Henry I. Bussey, Pharm.D.
Performing “toe raises” or calf flexing exercises is one method that has long been recommended as a way to promote blood flow in the legs in order to reduce the risk of developing blood clots in the legs (deep vein thrombosis or DVT) while on long flights. More recently some have voiced concerns about a similar risk for those of us who sit for long periods of time at our computers. To be honest, I try to do calf flexor exercises when working at my computer; but if I’m working intently, it simply is hard to remember to do so. An individual in the United Kingdom recently designed a sort of shoe that may help with this issue. The shoe has a curved bottom to facilitate such calf flexor exercises. You can learn more about these devices at http://www.calf-flexors.com/index.html I’ve been told that a large, international pharmacy chain is interested in bringing these devices to market in the U.S. While these devices would seem to be a good way to promote more exercise to increase circulation while sitting for long periods of time, I must admit that I am not aware of scientific data to prove this hypothesis or to confirm that use of the devices actually has the desired effect. But the concept certainly seems logical.
from Henry I. Bussey, Pharm.D.
What largely preventable condition kills more people each year in Europe and the U.S. than breast cancer, prostate cancer, motor vehicle accidents, and AIDS COMBINED? According to the World Thrombosis Day (WTD) group of the International Society of Thrombosis and Hemostasis, the condition is venous thrombolism (VTE). A new international study by the WTD group, however, reveals that approximately only half of those surveyed were aware of VTE, which includes deep vein thrombosis (DVT or blood clots in the legs) and pulmonary embolism (PE or blood clots in the lungs). And even fewer were able to identify risk factors for VTE, the usual symptoms, or that most VTEs can be prevented. Clearly there is a major international need to increase awareness of the risks of VTE and what can be done to prevent these potentially catastrophic and deadly events.
The entire study results are available online at http://onlinelibrary.wiley.com/doi/10.1111/jth.13031/abstract
Stay tuned for more information as World Thrombosis Day (Oct. 13th) approaches.
A group at Johns Hopkins Medical Center has been working (with support from ClotCare) to develop and promote ways to increase patient awareness of issues related to venous thrombosis (VTE). That group just provided ClotCare with the following message which also includes a link to a new patient-focused video.
In 2013, we were awarded a contract by the Patient-Centered Outcomes Research Institute (PCORI) with the goal of increasing patient understanding and improving patient-nurse communication about the harm of venous thromboembolism (VTE) and the benefits of preventive treatment. In partial fulfilment of this goal, we have developed a patient education video. The video was developed with significant input from patients and stakeholder organizations including Clot Care, North American Thrombosis Forum (NATF), National Blood Clot Alliance (NBCA) and the Johns Hopkins Hospital Patient and Family Advisory Council (JHH PFAC). Input was obtained through the Delphi Survey, multiple focus groups including a meeting with the JHH PFAC, and from participants at our 2015 VTE Symposium. Now that the video has been fully developed and launched, we would like it to be made widely available. It is already posted on our newly developed website, YouTube, Twitter and Facebook and has received an impressive response so far. To further enhance the reach of this important educational tool, we are requesting your help in disseminating it to your networks via your social media pages and your organizations’ websites. You can access the video at http://bit.ly/bloodclots.
Thank you and we look forward to your continuing partnership. The Johns Hopkins VTE Collaborative Elliott R. Haut MD PhD FACS, Michael B. Streiff MD FACP, Peggy S. Kraus PharmD CACP, Brandyn D. Lau MPH CPH, Deborah B. Hobson BSN, Kenneth Shermock PharmD PhD, Norma E. Farrow BA, Dauryne L. Shaffer MSN RN CCRN, Victor O. Popoola MBBS MPH Sc.M
Join the Anticoagulation Forum for the 3rd Anticoagulation Boot Camp, July 23rd and 24th, 2015 in Boston.
This compact 2-day conference offers comprehensive learning for those new to anticoagulation or a refresher on updates on the changing practice of anticoagulation.
The AC Forum expert faculty will provide an interactive setting in a small group learning model with plenty of time for Q&A and dynamic discussion. Nursing and pharmacy CE credits will be provided.
Prior programs have sold out so register soon to secure your spot. Visit http://www.acforumbootcamp.org for more information or to register.
by Henry I. Bussey, Pharm.D.
The National Heart Lung and Blood Institute (NHLBI) of the National Institutes of Health has invited submissions of study ideas. I submitted a suggestion that warfarin managed with INR self testing and online monitoring and management should be compared with one of the new oral anticoagulants in patients with atrial fibrillation. Visitors to the NHLBI at http://nhlbistrategicvisioning.ideascale.com/ can view the submissions. If you click on “Browse Submissions” that will take you to a page where you can enter “warfarin” to search the submissions and that will bring up my submission and one other. Please take a look at what I submitted and see if you would like to vote for the submission and/or add a comment. Thank you.
Susan C Fagan, Pharm.D.
At the International Stroke Conference in Nashville, TN, in February, 2015, worldwide headlines were made upon the presentation of 3 independent clinical trials, all proving that endovascular thrombectomy (removal of clot from inside the artery), in selected patients with proximal cerebral artery occlusion, dramatically improves the likelihood of a good outcome at 90 days. The audience, which included stroke specialists and scientists from around the world, broke into sustained applause at the robustly positive results, representing the FIRST really good news in stroke care since the 1995 presentation of the NINDS tPA Stroke Trial (tPA is “clot-busting” drug).
The ESCAPE (North America and the UK)1, EXTEND-IA (Australia and New Zealand)2, and the SWIFT-PRIME (Global) trials were all stopped early because of the previously reported positive results of intraarterial reperfusion therapy from the Netherlands (MR CLEAN)3. In the MR Clean trial, 88% of patients in the IA treated arm received endovascular therapy with a stent retriever, as was the case in the other 3 trials. Both ESCAPE and EXTEND-IA were published together in March, 2015. SWIFT-PRIME has yet to be published.
In all of these trials, stroke patients had to have a proximal occlusion of a large artery (usually the MCA), visible on angiography, and amenable to thrombectomy. Patients had to be treated within 6 hours of onset in SWIFT-PRIME and EXTEND-IA and within 12 hours in ESCAPE. These severely-afflicted patients tend to have dire consequences whether or not they receive intravenous (IV) tPA, with less than 30% of patients achieving independence at 90 days. Another key contributor to the positive impact of thrombectomy was the use of imaging criteria to identify patients with good collateral flow and salvageable tissue.
When the Solitaire stent retriever (see picture above) was advanced through the clot, expanded to “capture” the clot and then removed with the help of suction, there was a vast improvement in the number of patients achieving reperfusion at 24 hours compared to IV tPA alone (100% vs. 37%, p<0.001, in the EXTEND-IA trial), which probably explained the improved outcomes at 90 days in all three trials. In the ESCAPE trial, the largest of the 3 at 316 patients, there was an almost doubling (53% vs. 29%, p<0.001) in the number of patients independent at 90 days and the intervention group also had lower mortality (10.4% vs. 19.0%; p=0.04). There was NO increase in symptomatic intracerebral hemorrhage in any of the 3 trials (over tPA alone), although the statistical power to detect a difference was reduced by stopping study enrollment early (especially in the EXTEND-IA trial which only had 70 patients).
Take away points for clinicians:
- Only ischemic stroke patients with severe stroke, proximal MCA occlusion and good collaterals (small infarct core on imaging) are good candidates for this therapy and this represents <2% of all patients.
- Patients with these characteristics should be transported to a center where this intervention is available since it dramatically improves their chance of a good recovery. Reorganization of stroke care is occurring feverishly at stroke centers around the world to accommodate this new evidence. It is likely that guidelines will change in the near future!
- The Solitaire device (stent retriever) represents advanced technology that more effectively removes the clot and restores perfusion than previously available devices.
- The score is : Reperfusion : 2; Neuroprotection: 0 for ischemic stroke care
- Goyal M, Demchuk AM, Menon BK et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 2015;372:1019-1030 http://www.nejm.org/doi/full/10.1056/NEJMoa1414905
- Campbell BCV, Mitchell PJ, Kleinig TJ et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med 2015;373:1009-1018 http://www.nejm.org/doi/full/10.1056/NEJMoa1414792
- Berkhemer OA, Fransen PSS, Beumer D et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 2015;372:11-20 http://www.nejm.org/doi/pdf/10.1056/NEJMoa1411587
Henry I. Bussey, Pharm.D., FCCP
For those who want to raise awareness about the risks of thrombosis and/or learn about the most recent advances in preventing and/or treating these conditions, April and May offer at least four excellent opportunities.
April 9, 2015 in Boston, MA: The North American Thrombosis Forum (NATF) is having its Annual Spring Educational Program “New Pathways for Thromboembolic Disease Prevention” See http://natfonline.org/
April 23-25, 2015 in Washington, DC: The Anticoagulation Forum is having its biennial national meeting, See http://acforum.org/#&panel1-1
May 1, 2015 in Pittsburgh, PA: The Institute for Transfusion Medicine will be holding its annual one-day seminar on “Advances in Hemostasis and Thrombosis”, see http://www.itxmdiagnostics.com/UserFiles/file/2015%20Cascade%20Brochure.pdf
May 10, 2015 Chicago, IL: ClotCare Editorial Board member, Edith Nutescu, Pharm.D., has been working with organizer, Chistina Martin, to promote the “StopTheClot” 5K race in Chicago on Mothers’ Day. For more information see www.stoptheclotchicago.com This event is to raise awareness about the problem of thrombosis, and proceeds will help support the National Blood Clot Alliance