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        "resumen" => "<span class="elsevierStyleSectionTitle">Objective</span><p class="elsevierStyleSimplePara elsevierViewall">The incidence of venous thromboembolism &#40;VTE&#41; in patients with chronic obstructive pulmonary disease &#40;COPD&#41; ranges from 20&#37; to 60&#37; in different studies and the mortality rates are higher for patients with both conditions&#46; Heparin prophylaxis is therefore usually prescribed for COPD patients who are hospitalized for exacerbation&#46; Once their situation becomes stable&#44; however&#44; they are discharged to home without prophylaxis even though the low level of physical activity their disease allows continues to put them at risk for VTE&#46;</p><p class="elsevierStyleSimplePara elsevierViewall">The aim of this study was to test the efficacy of home heparin prophylaxis on reducing the incidence of VTE and on the overall mortality rate in patients with severe COPD&#46;</p> <span class="elsevierStyleSectionTitle">Patients and methods</span><p class="elsevierStyleSimplePara elsevierViewall">We conducted a prospective&#44; randomized controlled trial of 87 patients with severe COPD who required home oxygen therapy &#40;&#8805;18 h&#47;d&#41; and whose physical activity was highly restricted&#46; A total of 44 patients received low molecular weight heparin &#40;3500 IU&#47;d of bemiparin&#41; subcutaneously for 6 months&#46; The outcome measures were incidence of VTE and mortality at 3 and 6 months&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p class="elsevierStyleSimplePara elsevierViewall">Four patients &#40;9&#46;1&#37;&#41; died in the heparin group and 9 &#40;20&#46;4&#37;&#41; died in the control group&#59; the difference was not statistically significant &#40;<span class="elsevierStyleItalic">P</span> &#61;&#46;23&#41;&#46; VTE without pulmonary embolism developed in 1 patient &#40;2&#37;&#41; in each group&#46; Slight bleeding complications appeared in 9 patients &#40;20&#46;4&#37;&#41; in the heparin group and 1 patient &#40;2&#46;3&#37;&#41; in the control group&#44; a difference that was statistically significant &#40;<span class="elsevierStyleItalic">P</span> &#61;&#46;015&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p class="elsevierStyleSimplePara elsevierViewall">Home prophylaxis with heparin does not reduce the incidence of VTE or overall mortality in patients with severe COPD&#46;</p>"
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        "resumen" => "<span class="elsevierStyleSectionTitle">Objetivo</span><p class="elsevierStyleSimplePara elsevierViewall">La incidencia de enfermedad tromboemb&#243;lica venosa &#40;ETV&#41; en pacientes con enfermedad pulmonar obs-tructiva cr&#243;nica &#40;EPOC&#41; oscila entre el 20 y el 60&#37; seg&#250;n las series&#44; y la mortalidad por ETV es superior en estos enfer-mos&#46; Por ello suele prescribirse profilaxis con heparina a los pacientes con EPOC hospitalizados por una agudizaci&#243;n&#46; Sin embargo&#44; una vez que se estabiliza su situaci&#243;n&#44; se les remite a su domicilio sin dicha profilaxis&#44; a pesar de que la escasa actividad f&#237;sica que les permite su enfermedad sigue constituyendo un factor de riesgo para la aparici&#243;n de ETV&#46; El objetivo de este estudio ha sido analizar si la profilaxis domiciliaria con heparina reduce la aparici&#243;n de ETV y la mortalidad global en los enfermos con EPOC evolucionada&#46;</p> <span class="elsevierStyleSectionTitle">Pacientes y m&#233;todos</span><p class="elsevierStyleSimplePara elsevierViewall">Se ha realizado un ensayo cl&#237;nico prospectivo aleatorizado con 87 pacientes afectados de EPOC grave que precisaban oxigenoterapia domiciliaria &#40;18 h o m&#225;s al d&#237;a&#41;&#44; con una alta limitaci&#243;n de la actividad f&#237;sica&#46; Un total de 44 sujetos recibi&#243; heparina de bajo peso molecular &#40;HBPM&#59; 3&#46;500 U&#47;d&#237;a de bemiparina&#41; por v&#237;a subcut&#225;nea durante 6 meses&#46; Las variables estudiadas fueron la incidencia de ETV y la mortalidad a los 3 y 6 meses&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p class="elsevierStyleSimplePara elsevierViewall">Durante el estudio fallecieron 4 pacientes del grupo que recibi&#243; HBPM &#40;9&#44;1&#37;&#41; y 9 del grupo control &#40;20&#44;4&#37;&#41;&#59; las diferencias entre ambos grupos no fueron esta-d&#237;sticamente significativas &#40;p &#61; 0&#44;23&#41;&#46; Present&#243; trombosis venosa profunda sin embolia pulmonar un paciente de cada grupo &#40;2&#37;&#41;&#46; Aparecieron complicaciones hemorr&#225;gicas leves en 9 pacientes del grupo con HBPM &#40;20&#44;4&#37;&#41;&#44; frente a una en el grupo control &#40;2&#44;3&#37;&#41;&#44; diferencia que fue estad&#237;sti-camente significativa &#40;p &#61; 0&#44;015&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p class="elsevierStyleSimplePara elsevierViewall">La profilaxis domiciliaria con heparina no reduce la aparici&#243;n de ETV ni la mortalidad global en los pacientes con EPOC avanzada&#46;</p>"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Low-dose heparin prophylaxis against fatal pulmonary embolism"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "S Sagar"
                            1 => "J Massey"
                            2 => "JM Sanderson"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Br Med J"
                        "fecha" => "1975"
                        "volumen" => "4"
                        "paginaInicial" => "257"
                        "paginaFinal" => "259"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1104060"
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                          ]
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                    ]
                  ]
                ]
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              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Reduction of mortality in general medical patients by low-dose heparin prophylaxis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "H Halkin"
                            1 => "J Goldberg"
                            2 => "M Modan"
                            3 => "B Modan"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Intern Med"
                        "fecha" => "1982"
                        "volumen" => "96"
                        "paginaInicial" => "561"
                        "paginaFinal" => "565"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7073148"
                            "web" => "Medline"
                          ]
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "JF Bergmann"
                            1 => "C Caulin"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet"
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                        "volumen" => "348"
                        "paginaInicial" => "205"
                        "paginaFinal" => "206"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8684189"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
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                    0 => array:2 [
                      "titulo" => "Randomised&#44; controlled trial of low-dose heparin prophylaxis for prevention of fatal pulmonary embolism in patients with Infectious diseases"
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                          "autores" => array:1 [
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                    0 => array:1 [
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                        "tituloSerie" => "Lancet"
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                        "paginaInicial" => "1357"
                        "paginaFinal" => "1361"
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                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8637340"
                            "web" => "Medline"
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                        0 => array:2 [
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                          "autores" => array:6 [
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                            1 => "E Calbo"
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                            4 => "S Quintana"
                            5 => "JL Heredia"
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                        "paginaFinal" => "1448"
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                            2 => "JY Darmon"
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                            4 => "A Eldor"
                            5 => "C Janbon"
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                      "doi" => "10.1056/NEJM199909093411103"
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                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "1999"
                        "volumen" => "341"
                        "paginaInicial" => "793"
                        "paginaFinal" => "800"
                        "link" => array:1 [
                          0 => array:2 [
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              "identificador" => "bib7"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "GOLD Scientific Committee&#46; Global strategy for the diagnosis&#44; management&#44; and prevention of chronic obstructive pulmonary disease&#46; NHLBI&#47;WHO Global Initiative for Chronic Obstructive Lung Disease &#40;GOLD&#41; Workshop summary"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "RA Pauwels"
                            1 => "AS Buist"
                            2 => "PM Calverley"
                            3 => "CR Jenkins"
                            4 => "SS Hurd"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/ajrccm.163.5.2101039"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "2001"
                        "volumen" => "163"
                        "paginaInicial" => "1256"
                        "paginaFinal" => "1276"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11316667"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib8"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Outcomes following acute exacerbations of severe chronic obstructive pulmonary disease&#46; The SUPPORT investigations &#40;Study to Understand Prognosis and Preferences for Outcomes and Risk of Treatments&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "AF Connors Jr"
                            1 => "NV Dawson"
                            2 => "C Thomas"
                            3 => "FE Herrell Jr"
                            4 => "N Desbiens"
                            5 => "WJ Fulkerson"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/ajrccm.154.4.8887592"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "1996"
                        "volumen" => "154"
                        "paginaInicial" => "959"
                        "paginaFinal" => "967"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8887592"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib9"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Relevance of deep venous thrombosis of the leg in patients with acute exacerbated chronic obstructive pulmonary disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "B Schonhofer"
                            1 => "D Kholer"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Pneumologie"
                        "fecha" => "1999"
                        "volumen" => "53"
                        "paginaInicial" => "10"
                        "paginaFinal" => "14"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10091512"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib10"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Significance of acute pulmonary embolism for the exacerbation of chronic obstructive pulmonary disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "G Buzoky"
                            1 => "E Ruby"
                            2 => "I Goher"
                            3 => "A Mohos"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Orv Hetil"
                        "fecha" => "2003"
                        "volumen" => "144"
                        "paginaInicial" => "317"
                        "paginaFinal" => "322"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12666379"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib11"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The frequency of deep venous thrombosis and pulmonary embolus in acute exacerbation of chronic obstructive pulmonary disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "M Erelel"
                            1 => "&#199; &#199;uhadaroglu"
                            2 => "T Ece"
                            3 => "O Arseven"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Respir Med"
                        "fecha" => "2002"
                        "volumen" => "96"
                        "paginaInicial" => "515"
                        "paginaFinal" => "518"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12194636"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib12"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Gu&#237;a SEPAR para el diagn&#243;stico&#44; tratamiento y seguimiento del embolismo pulmonar"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "F Uresandi"
                            1 => "J Blanquer"
                            2 => "F Conget"
                            3 => "MA de Gregorio"
                            4 => "JL Lobo"
                            5 => "R Otero"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Bronconeumol"
                        "fecha" => "2004"
                        "volumen" => "40"
                        "paginaInicial" => "580"
                        "paginaFinal" => "594"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15574273"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib13"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The diagnosis of acute pulmonary embolism in patients with chronic obstructive pulmonary disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "BA Lesser"
                            1 => "KV Beeper"
                            2 => "PD Stein"
                            3 => "HA Saltzman"
                            4 => "J Chen"
                            5 => "T Thompson"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "1992"
                        "volumen" => "102"
                        "paginaInicial" => "17"
                        "paginaFinal" => "22"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1623748"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib14"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pulmonary thromboembolism"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "S Filipecki"
                            1 => "J Kober"
                            2 => "D Kamonsky"
                            3 => "W Tomkowski"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Monaldi Arch Chest Dis"
                        "fecha" => "1997"
                        "volumen" => "52"
                        "paginaInicial" => "5492"
                        "paginaFinal" => "5493"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib15"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Revisi&#243;n de la importancia de la EPOC como factor de riesgo cardiovascular"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "J Izquierdo Alonso"
                            1 => "R Arroyo-Espliguero"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Bronconeumol"
                        "fecha" => "2005"
                        "volumen" => "41"
                        "paginaInicial" => "410"
                        "paginaFinal" => "412"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16117944"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib16"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A comparative double-blind&#44; randomised trial of a new second generation LMWH &#40;bemiparin&#41; and UFH in the prevention of post-operative venous thromboembolism&#46; The Bemiparin Assessment group"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "VV Kakkar"
                            1 => "J Howes"
                            2 => "V Sharma"
                            3 => "Z Kadziola"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Thromb Haemost"
                        "fecha" => "2000"
                        "volumen" => "83"
                        "paginaInicial" => "523"
                        "paginaFinal" => "529"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10780310"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib17"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevention of venous thromboembolism after orthopedic surgery&#58; the EXPRESS study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "C Cimminiello"
                            1 => "A Planes"
                            2 => "MM Samama"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1538-7836.2004.01006.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Thromb Haemost"
                        "fecha" => "2004"
                        "volumen" => "2"
                        "paginaInicial" => "2036"
                        "paginaFinal" => "2040"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15550036"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib18"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Evaluation du risque thromboembolique veineux en milieu m&#233;dical"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "P Mismetti"
                            1 => "D Juillard-Delsort"
                            2 => "B Tardy"
                            3 => "S Laporte-Simitsidis"
                            4 => "H Decousus"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Th&#233;rapie"
                        "fecha" => "1998"
                        "volumen" => "53"
                        "paginaInicial" => "565"
                        "paginaFinal" => "570"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10070234"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib19"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Risk of and prophylaxis for venous thromboembolism in hospital patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "colaboracion" => "Thromboembolic Risk Factors &#40;THRIFT&#41; Consensus Group"
                          "etal" => false
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "BMJ"
                        "fecha" => "1992"
                        "volumen" => "305"
                        "paginaInicial" => "567"
                        "paginaFinal" => "574"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1298229"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib20"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "International Consensus Statement &#40;guidelines according to scientific evidence&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "Prevention of venous thromboembolism"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Int Angiol"
                        "fecha" => "1997"
                        "volumen" => "16"
                        "paginaInicial" => "3"
                        "paginaFinal" => "38"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9165356"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib21"
              "etiqueta" => "21"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A European view on the North American Fifth Consensus on Antithrombotic Therapy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "M Verstraete"
                            1 => "CR Prentice"
                            2 => "M Samama"
                            3 => "R Verhaeghe"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2000"
                        "volumen" => "117"
                        "paginaInicial" => "1755"
                        "paginaFinal" => "1770"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10858413"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib22"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevention of venous thromboembolism"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "WH Geerts"
                            1 => "JA Heit"
                            2 => "GP Clagett"
                            3 => "GF Pineo"
                            4 => "CW Colwell"
                            5 => "FA Anderson Jr"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2001"
                        "volumen" => "119"
                        "paginaInicial" => "132S"
                        "paginaFinal" => "175S"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11157647"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib23"
              "etiqueta" => "23"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pulmonary embolism and sibilant types of chronic obstructive pulmonary disease decompensations"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "D Mispelaere"
                            1 => "JC Glerant"
                            2 => "M Andebert"
                            3 => "A Remond"
                            4 => "MA Sevestre-Pietri"
                            5 => "V Jounieaux"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Mal Respir"
                        "fecha" => "2002"
                        "volumen" => "19"
                        "paginaInicial" => "399"
                        "paginaFinal" => "400"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12417852"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            23 => array:3 [
              "identificador" => "bib24"
              "etiqueta" => "24"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevention of venous thromboembolism&#58; The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "WH Geerts"
                            1 => "GF Pineo"
                            2 => "JA Heit"
                            3 => "D Bergqvist"
                            4 => "MR Lassen"
                            5 => "CW Colwell"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1378/chest.126.3_suppl.338S"
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2004"
                        "volumen" => "126"
                        "paginaInicial" => "338S"
                        "paginaFinal" => "400S"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15383478"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            24 => array:3 [
              "identificador" => "bib25"
              "etiqueta" => "25"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cardiovascular Disease Educational and Research Trust and the International Union of Angiology&#46; Prevention of venous thromboembolism international consensus statement&#46; Guidelines compiled in accordance with de scientific evidence"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "AN Nicolaides"
                            1 => "HK Breddin"
                            2 => "J Fareed"
                            3 => "S Goldhaber"
                            4 => "S Haas"
                            5 => "R Hull"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Int Angiol"
                        "fecha" => "2001"
                        "volumen" => "20"
                        "paginaInicial" => "1"
                        "paginaFinal" => "37"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11342993"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            25 => array:3 [
              "identificador" => "bib26"
              "etiqueta" => "26"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevention of venous thromboembolism"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "GP Clugett"
                            1 => "FA Anderson Jr"
                            2 => "J Heit"
                            3 => "MN Levine"
                            4 => "EW Salzman"
                            5 => "HB Wheeler"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "1995"
                        "volumen" => "108"
                        "paginaInicial" => "312S"
                        "paginaFinal" => "334S"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7555186"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            26 => array:3 [
              "identificador" => "bib27"
              "etiqueta" => "27"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Venous thromboembolism in medical patients&#46; The scope of the problem"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "S Hass"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1055/s-2003-45413"
                      "Revista" => array:7 [
                        "tituloSerie" => "Semin Thromb Hemost"
                        "fecha" => "2003"
                        "volumen" => "29"
                        "numero" => "Suppl 1"
                        "paginaInicial" => "17"
                        "paginaFinal" => "21"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14730474"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            27 => array:3 [
              "identificador" => "bib28"
              "etiqueta" => "28"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "European consensus statement on the prevention of venous thromboembolism"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "S Haas"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Blood Coagul Fibrinolysis"
                        "fecha" => "1993"
                        "volumen" => "4"
                        "numero" => "Suppl 1"
                        "paginaInicial" => "5"
                        "paginaFinal" => "8"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            28 => array:3 [
              "identificador" => "bib29"
              "etiqueta" => "29"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Heparin prophylaxis for medical patients&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "FA Lederle"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Intern Med"
                        "fecha" => "1998"
                        "volumen" => "128"
                        "paginaInicial" => "768"
                        "paginaFinal" => "770"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9556472"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            29 => array:3 [
              "identificador" => "bib30"
              "etiqueta" => "30"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prognostic factors in medically treated patients with pulmonary embolism"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J Lewczuk"
                            1 => "P Piszko"
                            2 => "J Jagas"
                            3 => "A Porada"
                            4 => "S Wojciak"
                            5 => "B Sobkowicz"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2001"
                        "volumen" => "119"
                        "paginaInicial" => "818"
                        "paginaFinal" => "823"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11243963"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            30 => array:3 [
              "identificador" => "bib31"
              "etiqueta" => "31"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Risk factors of venous thromboembolism in hospitalised patients with acute medical illness &#40;Analysis of MEDENOX Study&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "R Alikhan"
                            1 => "AT Cohen"
                            2 => "S Combe"
                            3 => "MM Samama"
                            4 => "L Desjardins"
                            5 => "A Eldor"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/archinte.164.9.963"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Intern Med"
                        "fecha" => "2004"
                        "volumen" => "164"
                        "paginaInicial" => "963"
                        "paginaFinal" => "968"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15136304"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            31 => array:3 [
              "identificador" => "bib32"
              "etiqueta" => "32"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevention of venous thromboembolism in internal medicine with unfractionated or low-molecular-weight heparins&#58; a meta-analysis of randomised clinical trials"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P Mismetti"
                            1 => "S Laporte-Simitsidis"
                            2 => "B Tardy"
                            3 => "M Cucherat"
                            4 => "A Buchm&#252;ller"
                            5 => "D Juillard-Delsart"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Thromb Haemost"
                        "fecha" => "2000"
                        "volumen" => "83"
                        "paginaInicial" => "14"
                        "paginaFinal" => "19"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10669147"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            32 => array:3 [
              "identificador" => "bib33"
              "etiqueta" => "33"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Venous thromboembolism prophylaxis in the medically ill patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "FA Michota"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Chest Med"
                        "fecha" => "2003"
                        "volumen" => "24"
                        "paginaInicial" => "93"
                        "paginaFinal" => "101"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12685058"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
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Vol. 42. Issue 3.
Pages 130-134 (March 2006)
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Vol. 42. Issue 3.
Pages 130-134 (March 2006)
Original Articles
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Can Home Prophylaxis for Venous Thromboembolism Reduce Mortality Rates in Patients With Chronic Obstructive Pulmonary Disease?
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M. Modesto-Alaponta,
Corresponding author
manumalap@ono.com

Correspondence: Dr. M. Modesto-Alapont. Servicio de Neumología. Hospital Universitario La Fe. Avda. Campanar, 21. 46009 Valencia. España
, D. Nauffal-Manzura, E. Ansótegui-Barreraa, R. Menéndez-Villanuevaa, A. Ballestab, R. Touzab, M. Perpiñá-Torderaa
a Servicio de Neumología, Hospital Universitario La Fe, Valencia, Spain
b Servicio de Radiología, Hospital Universitario La Fe, Valencia, Spain
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Objective

The incidence of venous thromboembolism (VTE) in patients with chronic obstructive pulmonary disease (COPD) ranges from 20% to 60% in different studies and the mortality rates are higher for patients with both conditions. Heparin prophylaxis is therefore usually prescribed for COPD patients who are hospitalized for exacerbation. Once their situation becomes stable, however, they are discharged to home without prophylaxis even though the low level of physical activity their disease allows continues to put them at risk for VTE.

The aim of this study was to test the efficacy of home heparin prophylaxis on reducing the incidence of VTE and on the overall mortality rate in patients with severe COPD.

Patients and methods

We conducted a prospective, randomized controlled trial of 87 patients with severe COPD who required home oxygen therapy (≥18 h/d) and whose physical activity was highly restricted. A total of 44 patients received low molecular weight heparin (3500 IU/d of bemiparin) subcutaneously for 6 months. The outcome measures were incidence of VTE and mortality at 3 and 6 months.

Results

Four patients (9.1%) died in the heparin group and 9 (20.4%) died in the control group; the difference was not statistically significant (P =.23). VTE without pulmonary embolism developed in 1 patient (2%) in each group. Slight bleeding complications appeared in 9 patients (20.4%) in the heparin group and 1 patient (2.3%) in the control group, a difference that was statistically significant (P =.015).

Conclusions

Home prophylaxis with heparin does not reduce the incidence of VTE or overall mortality in patients with severe COPD.

Key words:
COPD
Pulmonary embolism
Deep vein thrombosis
Venous thromboembolism prophylaxis
Objetivo

La incidencia de enfermedad tromboembólica venosa (ETV) en pacientes con enfermedad pulmonar obs-tructiva crónica (EPOC) oscila entre el 20 y el 60% según las series, y la mortalidad por ETV es superior en estos enfer-mos. Por ello suele prescribirse profilaxis con heparina a los pacientes con EPOC hospitalizados por una agudización. Sin embargo, una vez que se estabiliza su situación, se les remite a su domicilio sin dicha profilaxis, a pesar de que la escasa actividad física que les permite su enfermedad sigue constituyendo un factor de riesgo para la aparición de ETV. El objetivo de este estudio ha sido analizar si la profilaxis domiciliaria con heparina reduce la aparición de ETV y la mortalidad global en los enfermos con EPOC evolucionada.

Pacientes y métodos

Se ha realizado un ensayo clínico prospectivo aleatorizado con 87 pacientes afectados de EPOC grave que precisaban oxigenoterapia domiciliaria (18 h o más al día), con una alta limitación de la actividad física. Un total de 44 sujetos recibió heparina de bajo peso molecular (HBPM; 3.500 U/día de bemiparina) por vía subcutánea durante 6 meses. Las variables estudiadas fueron la incidencia de ETV y la mortalidad a los 3 y 6 meses.

Resultados

Durante el estudio fallecieron 4 pacientes del grupo que recibió HBPM (9,1%) y 9 del grupo control (20,4%); las diferencias entre ambos grupos no fueron esta-dísticamente significativas (p = 0,23). Presentó trombosis venosa profunda sin embolia pulmonar un paciente de cada grupo (2%). Aparecieron complicaciones hemorrágicas leves en 9 pacientes del grupo con HBPM (20,4%), frente a una en el grupo control (2,3%), diferencia que fue estadísti-camente significativa (p = 0,015).

Conclusiones

La profilaxis domiciliaria con heparina no reduce la aparición de ETV ni la mortalidad global en los pacientes con EPOC avanzada.

Palabras clave:
EPOC
Embolia pulmonar
Trombosis venosa profunda
Profilaxis de la tromboembolia venosa
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REFERENCES
[1]
S Sagar, J Massey, JM Sanderson.
Low-dose heparin prophylaxis against fatal pulmonary embolism.
Br Med J, 4 (1975), pp. 257-259
[2]
H Halkin, J Goldberg, M Modan, B Modan.
Reduction of mortality in general medical patients by low-dose heparin prophylaxis.
Ann Intern Med, 96 (1982), pp. 561-565
[3]
JF Bergmann, C Caulin.
Heparin prophylaxis in bedridden patients.
Lancet, 348 (1996), pp. 205-206
[4]
B Gardlun.
Randomised, controlled trial of low-dose heparin prophylaxis for prevention of fatal pulmonary embolism in patients with Infectious diseases.
Lancet, 347 (1996), pp. 1357-1361
[5]
P Almagro, E Calbo, A Ochoa de Echagüen, B Barreiroi, S Quintana, JL Heredia, et al.
Mortality after hospitalization for COPD.
Chest, 121 (2002), pp. 1441-1448
[6]
MM Samama, AT Cohen, JY Darmon, L Desjardins, A Eldor, C Janbon, for The Prophylaxis in Medical Patients with Enoxaparin Study Group, et al.
A comparison of enoxaparin with placebo for the prevention of venous thromboembolism in acutely ill medical patients.
N Engl J Med, 341 (1999), pp. 793-800
[7]
RA Pauwels, AS Buist, PM Calverley, CR Jenkins, SS Hurd.
GOLD Scientific Committee. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) Workshop summary.
Am J Respir Crit Care Med, 163 (2001), pp. 1256-1276
[8]
AF Connors Jr, NV Dawson, C Thomas, FE Herrell Jr, N Desbiens, WJ Fulkerson, et al.
Outcomes following acute exacerbations of severe chronic obstructive pulmonary disease. The SUPPORT investigations (Study to Understand Prognosis and Preferences for Outcomes and Risk of Treatments).
Am J Respir Crit Care Med, 154 (1996), pp. 959-967
[9]
B Schonhofer, D Kholer.
Relevance of deep venous thrombosis of the leg in patients with acute exacerbated chronic obstructive pulmonary disease.
Pneumologie, 53 (1999), pp. 10-14
[10]
G Buzoky, E Ruby, I Goher, A Mohos.
Significance of acute pulmonary embolism for the exacerbation of chronic obstructive pulmonary disease.
Orv Hetil, 144 (2003), pp. 317-322
[11]
M Erelel, Ç Çuhadaroglu, T Ece, O Arseven.
The frequency of deep venous thrombosis and pulmonary embolus in acute exacerbation of chronic obstructive pulmonary disease.
Respir Med, 96 (2002), pp. 515-518
[12]
F Uresandi, J Blanquer, F Conget, MA de Gregorio, JL Lobo, R Otero, et al.
Guía SEPAR para el diagnóstico, tratamiento y seguimiento del embolismo pulmonar.
Arch Bronconeumol, 40 (2004), pp. 580-594
[13]
BA Lesser, KV Beeper, PD Stein, HA Saltzman, J Chen, T Thompson, et al.
The diagnosis of acute pulmonary embolism in patients with chronic obstructive pulmonary disease.
Chest, 102 (1992), pp. 17-22
[14]
S Filipecki, J Kober, D Kamonsky, W Tomkowski.
Pulmonary thromboembolism.
Monaldi Arch Chest Dis, 52 (1997), pp. 5492-5493
[15]
J Izquierdo Alonso, R Arroyo-Espliguero.
Revisión de la importancia de la EPOC como factor de riesgo cardiovascular.
Arch Bronconeumol, 41 (2005), pp. 410-412
[16]
VV Kakkar, J Howes, V Sharma, Z Kadziola.
A comparative double-blind, randomised trial of a new second generation LMWH (bemiparin) and UFH in the prevention of post-operative venous thromboembolism. The Bemiparin Assessment group.
Thromb Haemost, 83 (2000), pp. 523-529
[17]
C Cimminiello, A Planes, MM Samama.
Prevention of venous thromboembolism after orthopedic surgery: the EXPRESS study.
J Thromb Haemost, 2 (2004), pp. 2036-2040
[18]
P Mismetti, D Juillard-Delsort, B Tardy, S Laporte-Simitsidis, H Decousus.
Evaluation du risque thromboembolique veineux en milieu médical.
Thérapie, 53 (1998), pp. 565-570
[19]
Thromboembolic Risk Factors (THRIFT) Consensus Group.
Risk of and prophylaxis for venous thromboembolism in hospital patients.
BMJ, 305 (1992), pp. 567-574
[20]
Prevention of venous thromboembolism.
International Consensus Statement (guidelines according to scientific evidence).
Int Angiol, 16 (1997), pp. 3-38
[21]
M Verstraete, CR Prentice, M Samama, R Verhaeghe.
A European view on the North American Fifth Consensus on Antithrombotic Therapy.
Chest, 117 (2000), pp. 1755-1770
[22]
WH Geerts, JA Heit, GP Clagett, GF Pineo, CW Colwell, FA Anderson Jr, et al.
Prevention of venous thromboembolism.
Chest, 119 (2001), pp. 132S-175S
[23]
D Mispelaere, JC Glerant, M Andebert, A Remond, MA Sevestre-Pietri, V Jounieaux.
Pulmonary embolism and sibilant types of chronic obstructive pulmonary disease decompensations.
Rev Mal Respir, 19 (2002), pp. 399-400
[24]
WH Geerts, GF Pineo, JA Heit, D Bergqvist, MR Lassen, CW Colwell, et al.
Prevention of venous thromboembolism: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.
[25]
AN Nicolaides, HK Breddin, J Fareed, S Goldhaber, S Haas, R Hull, et al.
Cardiovascular Disease Educational and Research Trust and the International Union of Angiology. Prevention of venous thromboembolism international consensus statement. Guidelines compiled in accordance with de scientific evidence.
Int Angiol, 20 (2001), pp. 1-37
[26]
GP Clugett, FA Anderson Jr, J Heit, MN Levine, EW Salzman, HB Wheeler.
Prevention of venous thromboembolism.
Chest, 108 (1995), pp. 312S-334S
[27]
S Hass.
Venous thromboembolism in medical patients. The scope of the problem.
Semin Thromb Hemost, 29 (2003), pp. 17-21
[28]
S Haas.
European consensus statement on the prevention of venous thromboembolism.
Blood Coagul Fibrinolysis, 4 (1993), pp. 5-8
[29]
FA Lederle.
Heparin prophylaxis for medical patients?.
Ann Intern Med, 128 (1998), pp. 768-770
[30]
J Lewczuk, P Piszko, J Jagas, A Porada, S Wojciak, B Sobkowicz, et al.
Prognostic factors in medically treated patients with pulmonary embolism.
Chest, 119 (2001), pp. 818-823
[31]
R Alikhan, AT Cohen, S Combe, MM Samama, L Desjardins, A Eldor, et al.
Risk factors of venous thromboembolism in hospitalised patients with acute medical illness (Analysis of MEDENOX Study).
Arch Intern Med, 164 (2004), pp. 963-968
[32]
P Mismetti, S Laporte-Simitsidis, B Tardy, M Cucherat, A Buchmüller, D Juillard-Delsart, et al.
Prevention of venous thromboembolism in internal medicine with unfractionated or low-molecular-weight heparins: a meta-analysis of randomised clinical trials.
Thromb Haemost, 83 (2000), pp. 14-19
[33]
FA Michota.
Venous thromboembolism prophylaxis in the medically ill patients.
Clin Chest Med, 24 (2003), pp. 93-101
Copyright © 2006. Sociedad Española de Neumología y Cirugía Torácica (SEPAR)
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