New Class Of Medication Yields Better Outcomes: Direct Oral Anticoagulants Improve Treatment Success For Lower Extremity Acute DVT
Katherine Hekman, MD, Calvin Chao, MD, Courtney E. Morgan, MD, Irene B. Helenowski, MD, Mark K. Eskandari, MD.
Northwestern University, Chicago, IL, USA.
OBJECTIVEOptimal therapy for acute lower extremity deep venous thrombosis (DVT) remains an enigma. While clinical trials demonstrate non-inferiority with an oral anti-Xa inhibitor, or direct oral anticoagulant (DOAC), versus combined low molecular weight heparin (LMWH) and oral vitamin K agonist (VKA), the most effective regimen remains to be determined.
METHODSThis study is a single-center retrospective review from October 2014-December 2015 of patients with a diagnosis of acute DVT and subsequent serial lower extremity venous duplex. Demographics, medical history, medications, serial ultrasound findings as well as the primary anticoagulant used for treatment were collected and analyzed by two independent data extractors. Successful treatment was defined as no new DVT or progression of existing DVT within 3 months of diagnosis of the index clot. Risk factors for treatment failure were assessed using standard odds ratios and Fischer’s exact test.
RESULTS Among 496 patients with acute DVT, 54% (n=266) were men, mean age was 61 years, 35% (n=174) were popliteal or more proximal clots, and 445 had documentation of the primary treatment for DVT: 21% (n=93) received nothing; 20% (n=91) received an oral VKA; 34% (n=150) received a DOAC; 20% (n=88) received LMWH; and 5% (n=21) received another class of anticoagulant. Within 3 months, 21% (n=90 out of 427) had treatment failure defined as any new DVT or progression of prior DVT. Patients treated with a DOAC were less likely to experience treatment failure when compared with any other treatment (odds ratio 0.43; 95% confidence intervals [0.23, 0.78]; p=0.005), and when compared with traditional oral VKA (OR 0.44; 95% CI [0.21, 0.92]; p=0.029). None of prior history of DVT, pulmonary embolism, thrombophilia, renal insufficiency, hepatic insufficiency, cancer, or antiplatelet therapy correlated with treatment failure. Neither the number of anticoagulants (0-2 versus >2) nor the duration of treatment (<3 months versus 3+ months) correlated with treatment failure (p=0.12 and p=0.41, respectively). Proximal and distal DVTs showed no difference in treatment failure (19% versus 22%, respectively; p=0.43).
CONCLUSIONIn summary, the use of a DOAC for acute lower extremity DVT yielded better overall outcomes and fewer treatment failures at 3 months as compared to traditional oral VKA therapy based on serial duplex imaging.
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