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Importance of meta-analysis of long-term trials of low–molecular-weight heparin vs vitamin K antagonist in pulmonary embolism

Published:January 21, 2013DOI:https://doi.org/10.1016/j.ajem.2012.12.012
      Numerous studies as well as meta-analyses showed that low–molecular-weight heparin (LMWH) was better than vitamin K antagonist (VKA) in the long-term therapy for venous thromboembolism (VTE) [
      • Lopez-Beret P.
      • Orgaz A.
      • Fontcuberta J.
      • et al.
      Low molecular weight heparin versus oral anticoagulants in the long term treatment of deep venous thrombosis.
      ,
      • Daskalopoulos M.E.
      • Daskalopoulou S.S.
      • Tzortis E.
      • et al.
      Long-term treatment of deep venous thrombosis with a low molecular weight heparin (tinzaparin): a prospective randomised trial.
      ,
      • Hull R.D.
      • Pineo G.F.
      • Brant R.F.
      • et al.
      LITE Trial Investigators. Self-managed long-term low–molecular-weight heparin therapy: the balance of benefits and harms.
      ,
      • González-Fajardo J.A.
      • Martin-Pedrosa M.
      • Castrodeza J.
      • et al.
      Effect of the anticoagulant therapy in the incidence of post-thrombotic syndrome and recurrent thromboembolism: comparative study of enoxaparin versus coumarin.
      ,
      • Iorio A.
      • Guercini F.
      • Pini M.
      Low–molecular-weight heparin for the long-term treatment of symptomatic venous thromboembolism: meta-analysis of the randomized comparisons with oral anticoagulants.
      ,
      • Hull R.D.
      • Liang J.
      • Townshend G.
      Long-term low–molecular-weight heparin and the post-thrombotic syndrome: a systematic review.
      ]. This is mostly due to the recognized advantage of LMWH vs VKA in long-term VTE treatment of cancer patients [
      • Ferretti G.
      • Bria E.
      • Giannarelli D.
      • et al.
      Is recurrent venous thromboembolism after therapy reduced by low–molecular-weight heparin compared with oral anticoagulants?.
      ,
      • Romera-Villegas A.
      • Cairols-Castellote M.A.
      • Vila-Coll R.
      • et al.
      Long-term use of different doses of low–molecular-weight heparin versus vitamin K antagonists in the treatment of venous thromboembolism.
      ]. Otherwise, long-term LMWH and VKA are believed to have similar risk/benefit ratio in VTE or pulmonary thromboembolism (PTE) patients [
      • Romera-Villegas A.
      • Cairols-Castellote M.A.
      • Vila-Coll R.
      • et al.
      Long-term use of different doses of low–molecular-weight heparin versus vitamin K antagonists in the treatment of venous thromboembolism.
      ]. After the exclusion of studies enrolling only cancer patients, LMWH was somewhat better: there was a 21% reduction of the risk of recurrent symptomatic VTE during treatment in favor of LMWH vs VKA; but it was statistically nonsignificant [
      • Ferretti G.
      • Bria E.
      • Giannarelli D.
      • et al.
      Is recurrent venous thromboembolism after therapy reduced by low–molecular-weight heparin compared with oral anticoagulants?.
      ], whereas the risk of (major) bleeding was significantly lower in the LMWH group [
      • Iorio A.
      • Guercini F.
      • Pini M.
      Low–molecular-weight heparin for the long-term treatment of symptomatic venous thromboembolism: meta-analysis of the randomized comparisons with oral anticoagulants.
      ,
      • van der Heijden J.F.
      • Hutten B.A.
      • Büller H.R.
      • et al.
      Vitamin K antagonists or low–molecular-weight heparin for the long term treatment of symptomatic venous thromboembolism.
      ] or at least similar [
      • Ferretti G.
      • Bria E.
      • Giannarelli D.
      • et al.
      Is recurrent venous thromboembolism after therapy reduced by low–molecular-weight heparin compared with oral anticoagulants?.
      ], which is important, indeed.
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