Grange Blanche

Le problème majeur du traitement des TVP (thrombose veineuse profonde) est la durée de l’anticoagulation.

Six semaines, 3 mois, ou plus pour les TVP distales ? Trois mois, 6 mois, ou plus pour les proximales ? Dosage de D-dimères 1 mois après l’arrêt des AVK pour estimer le risque résiduel ?

Il existe bien des recommandations récentes, comme celles de l’Afssaps de novembre 2009, mais elles laissent des tas de zones d’ombre, non couvertes par la science.

Alors, quand j’ai vu que le grand, l’immense Samuel Z Goldhaber avait écrit un article sur le sujet dans le Circulation du jour, j’ai sauté avidement dessus.

Mais même lui ne sait pas trop.

Il propose une espèce de prise en charge mixte associant suivi des recommandations et estimation du risque individuel. Mais n’est-ce pas ce que l’on fait tous les jours?

L’article pose néanmoins les jalons de ce qui sera peut-être l’avenir de la prise en charge de la TVP:

These high recurrence rates for both idiopathic and provoked VTE require a paradigm shift in our thinking about PE and DVT. In many instances, VTE appears to be similar to chronic illnesses such as coronary artery disease or diabetes mellitus because VTE recurs so frequently. In the absence of a clinical recurrence, it is likely that many patients remain hypercoagulable after discontinuing anticoagulation. We must question and probably discard the classic teaching that most PE or DVT can be safely treated in a time-limited fashion.

Comme dans tous les articles de cette section de Circulation (Clinician Update), l’auteur part d’un ou de plusieurs cas cliniques.

La prise en charge préconisée par Goldhaber a néanmoins conduit à un échec dans un des cas donnés en exemple:

This 24-year-old woman had features of both a provoked and an idiopathic event. We discontinued anticoagulation and instructed her to return in 6 weeks for D-dimer testing. Her D-dimer was low normal (243 ng/mL with normal <500 ng/mL). We phoned her and provided reassurance that her risk was low and that she could remain off anticoagulation. Three months later, she presented with recurrent leg discomfort and imaging evidence of acute right common femoral vein thrombosis. She was treated with enoxaparin as a bridge to warfarin. She is now reconciled to receiving lifelong anticoagulation.

J’adore cette façon de présenter les choses.

Goldhaber est un immense monsieur qui règne sur son domaine de prédilection, la thrombose, depuis des décennies mais il conclut un article plein de doutes assumés dans la plus prestigieuse revue de cardiologie par un échec clinique de sa prise en charge.

Grandeur et humilité.

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Samuel Z. Goldhaber, and Gregory Piazza. Optimal Duration of Anticoagulation After Venous Thromboembolism. Circulation 123: 664-667, doi:10.1161/CIRCULATIONAHA.110.970822

Nunc Lento Sonitu Dicunt, Morieris (Now this bell, tolling softly for another, says to me, Thou must die.)

Perchance, he for whom this bell tolls may be so ill, as that he knows not it tolls for him; and perchance I may think myself so much better than I am, as that they who are about me, and see my state, may have caused it to toll for me, and I know not that. The church is Catholic, universal, so are all her actions; all that she does belongs to all. When she baptizes a child, that action concerns me; for that child is thereby connected to that body which is my head too, and ingrafted into that body whereof I am a member. And when she buries a man, that action concerns me: all mankind is of one author, and is one volume; when one man dies, one chapter is not torn out of the book, but translated into a better language; and every chapter must be so translated; God employs several translators; some pieces are translated by age, some by sickness, some by war, some by justice; but God’s hand is in every translation, and his hand shall bind up all our scattered leaves again for that library where every book shall lie open to one another. As therefore the bell that rings to a sermon calls not upon the preacher only, but upon the congregation to come, so this bell calls us all; but how much more me, who am brought so near the door by this sickness.

There was a contention as far as a suit (in which both piety and dignity, religion and estimation, were mingled), which of the religious orders should ring to prayers first in the morning; and it was determined, that they should ring first that rose earliest. If we understand aright the dignity of this bell that tolls for our evening prayer, we would be glad to make it ours by rising early, in that application, that it might be ours as well as his, whose indeed it is.

The bell doth toll for him that thinks it doth; and though it intermit again, yet from that minute that this occasion wrought upon him, he is united to God. Who casts not up his eye to the sun when it rises? but who takes off his eye from a comet when that breaks out? Who bends not his ear to any bell which upon any occasion rings? but who can remove it from that bell which is passing a piece of himself out of this world?

No man is an island, entire of itself; every man is a piece of the continent, a part of the main. If a clod be washed away by the sea, Europe is the less, as well as if a promontory were, as well as if a manor of thy friend’s or of thine own were: any man’s death diminishes me, because I am involved in mankind, and therefore never send to know for whom the bell tolls; it tolls for thee.

Neither can we call this a begging of misery, or a borrowing of misery, as though we were not miserable enough of ourselves, but must fetch in more from the next house, in taking upon us the misery of our neighbours. Truly it were an excusable covetousness if we did, for affliction is a treasure, and scarce any man hath enough of it. No man hath affliction enough that is not matured and ripened by it, and made fit for God by that affliction. If a man carry treasure in bullion, or in a wedge of gold, and have none coined into current money, his treasure will not defray him as he travels. Tribulation is treasure in the nature of it, but it is not current money in the use of it, except we get nearer and nearer our home, heaven, by it. Another man may be sick too, and sick to death, and this affliction may lie in his bowels, as gold in a mine, and be of no use to him; but this bell, that tells me of his affliction, digs out and applies that gold to me: if by this consideration of another’s danger I take mine own into contemplation, and so secure myself, by making my recourse to my God, who is our only security.

Meditation #17 By John Donne From Devotions upon Emergent Occasions (1623).

Pas drôle drôle pour une lecture du jeudi matin, mais j’aime bien ce texte, notamment son paragraphe le plus connu No man is an island…

Ceci aussi pour dire aussi que le glas sonne plus souvent pour les médecins que pour les autres. Je ne vois pas cela comme une malédiction, ni comme John Donne, un trésor. Plutôt comme une piqure de rappel pour garder son esprit ouvert et tolérant.

(Non, je n’ai pas perdu de patient récemment mais certains m’inquiètent)