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Previous Volume 330:1864-1869 June 30, 1994 Number 26 Next

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ABSTRACT

Background It is uncertain whether patients with proximal deep-vein thrombosis should be treated with streptokinase followed by intravenous heparin or with intravenous heparin alone. Published reports indicate that streptokinase plus heparin increases the risk of bleeding, including central nervous system bleeding and death, but decreases the risk of postphlebitic syndrome. Previous recommendations regarding these treatments have not considered patients' preferences or the values they attach to the possible outcomes of therapy.

Methods We used decision analysis to combine published estimates of the probabilities of various adverse outcomes of treatment (bleeding, pulmonary embolism, postphlebitic syndrome, and death) with the values patients placed on these outcomes. We questioned 36 patients about the values they attached to each outcome. Sixteen patients had had deep-vein thrombosis, and 20 had not.

Results By the values they attached to the outcomes, all 36 patients indicated that they were unwilling to accept an increased risk of death to avoid postphlebitic syndrome. According to the decision analysis, heparin alone was the better treatment for all 36 patients. As compared with streptokinase plus heparin, heparin alone provided 29 days of additional life expectancy over the predicted life expectancy of 20 years. Although the difference between the two treatments was small, heparin alone remained the better treatment in sensitivity analyses that examined the reasonable ranges of probabilities of the clinical outcomes.

Conclusions The values patients placed on the outcomes of treatment for deep-vein thrombosis support the use of heparin alone over the combined use of streptokinase and heparin.

Source Information

From the Divisions of General Medicine and Clinical Epidemiology (J.J.O., R.A.M., A.T.E., S.W.M.) and the Department of Pediatrics (S.M.D.), University of North Carolina at Chapel Hill, Chapel Hill.

Address reprint requests to Dr. McNutt at 5025 Old Clinic Bldg., Campus Box 7110, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7110.

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