Major areas of interest in VTE

In your opinion, are there any new trial results, drugs, or procedures in the field of thromboembolic disease that are worth particular attention?

James Douketis: Yes, there are several actually in 2017 alone. So you should be aware of the ATTRACT trial, which was presented and will be published soon. This is a trial looking at patients who had fairly large proximal deep vein thrombosis (DVT) and it looks to see whether pharmacomechanical thrombolysis – putting a catheter in, injecting small amounts of thrombolytic therapy, and then using a mechanical method to remove the clot – provides additional therapeutic benefit above that of conventional anticoagulation. The goal of this trial is to see if this more aggressive approach prevents the postthrombotic syndrome, which, as you know, involves chronic swelling and pain and can be quite debilitating for people. The preliminary results show that it does not help – which is a bit counterintuitive – but the silver lining in that negative result may be that it appears to be beneficial in a subgroup with very extensive – what we call iliofemoral – DVT that extends into the pelvis.

The second trial that you should be aware of is called EPCAT II. This looks at the prevention of DVT after major orthopedic surgery: hip or knee replacement. It will be published later this summer. This is very interesting because it is looking at patients who have hip or knee replacement; they all receive about 4 to 5 days of prophylaxis, in this case with rivaroxaban, and then they continue with either aspirin or rivaroxaban. If this shows that aspirin is sufficient in addition to maybe a few days of an anticoagulant, this gives us another option. We know that aspirin is an old drug and it is making a comeback, and this is one clinical domain where we may be seeing more use of it. So stay tuned for that.

The third trial is called the COMPASS trial, which looks at the use of adding a low-dose anticoagulant in patients with stable coronary artery disease or stable peripheral arterial disease. The latter group has been really challenging in terms of finding therapies that are effective and safe.

I think that the ATTRACT trial for acute DVT, the EPCAT II trial for prevention of postorthopedic DVT, and the COMPASS trial for patients with coronary disease and peripheral arterial disease are 3 landmark trials that we should all keep our eyes and ears on and look for.