Starting compression therapy immediately after diagnosis with deep vein thrombosis (DVT) was associated with significantly fewer complications over the mid- to longer-term, a substudy of the IDEAL DVT trial suggested.
Quickly starting compression was associated with an absolute 20.4% lower incidence of residual vein obstruction (RVO) compared with no compression therapy (46.3% versus 66.7%, OR 0.46, P=0.005), Elham Amin, MD, of Maastricht University Medical Centre in the Netherlands, and colleagues reported in the journal Blood.
That impact at 6 months in turn led to an 8% absolute reduction of post-thrombotic syndrome at 24 months. At that point, post-thrombotic syndrome was present in 46% of patients without RVO versus 54% in those with RVO (OR 0.65, 95% CI 0.46-0.92).
Because “there is no cure for the condition … acute treatment of DVT should include prompt prevention of post-thrombotic syndrome,” the researchers pointed out. “This [study] suggests that RVO does contribute to the development of post-thrombotic syndrome and that compression therapy may prevent [it] from the very early start of thrombosis treatment.”
The IDEAL DVT substudy involved a total of 592 patients (mean age of 57) assigned to early compression use by prespecified protocols by center (each participating center followed only one strategy). Thus 72 patients received no early compression before edema was resorbed, 369 patients received multi-layer compression bandaging in that period, and 151 patients wore compression hosiery (Mediven Struva 35 mm Hg) from the start.
Compression therapy groups initiated it within 24 hours of patients being diagnosed with DVT, continued until the edema was resorbed (typically 4 weeks). After that, all patients were fitted with compression stockings worn for a period of 6 months.
Patients were also anticoagulated, with a mean duration of 258 days. The presence of RVO was assessed 1 week prior to discontinuing anticoagulation.
The average interlude from DVT diagnosis to assessment of RVO was 5.3 months. “In total, 289 out of 592 patients (48.8%) had RVO on ultrasound,” the investigators observed.
At 6 months follow-up, 55.7% of patients who subsequently went on to develop post-thrombotic syndrome had evidence of a prior RVO compared to 44.3% of patients who did not develop the syndrome (OR 0.66, P=0.029).
There was no association between the development of RVO and recurrent venous thromboembolism.
The researchers also noted that both forms of compression therapy used in the substudy were equally effective. “We suggest that in addition to adequate anticoagulation therapy, immediate compression therapy — either with multi-layer bandaging or with compression hosiery — should be implemented in daily clinical practice … in order to optimize the prevention of post-thrombotic syndrome.”
Limitations of the study include the fact that it was a subanalysis of data from a large randomized trial and as such, the sample was not randomized.
“This study was a substudy of another clinical trial, so at most it is hypothesis-generating,” cautioned Mary Cushman, MD, of the University of Vermont Medical Center in Burlington.
A randomized controlled clinical trial is needed before hematologists could advocate wider adoption of this treatment, she suggested in commenting on the study. “And from the practical side, it might be cumbersome to provide this treatment, since many patients with DVT are treated as outpatients or only with brief hospitalization for 1 to 2 nights.”
Unlike in the Netherlands where compression therapy is routinely offered in acute DVT, compression therapy is not normal practice in the U.S., because there hasn’t been good research or guidelines supporting this approach, Cushman told MedPage Today.
“For a number of years, we routinely used knee-high compression stockings starting 2 weeks after diagnosis to try to prevent PTS [post-thrombotic syndrome].”
This practice was based on relatively small clinical trials that suggested benefit to the strategy, she added. However, use dropped off after a
larger, relatively recent trial showed no impact from the use of knee-high compression stockings on PTS.
“We know that having high-quality anticoagulation after a DVT is helpful to prevent PTS, so early diagnosis and optimal treatment are important,” Cushman said. The main problem is that the public is not very aware of the symptoms of DVT, so diagnosis is often delayed, which may increase the chance of PTS.
The best strategy is to prevent DVT in the first place, she stressed, noting that the American Society of Hematology is about to release new guidelines on how to prevent DVT in high-risk patients, such as those in hospital.
The trial was funded by a grant by ZonMw the Netherlands.
The authors reported no financial ties to industry.
Cushman had no conflicts of interest to declare.
