comparison of 5-mg and 10-mg loading doses in initiation of warfarin therapy. Ann Intern Med. 1997; 126:133-6. Google Scholar18. Demers C, Ginsberg JS, Brill-Edwards P, Panju A, Warkentin TE, Anderson DR, et al. Rapid anticoagulation using ancrod for heparin-induced thrombocytopenia. Blood. 1991; 78:2194-7. Google Scholar19. Magnani HN. Heparin-induced thrombocytopenia (HIT): an overview of 230 patients treated with orgaran (Org 10172). Thromb Haemost. 1993; 70:554-61. Google Scholar20. Schiele F, Vuillemenot A, Kramarz P, Kieffer Y, Anguenot T, Bernard Y, et al. Use of recombinant hirudin as antithrombotic treatment in patients with heparin-induced thrombocytopenia. Am J Hematol. 1995; 50:20-5. Google Scholar Author, Article, and Disclosure InformationAuthors: Gary E. Raskob, MSc; James N. George, MDAffiliations: University of Oklahoma Health Sciences Center Oklahoma City, OK 73190Corresponding Author: Gary E. Raskob, MSc, Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Box 26901, Oklahoma City, OK 73190.Current Author Addresses: Mr. Raskob: Departments of Biostatistics and Epidemiology and Medicine, University of Oklahoma Health Sciences Center, Box 26901, Oklahoma City, OK 73190. Dr. George: Hematology-Oncology Section, University of Oklahoma Health Sciences Center, Box 26901, Oklahoma City, OK 73190. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoThe Pathogenesis of Venous Limb Gangrene Associated with Heparin-Induced Thrombocytopenia Theodore E. Warkentin , Leela J. Elavathil , Catherine P.M. Hayward , Marilyn A. Johnston , Jean I. Russett , and John G. Kelton Metrics Cited byA randomized trial of restarting warfarin at maintenance versus loading doses following an elective procedureMultiple thromboembolism with multiple causes in a 69-year-old woman: a case reportReview: Recent Advances in Argatroban-Warfarin Transition in Patients With Heparin-induced ThrombocytopeniaCOMPUTATIONAL STUDY FOR BINDING OF OSCILLARIN TO HUMAN α-THROMBINVenous gangrene and cancer: A cool look at a burning issueQuantum and Molecular Dynamics Study for Binding of Macrocyclic Inhibitors to Human α-ThrombinWarfarin-induced Skin Necrosis and Venous Limb Gangrene: Lesson from a Case Induced the Serious Complications by the Anticoagulants During the Treatment of Acute Artery OcclusionTransition to an Oral Anticoagulant in Patients With Heparin-Induced ThrombocytopeniaWarfarin-induced limb gangrene in the setting of lung adenocarcinomaEstimation of Binding Affinities for Selective Thrombin Inhibitors via Monte Carlo SimulationsSafety of Warfarin Anticoagulation in Patients With Heparin-Induced ThrombocytopeniaInadequacy of Current Prevention Strategies for Heparin-Induced ThrombocytopeniaThe development of novel noncovalent thrombin inhibitorsState-of-the-Art Review : Heparin-induced Thrombocytopenia and Thrombosis Syndrome 1 November 1997Volume 127, Issue 9Page: 839-841KeywordsAnticoagulantsDeep vein thrombosisHeparinHeparin-induced thrombocytopeniaNecrosisPatientsProtein C deficiencyProteinsThrombosisVenous thromboembolism ePublished: 15 August 2000 Issue Published: 1 November 1997 Copyright & PermissionsCopyright © 1997 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...