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Meta-Analysis
. 2014 May 7;2014(5):CD003747.
doi: 10.1002/14651858.CD003747.pub4.

Heparin for the prevention of venous thromboembolism in acutely ill medical patients (excluding stroke and myocardial infarction)

Raza Alikhan  1 , Rachel Bedenis, Alexander T Cohen
Affiliations
Meta-Analysis

Heparin for the prevention of venous thromboembolism in acutely ill medical patients (excluding stroke and myocardial infarction)

Raza Alikhan et al. Cochrane Database Syst Rev. .

Abstract

Background: Venous thromboembolic disease has been extensively studied in surgical patients. The benefit of thromboprophylaxis is now generally accepted, but it is medical patients who make up the greater proportion of the hospital population. Medical patients differ from surgical patients with regard to their health and the pathogenesis of thromboembolism and the impact that preventative measures can have. The extensive experience from thromboprophylaxis studies in surgical patients is therefore not necessarily applicable to non-surgical patients. This is an update of a review first published in 2009.

Objectives: To determine the effectiveness and safety of heparin (unfractionated heparin or low molecular weight heparin) thromboprophylaxis in acutely ill medical patients admitted to hospital, excluding those admitted to hospital with an acute myocardial infarction or stroke (ischaemic or haemorrhagic) or those requiring admission to an intensive care unit.

Search methods: For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched November 2013) and CENTRAL (2013, Issue 10).

Selection criteria: Randomised controlled trials comparing unfractionated heparin (UFH) or low molecular weight heparin (LMWH) with placebo or no treatment, or comparing UFH with LMWH.

Data collection and analysis: One review author identified possible trials and a second review author confirmed their eligibility for inclusion in the review. Two review authors extracted the data. Disagreements were resolved by discussion. We performed the meta-analysis using a fixed-effect model with the results expressed as odds ratios (ORs) with 95% confidence intervals (CIs).

Main results: Sixteen studies with a combined total of 34,369 participants with an acute medical illness were included in this review. We identified 10 studies comparing heparin with placebo or no treatment and six studies comparing LMWH to UFH. Just under half of the studies had an open-label design, putting them at a risk of performance bias. Descriptions of random sequence generation and allocation concealment were missing in most of the studies. Heparin reduced the odds of deep vein thrombosis (DVT) (OR 0.38; 95% CI 0.29 to 0.51; P < 0.00001). The estimated reductions in symptomatic non-fatal pulmonary embolism (PE) (OR 0.46; 95% CI 0.19 to 1.10; P = 0.08), fatal PE (OR 0.71; 95% CI 0.43 to 1.15; P = 0.16) and in combined non-fatal PE and fatal PE (OR 0.65; 95% CI 0.42 to 1.00; P = 0.05) associated with heparin were imprecise. Heparin resulted in an increase in major haemorrhage (OR 1.81; 95% CI 1.10 to 2.98; P = 0.02). There was no clear evidence that heparin had an effect on all-cause mortality and thrombocytopaenia. Compared with UFH, LMWH reduced the risk of DVT (OR 0.77; 95% CI 0.62 to 0.96; P = 0.02) and major bleeding (OR 0.43; 95% CI 0.22 to 0.83; P = 0.01). There was no clear evidence that the effects of LMWH and UFH differed for the PE outcomes, all-cause mortality and thrombocytopaenia.

Authors' conclusions: The data from this review describe a reduction in the risk of DVT in patients presenting with an acute medical illness who receive heparin thromboprophylaxis. This needs to be balanced against an increase in the risk of bleeding associated with thromboprophylaxis. The analysis favoured LMWH compared with UFH, with a reduced risk of both DVT and bleeding.

PubMed Disclaimer

Conflict of interest statement

Dr Alikhan has received travel expenses to attend educational meetings from the following companies marketing parenteral anticoagulants: Aventis, Leo Pharma and Pfizer.

Dr Cohen is a medical consultant and has received consultancy and clinical trial funding from many pharmaceutical companies, including Bayer, Boehringer‐Ingelheim, BMS, Daiichi, GSK, Johnson and Johnson, Mitsubishi Pharma, Pfizer, Portola, Sanofi‐Avenits, Schering Plough, and Takeda. He is an advisor to the UK Government Health Select Committee, the all‐party working group on thrombosis, the Department of Health, and the NHS on the prevention of VTE. He is also an advisor to Lifeblood, the thrombosis charity, and is the founder of the European educational charity the Coalition to Prevent Venous Thromboembolism. Dr Cohen is one of the principal investigators of the Medenox (MEDENOX 1999), Prevent (PREVENT 2004) and Exclaim (EXCLAIM) trials.

A member of the PVD editorial base performed data extraction and risk of bias assessment on studies where both Dr Alikhan and Dr Cohen were involved.

Figures

1
1
Study flow diagram.
2
2
Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
3
3
Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
1.1
1.1. Analysis
Comparison 1 Heparin versus placebo or no treatment, Outcome 1 Deep vein thrombosis.
1.2
1.2. Analysis
Comparison 1 Heparin versus placebo or no treatment, Outcome 2 Non‐fatal pulmonary embolism.
1.3
1.3. Analysis
Comparison 1 Heparin versus placebo or no treatment, Outcome 3 Fatal pulmonary embolism.
1.4
1.4. Analysis
Comparison 1 Heparin versus placebo or no treatment, Outcome 4 Combined non‐fatal and/or fatal pulmonary embolism.
1.5
1.5. Analysis
Comparison 1 Heparin versus placebo or no treatment, Outcome 5 All cause mortality.
1.6
1.6. Analysis
Comparison 1 Heparin versus placebo or no treatment, Outcome 6 Major bleeding.
1.7
1.7. Analysis
Comparison 1 Heparin versus placebo or no treatment, Outcome 7 Minor bleeding.
1.8
1.8. Analysis
Comparison 1 Heparin versus placebo or no treatment, Outcome 8 Thrombocytopaenia.
2.1
2.1. Analysis
Comparison 2 Low molecular weight heparin versus unfractionated heparin, Outcome 1 Deep vein thrombosis.
2.2
2.2. Analysis
Comparison 2 Low molecular weight heparin versus unfractionated heparin, Outcome 2 Non‐fatal pulmonary embolism.
2.3
2.3. Analysis
Comparison 2 Low molecular weight heparin versus unfractionated heparin, Outcome 3 Fatal pulmonary embolism.
2.4
2.4. Analysis
Comparison 2 Low molecular weight heparin versus unfractionated heparin, Outcome 4 Combined non‐fatal and/or fatal pulmonary embolism.
2.5
2.5. Analysis
Comparison 2 Low molecular weight heparin versus unfractionated heparin, Outcome 5 All cause mortality.
2.6
2.6. Analysis
Comparison 2 Low molecular weight heparin versus unfractionated heparin, Outcome 6 Major bleeding.
2.7
2.7. Analysis
Comparison 2 Low molecular weight heparin versus unfractionated heparin, Outcome 7 Minor bleeding.
2.8
2.8. Analysis
Comparison 2 Low molecular weight heparin versus unfractionated heparin, Outcome 8 Thrombocytopaenia.
See this image and copyright information in PMC

Update of

References

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