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Cochrane Database of Systematic Reviews

Low molecular weight heparin for prevention of venous thromboembolism in patients with lower‐limb immobilization

Información

DOI:
https://doi.org/10.1002/14651858.CD006681.pub4Copiar DOI
Base de datos:
  1. Cochrane Database of Systematic Reviews
Versión publicada:
  1. 06 agosto 2017see what's new
Tipo:
  1. Intervention
Etapa:
  1. Review
Grupo Editorial Cochrane:
  1. Grupo Cochrane de Vascular

Copyright:
  1. Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Autores

  • Aniek AG Zee

    Correspondencia a: Department of Surgery, VieCuri Medical Centre of Northern Limburg, Venlo, Netherlands

    [email protected]

  • Kelly van Lieshout

    Emergency Department, Deventer Ziekenhuis, Deventer, Netherlands

  • Maaike van der Heide

    VieCuri Medical Centre of Northern Limburg, Venlo, Netherlands

  • Loes Janssen

    Department of Clinical Epidemiology, VieCuri Medical Centre of Northern Limburg, Venlo, Netherlands

  • Heinrich MJ Janzing

    Department of Surgery, VieCuri Medical Centre of Northern Limburg, Venlo, Netherlands

Contributions of authors

AZ analyzed data, writing
KvL assessed trial quality, extracted data.
MvdH assessed trial quality, extracted data.
LJ co‐ordinated and advised on statistical methods, and redirected writing.
HMJJ cross‐checked information, supervised and redirected writing

Sources of support

Internal sources

  • No sources of support supplied

External sources

  • Chief Scientist Office, Scottish Government Health Directorates, The Scottish Government, UK.

    The Cochrane Vascular editorial base is supported by the Chief Scientist Office.

  • National Institute for Health Research (NIHR), UK.

    This project was supported by the NIHR, via Cochrane Incentive Award funding (16/72/06) to Cochrane Vascular. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Systematic Reviews Programme, NIHR, National Health Service (NHS), or the Department of Health.

Declarations of interest

AZ: none known
KvL: none known
MvdH: none known
LJ: none known
HMJJ: none known

Acknowledgements

The authors wish to acknowledge Dr M Testroote and Dr WAH Stigter for their contribution to previous versions of this review.

Version history

Published

Title

Stage

Authors

Version

2017 Aug 06

Low molecular weight heparin for prevention of venous thromboembolism in patients with lower‐limb immobilization

Review

Aniek AG Zee, Kelly van Lieshout, Maaike van der Heide, Loes Janssen, Heinrich MJ Janzing

https://doi.org/10.1002/14651858.CD006681.pub4

2014 Apr 25

Low molecular weight heparin for prevention of venous thromboembolism in patients with lower‐leg immobilization

Review

Mark Testroote, Willem AH Stigter, Loes Janssen, Heinrich MJ Janzing

https://doi.org/10.1002/14651858.CD006681.pub3

2008 Oct 08

Low molecular weight heparin for prevention of venous thromboembolism in patients with lower‐leg immobilization

Review

Mark Testroote, Willem AH Stigter, Dianne C de Visser, Heinrich MJ Janzing

https://doi.org/10.1002/14651858.CD006681.pub2

2007 Jul 18

Low molecular weight heparin for prevention of venous thromboembolism in patients with lower leg immobilization

Protocol

Mark Testroote, Willem Stigter, Heinrich Janzing, Dianne C de Visser

https://doi.org/10.1002/14651858.CD006681

Differences between protocol and review

'Risk of bias' and 'Summary of findings' tables added

Keywords

MeSH

PICO

Population
Intervention
Comparison
Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

PRISMA study flow diagram
Figuras y tablas -
Figure 1

PRISMA study flow diagram

Risk of bias graph: review authors' judgements about each risk of bias domain, presented as percentages across all included studies
Figuras y tablas -
Figure 2

Risk of bias graph: review authors' judgements about each risk of bias domain, presented as percentages across all included studies

Risk of bias summary: review authors' judgements about each risk of bias domain for each included study
Figuras y tablas -
Figure 3

Risk of bias summary: review authors' judgements about each risk of bias domain for each included study

Comparison 1 Low molecular weight heparin versus no prophylaxis or placebo, Outcome 1 Deep venous thrombosis: regardless of type of plaster, whether operated or not.
Figuras y tablas -
Analysis 1.1

Comparison 1 Low molecular weight heparin versus no prophylaxis or placebo, Outcome 1 Deep venous thrombosis: regardless of type of plaster, whether operated or not.

Comparison 1 Low molecular weight heparin versus no prophylaxis or placebo, Outcome 2 Deep venous thrombosis: in below‐knee cast, whether operated or not.
Figuras y tablas -
Analysis 1.2

Comparison 1 Low molecular weight heparin versus no prophylaxis or placebo, Outcome 2 Deep venous thrombosis: in below‐knee cast, whether operated or not.

Comparison 1 Low molecular weight heparin versus no prophylaxis or placebo, Outcome 3 Deep venous thrombosis: conservative treatment (i.e. non‐operated patients).
Figuras y tablas -
Analysis 1.3

Comparison 1 Low molecular weight heparin versus no prophylaxis or placebo, Outcome 3 Deep venous thrombosis: conservative treatment (i.e. non‐operated patients).

Comparison 1 Low molecular weight heparin versus no prophylaxis or placebo, Outcome 4 Deep venous thrombosis: operated patients.
Figuras y tablas -
Analysis 1.4

Comparison 1 Low molecular weight heparin versus no prophylaxis or placebo, Outcome 4 Deep venous thrombosis: operated patients.

Comparison 1 Low molecular weight heparin versus no prophylaxis or placebo, Outcome 5 Deep venous thrombosis: fractures.
Figuras y tablas -
Analysis 1.5

Comparison 1 Low molecular weight heparin versus no prophylaxis or placebo, Outcome 5 Deep venous thrombosis: fractures.

Comparison 1 Low molecular weight heparin versus no prophylaxis or placebo, Outcome 6 Deep venous thrombosis: soft‐tissue injuries.
Figuras y tablas -
Analysis 1.6

Comparison 1 Low molecular weight heparin versus no prophylaxis or placebo, Outcome 6 Deep venous thrombosis: soft‐tissue injuries.

Comparison 1 Low molecular weight heparin versus no prophylaxis or placebo, Outcome 7 Deep venous thrombosis: distal segment.
Figuras y tablas -
Analysis 1.7

Comparison 1 Low molecular weight heparin versus no prophylaxis or placebo, Outcome 7 Deep venous thrombosis: distal segment.

Comparison 1 Low molecular weight heparin versus no prophylaxis or placebo, Outcome 8 Deep venous thrombosis: proximal segment.
Figuras y tablas -
Analysis 1.8

Comparison 1 Low molecular weight heparin versus no prophylaxis or placebo, Outcome 8 Deep venous thrombosis: proximal segment.

Comparison 1 Low molecular weight heparin versus no prophylaxis or placebo, Outcome 9 Pulmonary embolism.
Figuras y tablas -
Analysis 1.9

Comparison 1 Low molecular weight heparin versus no prophylaxis or placebo, Outcome 9 Pulmonary embolism.

Comparison 1 Low molecular weight heparin versus no prophylaxis or placebo, Outcome 10 Symptomatic venous thromboembolism.
Figuras y tablas -
Analysis 1.10

Comparison 1 Low molecular weight heparin versus no prophylaxis or placebo, Outcome 10 Symptomatic venous thromboembolism.

Comparison 1 Low molecular weight heparin versus no prophylaxis or placebo, Outcome 11 Mortality due to pulmonary embolism.
Figuras y tablas -
Analysis 1.11

Comparison 1 Low molecular weight heparin versus no prophylaxis or placebo, Outcome 11 Mortality due to pulmonary embolism.

Comparison 1 Low molecular weight heparin versus no prophylaxis or placebo, Outcome 12 Mortality due to other causes.
Figuras y tablas -
Analysis 1.12

Comparison 1 Low molecular weight heparin versus no prophylaxis or placebo, Outcome 12 Mortality due to other causes.

Comparison 1 Low molecular weight heparin versus no prophylaxis or placebo, Outcome 13 Adverse outcomes.
Figuras y tablas -
Analysis 1.13

Comparison 1 Low molecular weight heparin versus no prophylaxis or placebo, Outcome 13 Adverse outcomes.

Summary of findings for the main comparison. Low molecular weight heparin compared to no prophylaxis or placebo in prevention of venous thromboembolism in patients with lower‐limb immobilization

Low molecular weight heparin compared to no prophylaxis or placebo in prevention of venous thromboembolism in patients with lower‐limb immobilization

Patient or population: prevention of venous thromboembolism in patients with lower‐limb immobilization
Setting: ambulatory setting
Intervention: low molecular weight heparin
Comparison: no prophylaxis or placebo

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

№ of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with no prophylaxis or placebo

Risk with low molecular weight heparin

Deep venous thrombosis

Study population

OR 0.45
(0.33 to 0.61)

1676
(7 RCTs)

⊕⊕⊕⊝
MODERATE 1

174 per 1000

87 per 1000
(65 to 114)

Pulmonary embolism

Study population

OR 0.50
(0.17 to 1.47)

2517
(5 RCTs)

⊕⊕⊝⊝
LOW 2

7 per 1000

4 per 1000
(1 to 10)

Symptomatic venous thromboembolism

Study population

OR 0.40
(0.21 to 0.76)

2924
(6 RCTs)

⊕⊕⊝⊝
LOW 3

21 per 1000

9 per 1000
(5 to 16)

Mortality due to pulmonary embolism

Study population

3111
(8 RCTs)

No mortality due to pulmonary embolism was reported

see comment

see comment

Mortality due to other causes

Study population

OR 0.33

(0.01 to 8.15)

3111
(8 RCTs)

⊕⊕⊝⊝
LOW 4

One death (in no prophylaxis/placebo group) was reported in the included studies

1 per 1000

0 per 1000

(0 to 5)

Adverse outcomes

Study population

OR 2.01
(0.83 to 4.86)

3178
(8 RCTs)

⊕⊕⊝⊝
LOW 5

40 per 1000

78 per 1000
(34 to 170)

*We calculated the assumed risk of the no prophylaxis or placebo group from the average risk in the no prophylaxis or placebo groups (i.e. the number of participants with events divided by total number of participants of the no prophylaxis or placebo group included in the meta‐analysis). The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; OR: odds ratio;

GRADE Working Group grades of evidence
High quality: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

1 Downgraded by one level as 3 out of 7 studies showed considerable risk of bias
2 Downgraded by two levels as 2 out of 5 studies showed considerable risk of bias, and imprecision of pooled results
3 Downgraded by two levels as 3 out of 6 studies showed considerable risk of bias, and imprecision of pooled results
4 Downgraded by two levels due to the low number of events, and imprecision of pooled results
5 Downgraded by two levels as 4 out of 8 studies showed considerable risk of bias, and imprecision of pooled results

Figuras y tablas -
Summary of findings for the main comparison. Low molecular weight heparin compared to no prophylaxis or placebo in prevention of venous thromboembolism in patients with lower‐limb immobilization
Comparison 1. Low molecular weight heparin versus no prophylaxis or placebo

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Deep venous thrombosis: regardless of type of plaster, whether operated or not Show forest plot

7

1676

Odds Ratio (M‐H, Fixed, 95% CI)

0.45 [0.33, 0.61]

2 Deep venous thrombosis: in below‐knee cast, whether operated or not Show forest plot

6

1080

Odds Ratio (M‐H, Fixed, 95% CI)

0.49 [0.34, 0.72]

3 Deep venous thrombosis: conservative treatment (i.e. non‐operated patients) Show forest plot

5

974

Odds Ratio (M‐H, Fixed, 95% CI)

0.31 [0.18, 0.53]

4 Deep venous thrombosis: operated patients Show forest plot

4

699

Odds Ratio (M‐H, Fixed, 95% CI)

0.54 [0.37, 0.80]

5 Deep venous thrombosis: fractures Show forest plot

6

1003

Odds Ratio (M‐H, Fixed, 95% CI)

0.48 [0.33, 0.70]

6 Deep venous thrombosis: soft‐tissue injuries Show forest plot

5

658

Odds Ratio (M‐H, Fixed, 95% CI)

0.39 [0.22, 0.68]

7 Deep venous thrombosis: distal segment Show forest plot

5

1208

Odds Ratio (M‐H, Fixed, 95% CI)

0.61 [0.42, 0.89]

8 Deep venous thrombosis: proximal segment Show forest plot

5

1217

Odds Ratio (M‐H, Fixed, 95% CI)

0.41 [0.19, 0.91]

9 Pulmonary embolism Show forest plot

5

2517

Odds Ratio (M‐H, Fixed, 95% CI)

0.50 [0.17, 1.47]

10 Symptomatic venous thromboembolism Show forest plot

6

2924

Odds Ratio (M‐H, Fixed, 95% CI)

0.40 [0.21, 0.76]

11 Mortality due to pulmonary embolism Show forest plot

8

3111

Odds Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

12 Mortality due to other causes Show forest plot

8

3111

Odds Ratio (M‐H, Fixed, 95% CI)

0.33 [0.01, 8.15]

13 Adverse outcomes Show forest plot

8

3178

Odds Ratio (M‐H, Random, 95% CI)

2.01 [0.83, 4.86]

Figuras y tablas -
Comparison 1. Low molecular weight heparin versus no prophylaxis or placebo