Background It is uncertain whether patients with proximal deep-veinthrombosis should be treated with streptokinase followed byintravenous heparin or with intravenous heparin alone. Publishedreports indicate that streptokinase plus heparin increases therisk of bleeding, including central nervous system bleedingand death, but decreases the risk of postphlebitic syndrome.Previous recommendations regarding these treatments have notconsidered patients' preferences or the values they attach tothe possible outcomes of therapy.
Methods We used decision analysis to combine published estimatesof the probabilities of various adverse outcomes of treatment(bleeding, pulmonary embolism, postphlebitic syndrome, and death)with the values patients placed on these outcomes. We questioned36 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 36patients indicated that they were unwilling to accept an increasedrisk of death to avoid postphlebitic syndrome. According tothe decision analysis, heparin alone was the better treatmentfor all 36 patients. As compared with streptokinase plus heparin,heparin alone provided 29 days of additional life expectancyover the predicted life expectancy of 20 years. Although thedifference between the two treatments was small, heparin aloneremained the better treatment in sensitivity analyses that examinedthe reasonable ranges of probabilities of the clinical outcomes.
Conclusions The values patients placed on the outcomes of treatmentfor deep-vein thrombosis support the use of heparin alone overthe 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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