In the previously published RE-LY trial, dabigatran was non-inferior to warfarin in stroke prevention in patients with afib. In this pre-specified sub-group analysis, dabigatran performed better (for preventing vascular events and mortality) than warfarin at sites with poor warfarin control (i.e. higher time to therapeutic INR). Dabigatran may be better than “non-inferior” to warfarin in “real life”, where INR control is worse than in clinical trials (abstract)

In this large retrospective analysis of an ICU, the amount of blood transfused significantly decreased from 1997 to 2007. The percent of patients transfused decreased from 31% to 18%, the mean hemoglobin level before transfusion decreased from 7.9 to 7.3, and the mean number of transfusions decreased from 4.3 to 3.0. ICU transfusion practices have become more restrictive in accordance with clinical guideline recommendations (abstract)

In this trial of 200 hip fracture patients, they were randomized to IV iron or standard treatment. The iron group had lower rates of blood transfusions (41% vs 33%), which was significantly lower in the subgroup of patients with intra-capsular fractures (46% vs 14%). There were no significant differences in LOS or mortality. IV iron peri-operatively may reduce transfusion need in patients with hip fractures (abstract)

The 11 variable PE severity index (PESI) score accurately predicts the 30 day risk of death, but can be cumbersome to use. This study derived and validated a simpler 6 variable score, based on age, cancer, chronic pulmonary disease, heart rate, blood pressure, and oxygen saturation, which performed just as well as the 11 variable score. This simplified score is easier to use and has the same predictive value as the 11 variable score (abstract)

In this Cochrane meta-analysis, graduated compression stockings (GCS) were effective at reducing VTE in hospitalized patients, with the GCS group developing VTE at 13% and the control group at 26% (OR=0.35, CI 0.26-0.77) In those managed with GCS in addition to another prophylactic therapy, the rates were 4% versus 16% (OR=0.25, CI 0.17-0.36). Although the results of this meta-analysis are not surprising, they do help to quantify the risk reduction associated with the use of GCS (abstract)

Extended VTE prophylaxis in surgical patients is beneficial, but the appropriate duration of VTE prophylaxis in medical inpatients is unknown. In this large multi-national industry-sponsored trial, acutely ill medical patients >age 40 with limited mobility (bedrest OR bathroom privileges with another VTE risk factor) were randomized to enoxaparin 40mg/day for a month (after open label enoxaparin for 10-14 days). Extended VTE prophylaxis significantly reduced the risk of VTE (2.5% vs 4%), but at the expense of higher rates of bleeding (0.8% vs 0.3%). The subgroups that benefitted the most from extended prophylaxis were women, those >age 75, and those on bedrest (abstract). There was no benefit for extended prophylaxis in those with bathroom privileges, unless they had another VTE risk factor (age >75, cancer, or history of VTE).

In this retrospective cohort of inpatients on VTE thromboprophylaxis, only about 3/4 of those on LMWH and about 1/2 of those on UFH received all of their scheduled doses. Of the missed doses, 39%-44% were due to patient refusal. This study highlights the critical need for patient education, to ensure appropriate adherence of VTE thromboprophylaxis (abstract)

In this Cochrane meta-analysis, researchers analyzed the overall efficacy and safety of direct thrombin inhibitors, compared to warfarin or LMWH, in preventing VTE after orthopedic surgeries (hip and knee arthroplasty). In14 studies involving over 20,000 participants, they found no difference in efficacy between direct thrombin inhibitors, warfarin, or LMWH, but did find higher mortality and bleeding in the thrombin group compared to LMWH (but no difference between the thrombin group and warfarin) (abstract). The timing of the thrombin inhibitors also matters, as pre-operative dosing results in fewer VTE’s but likely higher bleeding. Dabigatran is the oral direct thrombin inhibitor that is currently approved in Canada and throughout Europe, but US FDA approval is pending.

In this retrospective analysis of over 170,000 patients with Afib, of the 18% who were at high risk of stroke (CHADS2 score of 3-6), only 42% of them were receiving anticoagulation with warfarin. The % on warfarin was not much different from those in low risk group (CHADS2 score of 0; 40% were on warfarin) or in the moderate risk group (CHADS2 score of 1-2; 44% were on warfarin). Only about a third of patients in each group received continuous warfarin for 6 months. This study highlights the inadequacies of treating high risk stroke patients with warfarin therapy, and the difficulties in keeping them on continuous therapy (abstract)

In this systematic review, researchers found that 32% of patients with DVT and no PE symptoms had diagnostic evidence of PE. Although the authors conclude that routine PE screening in patients with DVT may be advantageous, this is only true if it will change the short or long term management of the patient (abstract)