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J R Soc Med. 2001 November; 94(11): 608–609.
PMCID: PMC1282264

Anticoagulants for deep venous thrombosis

In their case report of superficial thrombophlebitis followed by pulmonary embolism (April 2001 JRSM, pp. 186-187) Dr Kesteven and Mr Robinson raise the question whether anticoagulants should be used to treat superficial venous thrombosis. This might be a good subject for a clinical trial; however, even the use of anticoagulants in venous thromboembolism—i.e. deep venous thrombosis (DVT) and pulmonary embolism (PE)—is open to doubt. No randomized placebo-controlled trial has ever been published supporting the efficacy or safety of anticoagulants in DVT. To justify anticoagulant treatment of DVT patients, textbooks and review articles generally lump DVT with PE and cite a placebo-controlled randomized trial of patients with PE by Barritt and Jordan1. The authors of this old and small study (n=35) used clinical signs and symptoms without lung scans or angiograms to diagnose PE. We now know that clinical suspicion of PE is confirmed by angiograms in only about 25% of cases2. Also, assignment of fatal PE as the cause of death was questionable in at least three of the five placebo group patients with severe underlying co-morbidity. In short, Barritt and Jordan's study does not qualify as scientific evidence supporting anticoagulant treatment to reduce the morbidity and/or mortality of patients with PE. Therefore, we cannot extrapolate the conclusion of Barritt and Jordan's trial to DVT patients or further extrapolate it to superficial venous thrombosis patients.

More recently in patients with DVT, Nielsen et al. compared heparin plus phenprocoumon anticoagulation with phenylbutazone in the only published randomized controlled trial3,4. It was a negative study with 1/48 anticoagulated patients and 0/42 phenylbutazone patients dying of pulmonary embolism.

For the articles and FDA correspondence detailing the case for withdrawing the indications for anticoagulants (heparins and vitamin K antagonists) in prophylaxis and treatment of venous thromboembolism, see my website: [http://hometown.aol.com/~dkcundiff/home.htm ].

References

1. Barritt DW, Jordan SC. Anticoagulant drugs in the treatment of pulmonary embolism — A controlled trial. Lancet 1960;1: 1309-12 [PubMed]
2. Carson JL, Kelley MA, Duff A, et al. The clinical course of pulmonary embolism. N Engl J Med 1992;326: 1240-5 [PubMed]
3. Nielsen HK, Husted SE, Krusell LR, Fasting H, Charles P, Hansen HH. Silent pulmonary embolism in patients with deep venous thrombosis. Incidence and fate in a randomized, controlled trial of anticoagulation versus no anticoagulation. J Intern Med 1994;235: 457-61 [PubMed]
4. Nielsen HK, Husted SE, Krusell LR, et al. Anticoagulant therapy in deep venous thrombosis. A randomized controlled study. Thrombosis Res 1994;73: 215-26 [PubMed]

Articles from Journal of the Royal Society of Medicine are provided here courtesy of Royal Society of Medicine Press