IN RESPONSE:
Our article discussed clinical trials that have influenced practice. The study by Barritt and Jordan (1) did so and was of historical importance. Barritt and Jordan found that in patients who were considered to have pulmonary embolism, 5 of 19 who did not receive anticoagulants died compared with 0 of 16 who did. This difference was statistically significant (P = 0.036). Several subsequent randomized trials (2-4) have supported Barritt and Jordan's contention that anticoagulants are indicated to treat patients with venous thromboembolism.
The study by Nielsen and colleagues (5) is interesting but did not influence practice. The authors themselves stated, "[T]he patient population ... is relatively small with wide confidence intervals for differences between groups. Before more general recommendations can be made, a large-scale placebo-controlled study is needed to evaluate the possible effect of [anticoagulant] treatment in DVT patients who can be mobilized from the first day." It should also be noted that the relative risk for progression of proximal venous thrombosis in this study was almost 40% greater in phenylbutazone-treated patients than in anticoagulant-treated patients.
1. Barritt DW, Jordan SC. Anticoagulant drugs in the treatment of pulmonary embolism. A controlled trial Lancet. 1960;1:1309-12.
2. Lagerstedt CI, Olsson CG, Fagher BO, Oqvist BW, Albrechtsson U. Need for long-term anticoagulant treatment in symptomatic calf-vein thrombosis Lancet. 1985;2:515-8. [PMID: 2863541].
3. Hull R, Delmore T, Genton E, Hirsh J, Gent M, Sackett D, et al. Warfarin sodium versus low-dose heparin in the long-term treatment of venous thrombosis N Engl J Med. 1979;301:855-8. [PMID: 384248].[Abstract]
4. Brandjes DP, Heijboer H, Büller HR, de Rijk M, Jagt H, ten Cate JW. Acenocoumarol and heparin compared with acenocoumarol alone in the initial treatment of proximal-vein thrombosis N Engl J Med. 1992;327:1485-9. [PMID: 1406880].[Abstract]
5. Nielsen HK, Husted SE, Krusell LR, Fasting H, Charles P, Hansen HH, et al. Anticoagulant therapy in deep venous thrombosis. A randomized controlled study Thromb Res. 1994;73:215-26. [PMID: 8191414].
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