Venous thromboembolism: Difference between revisions

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'''Editors-in-Chief:''' [[C. Michael Gibson, M.S., M.D.]]  '''Associate Editor-In-Chief''': [[User:Ujjwal Rastogi|Ujjwal Rastogi, MBBS]] [mailto:urastogi@perfuse.org]
{{Hypertriglyceridemia}}
{{Thrombosis}}
 
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[Priyamvada Singh|Priyamvada Singh, M.B.B.S.]] [mailto:psingh@perfuse.org]


==Overview==
==Overview==
Venous thromboembolism (VTE) is a hypernym which includes [[Deep venous thrombosis]] (DVT) and [[pulmonary embolism]] (PE). It is a major public health problem and one of the most common cause of preventable cause of death in hospital patients. It is the third most common cardiovascular disorder after [[coronary artery disease]] and [[stroke]]. It is frequently underestimated and misdiagnosed and failure to provide adequate prophylaxis and therapy can be fatal for the patient.
Treatment of hypertriglyceridemia is by restriction of carbohydrates and fat in the [[diet (nutrition)|diet]], as well as with [[niacin]], [[fibrate]]s and [[statin]]s (three classes of drugs).  Increased [[fish oil]] intake may substantially lower an individual's triglycerides.<ref>{{cite web |url=http://www.lipidsonline.org/slides/slide01.cfm?q=hypertriglyceridemia&dpg=13 |title=Lipids Online Slides: hypertriglyceridemia, ICAM-1, fish oil, E-selectin | format= |work=}}</ref><ref name="pmid2035283">{{cite journal |author=Terres W, Beil U, Reimann B, Tiede S, Bleifeld W |title=[Low-dose fish oil in primary hypertriglyceridemia. A randomized placebo-controlled study] |language=German |journal=Zeitschrift für Kardiologie |volume=80 |issue=1 |pages=20-4 |year=1991 |pmid=2035283 |doi=}}</ref><ref>{{cite web |url=http://www.findarticles.com/p/articles/mi_m0887/is_n4_v9/ai_8960077 |title=Fish oils in hypertriglyceridemia - Fish Oils Revisited Nutrition Research Newsletter - Find Articles |format= |work=}}</ref>. [[Clinical practice guidelines]] by the [[National Cholesterol Education Program]] (NCEP) suggests that pharmacotherapy be considered with triglycerides are over 200 mg/dl.<ref name="pmid11368702">{{cite journal |author= |title=Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III) |journal=JAMA |volume=285 |issue=19 |pages=2486-97 |year=2001 |pmid=11368702 |doi=|url=http://jama.ama-assn.org/cgi/content/full/285/19/2486}}</ref> The guidelines state "the sum of LDL + VLDL cholesterol (termed non-HDL cholesterol [total cholesterol - HDL cholesterol]) as a secondary target of therapy in persons with high triglycerides (200 mg/dL). The goal for non-HDL cholesterol in persons with high serum triglycerides can be set at 30 mg/dL higher than that for LDL cholesterol on the premise that a VLDL cholesterol level 30 mg/dL is normal."<ref name="pmid11368702"/>
 
==Classification Scheme==
VTE includes DVT and PE, which are further divided into:
*[[Deep Venous Thrombosis]]: Its classified as
**Superficial
**Upper extremity
**Isolated Calf
**Proximal
 
*[[Pulmonary embolism]]:its classified as
**Silent
**Symptomatic
**Fatal
 
==Epidemiology==
Annualy, more than 900,000 cases are reported to have clinicaly evident Venous thromboembolism. More than 300,000 deaths are attributed to pulmonary embolism in United states<ref name="pmid18296591">{{cite journal| author=Heit JA| title=The epidemiology of venous thromboembolism in the community. | journal=Arterioscler Thromb Vasc Biol | year= 2008 | volume= 28 | issue= 3 | pages= 370-2 | pmid=18296591 | doi=10.1161/ATVBAHA.108.162545 | pmc=PMC2873781 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18296591  }} </ref>.


==Risk Factors==
==Treatment==
==[[Adult Treatment Panel guidelines (ATP III) for serum triglyceride|ATP III guidelines for LDL and Non-HDL Cholesterol]]==
==[[Adult Treatment Panel guidelines (ATP III) for serum triglyceride|ATP III classification for serum triglyceride]]==


A group of researchers have come up with a risk-prediction algorithm for VTE, to start prophylaxis in patients at risk for VTE.
==Drug therapy==
The various variables are as follows<ref name="pmid21846713">{{cite journal| author=Hippisley-Cox J, Coupland C| title=Development
and validation of risk prediction algorithm (QThrombosis) to estimate future risk of venous thromboembolism:
prospective cohort study. | journal=BMJ | year= 2011 | volume= 343 | issue=  | pages= d4656 | pmid=21846713 | doi=10.1136/bmj.d4656
| pmc=PMC3156826 | url= }} </ref>


{|style="background:LightSkyBlue" border="1"
{|border="1" align="center" style="background:light gray"
|-
|-
|Age
| bgcolor="Gray" |''' Drug '''
|(continuous)
| bgcolor="Gray" |''' Mechanism of benefit '''
| bgcolor="Gray" |''' Dosage '''
| bgcolor="Gray" |''' Formulation '''
| bgcolor="Gray" |''' Advantages '''
| bgcolor="Gray" |''' Side-effects '''
| bgcolor="Gray" |''' Contraindication '''
|-
|-
|Body mass index
| '''Niacin/Nicotinic acid'''
|(continuous)
|  
* Reduces [[low density lipoprotein]] (LDL) (17-26%)<ref name="pmid17804845">{{cite journal| author=Brunzell JD| title=Clinical practice. Hypertriglyceridemia. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 10 | pages= 1009-17 | pmid=17804845 | doi=10.1056/NEJMcp070061 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17804845  }} </ref>
* Increases [[high density lipoprotein]] (HDL)
| 1.5 - 2 gm once daily
|
* Crystalline
* Extended release form
|
* [[Statin]] alone or combination therapy of niacin with statin are usually the first options in [[premature coronary artery disease]].
* Decreases [[atherosclerosis]] in [[hypertriglyceridemia]] patients.
|
* Flushing
* Pruritus
* Nausea
* Hepatitis (higher doses)
|
* Hypersensitivity
* Hepatic disease
|-
|-
|Smoking status
|(non-smoker; ex-smoker; light, moderate, or heavy smoker)
|-
|-
|Townsend deprivation score
| '''Omega-3 fatty acids'''
|(continuous)
|  
* Decreases hepatic [[lipogenesis]]
* Increases plasma [[lipoprotein lipase]] activity.
* Increases hepatic mitochondrial and peroxisomal [[beta-oxidation]]
* Inhibition of acyl CoA:1,2-[[diacylglycerol acyltransferase]] enzyme
* [[EPA]]and [[DHA]] are poor enzyme substrates for [[triglyceride]] synthesis in [[liver]] & inhibits esterification of other fatty acids.
|
* 3 g/day of EPA and DHA is under FDA's "[[Generally Recognized As Safe]]" category. <ref name="pmid16825676">{{cite journal| author=Wang C, Harris WS, Chung M, Lichtenstein AH, Balk EM, Kupelnick B et al.| title=n-3 Fatty acids from fish or fish-oil supplements, but not alpha-linolenic acid, benefit cardiovascular disease outcomes in primary- and secondary-prevention studies: a systematic review. | journal=Am J Clin Nutr | year= 2006 | volume= 84 | issue= 1 | pages= 5-17 | pmid=16825676 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16825676  }} </ref>
* Higher doses increases risk of bleeding
|
* Fatty fish (salmon,Herring), flaxseed, flaxseed oil, canola oil, soybean oil, and nuts.
* Capsule
|
* Decreases [[very low-density lipoprotein]] [[VLDL]] <ref name="pmid6736254">{{cite journal| author=Nestel PJ, Connor WE, Reardon MF, Connor S, Wong S, Boston R| title=Suppression by diets rich in fish oil of very low density lipoprotein production in man. | journal=J Clin Invest | year= 1984 | volume= 74 | issue= 1 | pages= 82-9 | pmid=6736254 | doi=10.1172/JCI111422 | pmc=PMC425187 | url= }} </ref>, <ref name="pmid11303007">{{cite journal| author=Durrington PN, Bhatnagar D, Mackness MI, Morgan J, Julier K, Khan MA et al.| title=An omega-3 polyunsaturated fatty acid concentrate administered for one year decreased triglycerides in simvastatin treated patients with coronary heart disease and persisting hypertriglyceridaemia. | journal=Heart | year= 2001 | volume= 85 | issue= 5 | pages= 544-8 | pmid=11303007 | doi= | pmc=PMC1729738 | url= }} </ref>
* Decreases serum triglyceride by ≥ 50%
|
* [[Bleeding]] at high doses
* Fishy smell, Can be reduced by
** Freezing of medication
** Trying different formulation
** Taking medication with food
* [[Nausea]]
(approximately 4 % of individuals at < 3 gm/d, and 20% at > 4gm/d experiences git side-effects)<ref name="pmid16825676">{{cite journal| author=Wang C, Harris WS, Chung M, Lichtenstein AH, Balk EM, Kupelnick B et al.| title=n-3 Fatty acids from fish or fish-oil supplements, but not alpha-linolenic acid, benefit cardiovascular disease outcomes in primary- and secondary-prevention studies: a systematic review. | journal=Am J Clin Nutr | year= 2006 | volume= 84 | issue= 1 | pages= 5-17 | pmid=16825676 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16825676  }} </ref>
|
* Hypersensitivity
|-
|-
|Varicose veins
| '''Fibrate'''
|(yes/no)
|
* Decreases triglyceride
* Decreases LDL
|
* Gemfibrozil 600mg BD
* Fenofibrate 145 mg OD
|
|
* Decreases non-fatal myocardial infarction
* No benefit on HDL levels, fatal coronary events or total mortality
|
* Myositis
* Gallbladder stone
|
* Hypersensitivity
* Hepatic disease
* End stage renal disease
|-
|-
|Congestive cardiac failure
|(yes/no)
|-
|Rheumatoid arthritis
|(yes/no)
|-
|Chronic renal disease
|(yes/no)
|-
|Inflammatory bowel disease
|(yes/no)
|-
|Cancer
|(lung, gastrointestinal, pancreas, renal, breast, prostate, other)
|-
|Recent hospital admission
|yes/no)
|-
|Recent hip fracture or hip surgery (or both)
|yes/no)
|-
|Current use of antipsychotic drugs
|(none, atypical, typical)
|-
|Current use of tamoxifen
|(yes/no)
|-
|Current use of hormone replacement therapy
|(none, equine or non-equine hormone replacement therapy)
|-
|Use of antiplatelets
|(yes/no)
|-
|Cardiovascular disease
|(stroke, transient ischaemic attack, or coronary heart disease)
|-
|Atrial fibrillation
|(yes/no)
|-
|Asthma
|(yes/no)
|-
|Chronic obstructive pulmonary disease
|(yes/no)
|-
|Family history of venous thromboembolism
|(yes/no)
|}
|}


==See also==
To calculate the risk prediction click [http://www.qthrombosis.org/index.php|here ]
*[[Venous thromboembolism: Under-recognized and under-treated]]
 
*[[Deep vein thrombosis]]  
==Supportive trial data==
*[[Pulmonary embolism]]
===[[Hypertriglyceridemia fibric acid|Fibric acid]]===
*[[Thrombosis]]
===[[Hypertriglyceridemia niacin|Niacin]]===
===[[Hypertriglyceridemia omega-3 fatty acids|Omega-3 fatty acids]]===
===[[Hypertriglyceridemia statin|Statin]]===


==References==
==References==
{{reflist|2}}
{{Reflist|2}}
 
[[fr:Hypertriglycéridémie]]
[[pt:Hipertrigliceridemia]]


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Revision as of 20:15, 5 October 2011

Template:Hypertriglyceridemia

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Priyamvada Singh, M.B.B.S. [2]

Overview

Treatment of hypertriglyceridemia is by restriction of carbohydrates and fat in the diet, as well as with niacin, fibrates and statins (three classes of drugs). Increased fish oil intake may substantially lower an individual's triglycerides.[1][2][3]. Clinical practice guidelines by the National Cholesterol Education Program (NCEP) suggests that pharmacotherapy be considered with triglycerides are over 200 mg/dl.[4] The guidelines state "the sum of LDL + VLDL cholesterol (termed non-HDL cholesterol [total cholesterol - HDL cholesterol]) as a secondary target of therapy in persons with high triglycerides (200 mg/dL). The goal for non-HDL cholesterol in persons with high serum triglycerides can be set at 30 mg/dL higher than that for LDL cholesterol on the premise that a VLDL cholesterol level 30 mg/dL is normal."[4]

Treatment

ATP III guidelines for LDL and Non-HDL Cholesterol

ATP III classification for serum triglyceride

Drug therapy

Drug Mechanism of benefit Dosage Formulation Advantages Side-effects Contraindication
Niacin/Nicotinic acid 1.5 - 2 gm once daily
  • Crystalline
  • Extended release form
  • Flushing
  • Pruritus
  • Nausea
  • Hepatitis (higher doses)
  • Hypersensitivity
  • Hepatic disease
Omega-3 fatty acids
  • Fatty fish (salmon,Herring), flaxseed, flaxseed oil, canola oil, soybean oil, and nuts.
  • Capsule
  • Bleeding at high doses
  • Fishy smell, Can be reduced by
    • Freezing of medication
    • Trying different formulation
    • Taking medication with food
  • Nausea

(approximately 4 % of individuals at < 3 gm/d, and 20% at > 4gm/d experiences git side-effects)[6]

  • Hypersensitivity
Fibrate
  • Decreases triglyceride
  • Decreases LDL
  • Gemfibrozil 600mg BD
  • Fenofibrate 145 mg OD
  • Decreases non-fatal myocardial infarction
  • No benefit on HDL levels, fatal coronary events or total mortality
  • Myositis
  • Gallbladder stone
  • Hypersensitivity
  • Hepatic disease
  • End stage renal disease

To calculate the risk prediction click [3]

Supportive trial data

Fibric acid

Niacin

Omega-3 fatty acids

Statin

References

  1. ↑ "Lipids Online Slides: hypertriglyceridemia, ICAM-1, fish oil, E-selectin".
  2. ↑ Terres W, Beil U, Reimann B, Tiede S, Bleifeld W (1991). "[Low-dose fish oil in primary hypertriglyceridemia. A randomized placebo-controlled study]". Zeitschrift für Kardiologie (in German). 80 (1): 20–4. PMID 2035283.
  3. ↑ "Fish oils in hypertriglyceridemia - Fish Oils Revisited Nutrition Research Newsletter - Find Articles".
  4. ↑ 4.0 4.1 "Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III)". JAMA. 285 (19): 2486–97. 2001. PMID 11368702.
  5. ↑ Brunzell JD (2007). "Clinical practice. Hypertriglyceridemia". N Engl J Med. 357 (10): 1009–17. doi:10.1056/NEJMcp070061. PMID 17804845.
  6. ↑ 6.0 6.1 Wang C, Harris WS, Chung M, Lichtenstein AH, Balk EM, Kupelnick B; et al. (2006). "n-3 Fatty acids from fish or fish-oil supplements, but not alpha-linolenic acid, benefit cardiovascular disease outcomes in primary- and secondary-prevention studies: a systematic review". Am J Clin Nutr. 84 (1): 5–17. PMID 16825676.
  7. ↑ Nestel PJ, Connor WE, Reardon MF, Connor S, Wong S, Boston R (1984). "Suppression by diets rich in fish oil of very low density lipoprotein production in man". J Clin Invest. 74 (1): 82–9. doi:10.1172/JCI111422. PMC 425187. PMID 6736254.
  8. ↑ Durrington PN, Bhatnagar D, Mackness MI, Morgan J, Julier K, Khan MA; et al. (2001). "An omega-3 polyunsaturated fatty acid concentrate administered for one year decreased triglycerides in simvastatin treated patients with coronary heart disease and persisting hypertriglyceridaemia". Heart. 85 (5): 544–8. PMC 1729738. PMID 11303007.

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