Thrombotic disorders: diagnosis and treatment

Hematologists are increasingly involved in the diagnosis and management of patients with venous and arterial thromboembolic disorders. There have been major advances in recent years in our understanding of the central role of hypercoagulability in the pathogenesis of thrombosis. This has led to new approaches to the diagnosis of patients at risk for thrombosis and the development of more rational antithrombotic strategies. In Section I, Dr. Andrew Schafer reviews current concepts of acquired and inherited hypercoagulable states. It is now recognized that most, if not all, patients with venous thromboembolism have a genetic basis for the disorder ("thrombophilia"). The level of lifelong, baseline hypercoagulability in any individual may be determined by the type(s) and number of thrombophilia(s) that are inherited. Clinical episodes of thrombosis are precipitated by acquired thrombogenic triggers, which may be overt (e.g., pregnancy) or subclinical. In Section II, Dr. Mark Levine discusses the complex problem of thrombosis in patients with cancer. The goals of treating acute venous thromboembolism in cancer patients are to prevent recurrence, minimize the risk of anticoagulant-induced bleeding, and improve quality of life. New developments have improved treatment of venous thromboembolism in these patients, including outpatient therapy and secondary prevention with low-molecular-weight heparin. In Section III, Dr. Barbara Konkle reviews the diagnosis and management of thrombotic complications associated with pregnancy and hormonal therapy. Patient management is discussed based on data on thrombotic risks associated with hormonal treatment of infertility, pregnancy and the post-partum period in women with and without underlying thrombophilic risk factors. In Section IV, Dr. Clive Kearon discusses the management of anticoagulation before and after elective surgery. In the past, there has been no consensus on the perioperative management of anticoagulation for patients who require long-term warfarin therapy. This review considers the expected risks and benefits of different approaches to anticoagulation in patients who require warfarin because of atrial fibrillation, a mechanical heart valve, or a history of venous thromboembolism.