Open Access Medical Books


Edited by Mohammed A. Abdelaal .

The estimated total number of symptomatic venous thromboembolism (VTE) events 
per annum within six European communities was 465,715 cases of DVT; 295,982 cases 
of PE and 370,012 VTE related deaths and almost three quarters of all VTE-related 
deaths were hospital–acquired deaths.
Across the Atlantic, VTE is a major health problem in the USA with the annual 
incidence of VTE of 108 per 100,000 person/year among Caucasians, with 250,000
incident cases occurring annually among the Caucasians in the United States. Among 
African Americans, the incidence appears to be similar or higher, but among the Asian 
and native-Americans, the incidence is lower.
In the Far East, VTE is not as common in Chinese as in Caucasians but is certainly not 
rare. The incidence of DVT and PE was reported to the 17.1 and 3.9 per 100,000 
populations, respectively.
Understanding the etiology and pathogenesis of thrombosis is important for 
developing management strategy including preventive. In this book, we have selected 
two important etiological aspects of venous thrombosis to highlight microparticles and 
homocysteine. Flowcytometry has shown that the levels of platelet-derived 
microparticles and endothelial-derived microparticles to be elevated in deep vein 
thrombosis and cardiovascular disease can constitute to hypercoagulability due to 
circulating procoagulant microparticles. To that end, Dr. Enjeti from Australia 
assembled a very informative account, chapter 1, on the role of microparticles in 
hemostasis and venous thromboembolism and concluded that there are three potential 
areas where measuring the microparticles with respect to VTE may be relevant: 
diagnostic, prognostic and therapeutic.
Hyperhomocysteinemia is a known risk factor for VTE. The risk of VTE recurrence in 
patients with hyperhomocysteinemia is unknown and so is the management of those 
patients after acute event of VTE. Dr. Plazar and Dr. Jurdana from Slovenia, Chapter 2, 
present a detailed updated account on this important topic including diagnosis and 
VTE is an important clinical problem because of the associated morbidity and 
mortality and its negative impact on the Healthcare System. The medical literature is 
very rich in publications on the subject, epidemiology, etiology, pathogenesis, risk 
stratification, VTE in different groups of medical and surgical conditions, diagnosis, 
management, guidelines for thromboprophylaxis and management. As it is not 
possible to have a comprehensive book that covers all aspects of VTE, in this book we 
have elected to address certain etiological aspects of venous thrombosis: VTE in 
neonates, children, chronic renal disease and VTE in cancer patient with special 
reference to anti-cancer agents associated with high risk of VTE, especially in tertiary 
care settings.
Several national and international registries have helped to define the epidemiology, 
risk factors for VTE in different age groups and demonstrated the important 
differences between VTE in adults and pediatric patients and called for evidencebased 
guidelines for management and prevention of VTE in neonates and children. In 
chapter 3, Dr. Lazaro and colleagues described the magnitude of this problem 
including diagnosis and management.
The same authors also gave a detailed account of VTE in patients with chronic renal 
disease, with special reference to epidemiology, pathogenesis, and treatment in this 
important group of patients with a special reference to unfractionated heparin, low 
molecular heparin, the pentasaccharide and some of the novel oral anticoagulants.
Although cancer has been clearly associated with venous thromboembolism, many 
aspects of this relation are still not well understood, including the cancer sites most 
associated with VTE and the risk for cancer development during follow-up of patients 
with idiopathic VTE. In chapter 4, the authors have depicted an informative updated 
account on the epidemiology, pathogenesis, patient-related factors, cancer-related 
factors and treatment related factors and their impact on the risk of VTE in cancer 
patients with special emphasis on some chemotherapeutic agents associated with VTE.
The authors also put up some practical information on thromboprophylaxis in cancer 
patients at different clinical settings.
The use of immunomodulatory agents thalidomide and, lately, its second generation 
Lenalidomide, has revolutionized the management of multiple myeloma patients. 
However, their use carries a significant risk of thrombosis. Dr. Mateos and Dr. Gonzalez- 
Porras, chapter 5, assembled an excellent account on those agents in a practical format, 
which helps the practicing oncologists and hematologists in handling those effective 
agents to minimize the risk of the VTE associated with the use of those agents.
Dr. Agutter and Dr. Malone from Theoretical Medicine and Biology Group, UK, argued 
elegantly for a rational approach for mechanical thromboprophylaxis in chapter 6. The 
authors summarized the valve cusp hypoxia hypothesis, discussed its clinical 
implications and suggested a sound approach to prophylaxis based on this hypothesis.
In their descriptive account in Chapter 7, titled Venous Thromboembolism as a 
Preventable Patient Injury - Experience of the Danish Patient Insurance Association 
(1996 - 2010), Dr. Christoffersen and Dr. Hove describe situations where VTE may be 
judged to be a patient injury and the cases cited from the database all emphasize the 
need for healthcare practitioner to be aware of the medico-legal aspects of VTE cases, 
and use updated approved guidelines on VTE prophylaxis.
The medical practice guidelines are usually prepared by standing Task 
Force/Committees and approved by Executive and/or Council. These evidence-based 
guidelines reflect emerging clinical and scientific advances in the specific clinical 
discipline and related specialties as to the date of issue. However, they are subject to 
change and local institutions are advised that they may modify the guidelines for their 
own use with full documentation of those modifications. Moreover, the guideline are 
not meant as dictating an exclusive line of treatment or procedure to be followed and
are not intended to substitute the clinical judgment of the attending physician. 
The American Public Health Association issued a white paper in 2003, entitled “Deep 
Vein Thrombosis: Awareness to protect patient lives” and issued a call for action 
stating that DVT and PE constitute major health problem in the USA and more people 
die of PE than motor vehicle accidents, breast cancer or AIDS, and physicians, 
healthcare providers, public heath advocates and consumers must be aware of the 
preventability of this epidemic and act accordingly.
For patients with a high/very high risk of VTE combined pharmacological and 
mechanical prophylaxis should be ordered. However, failure of physicians and 
healthcare providers to adhere to VTE prophylaxis guidelines/protocols in high/very 
high-risk patients remains a problem in many countries. Hospitals with adequate 
electronic information systems may consider implementation of electronic alerts to 
enforce adherence to thromboprophylaxis guidelines/protocols. However, the same 
strategy can be implemented by institutions without electronic systems if the 
awareness and willingness of the healthcare providers to cooperate on this important 
aspect of patient’s safety is ensured. In the near future, the voluntary aspects of 
ordering thromboprophylaxis is very likely to be replaced with an obligatory one, as 
regulating authorities and insurance companies demand that VTE is a preventable 
patient injury.

Dr Mohamed A. Abdelaal
Senior Consultant Hematologist, Head of Pathology & Laboratory Medicine;
Head of King Abdullah International Medical Research Center
Jeddah, Saudi Arabia

Chapter 1 Microparticles: Role in Haemostasis and Venous Thromboembolism 3
Anoop K. Enjeti and Michael Seldon

Chapter 2 Hyperhomocysteinemia: Relation to Cardiovascular Disease and Venous Thromboembolism 17
Nadja Plazar and Mihaela Jurdana

Chapter 3 Venous Thromboembolism in Neonates, Children and Patients with Chronic Renal Disease –  Special Considerations 37
Pedro Pablo García Lázaro, Gladys Patricia Cannata Arriola, Gloria Soledad Cotrina Romero and Pedro Arauco Nava

Chapter 4 Venous Thromboembolism in Cancer Patients 73
Galilah F. Zaher and Mohamed A. Abdelaal

Chapter 5 Thrombosis Associated with Immunomodulatory Agents in Multiple Myeloma 115
Jose Ramon Gonzalez-Porras and María-Victoria Mateos

Chapter 6 Aetiology of Deep Venous Thrombosis - Implications for Prophylaxis 131
Paul S. Agutter and P. Colm Malone

Chapter 7 Venous Thromboembolism as a Preventable Patient Injury: Experience of the Danish
Patient Insurance Association (1996 - 2010) 159

Jens Krogh Christoffersen and Lars Dahlgaard Hove

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Published by: Unknown - Monday, January 21, 2013


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