Trattamento del tromboembolismo venoso con anticoagulanti tradizionali e di nuova generazione.

The paradigm of treatment of acute venous thromboembolism (VTE) has been recently challenged by the new direct oral anticoagulants (DOACs). The aim of the research project was to evaluate the impact of DOACs on the management of pulmonary embolism (PE), isolated distal deep vein thrombosis (IDDVT) and bleeding. The approval process of DOACs was delayed in Italy and did not include IDDVT and, until 2015, PE. Therefore, the projects underwent some changes, with the aim of building solid bases for subsequent studies that will adopt DOACs. The project on PE was focused on the prognostic stratification, by applying the Pulmonary Embolism Severity Index (PESI). The results of the study showed a 2 days significant difference of the median duration of hospital stay between low risk vs. high risk patients, as identified retrospectively by PESI. However, this difference has little clinical significance and led to hypothesize that prospectively adopting PESI may have a significant impact. With regards to IDDVT, a retrospective study was performed on 321 patients, who were treated with a short course of anticoagulation. The results showed a non negligible 15% rate of recurrent VTE events. Therefore, many cases of IDDVT should be considered in the context of major VTE and may benefit from an extended treatment. Finally, the management of anticoagulant-associated bleeding was explored in a literature review and includes general resuscitation, diagnosis and local treatment of the bleeding source, as well as transfusion of red cells, clotting factor replacements and administration of antidotes and other prohaemostatic agents. Reversal strategies for the ‘conventional’ anticoagulants are based on clinical evidence, whereas evidence on DOACs is emerging