BMJ 1994;308:235-246 (22 January)

Papers

Collaborative overview of randomised trials of antiplatelet therapy - III: Reduction in venous thrombosis and pulmonary embolism by antiplatelet prophylaxis among surgical and medical patients

APT Statistical Secretariat, ICRF/BHF/MRC Clinical Trial Service Unit, Nuffield Department of Clinical Medicine, Radcliffe Infirmary, Oxford OX2 6HE, or APT Clinical Secretariat, Department of Clinical Neurosciences, Western General Hospital, Edinburgh EH4 2XU.

Abstract

Objective : To determine the efficacy of antiplatelet therapy as prophylaxis against deep venous thrombosis or pulmonary embolism in surgical and high risk medical patients.
Design : Overviews of all randomised trials of antiplatelet therapy that could have been available by March 1990 and in which deep venous thrombosis was assessed systematically.
Setting : 53 trials (total 8400 patients) of an average of two weeks of antiplatelet therapy versus control in general or orthopaedic surgery; nine trials (600 patients) of antiplatelet therapy versus control in other types of immobility; 18 trials (1000 patients) of one antiplatelet regimen versus another.
Results : Overall, a few weeks of antiplatelet therapy produced a highly significant (2P < 0.00001) reduction in deep venous thrombosis. 25% of patients allocated antiplatelet therapy versus 34% of appropriately adjusted controls had deep venous thrombosis detected by systematic fibrinogen scanning or venography, representing prevention in about 90 patients per 1000 allocated antiplatelet therapy. There was an even greater proportional reduction in pulmonary embolism: such emboli were detected among 47 (1.0%) antiplatelet allocated patients versus an adjusted control total of 129 (2.7%), representing prevention among about 17 patients per 1000 treated (2P < 0.00001). In analyses confined to surgical trials, the proportional reductions were similar and separately significant for nonfatal pulmonary embolism (0.7% antiplatelet therapy upsilion 1.8% control; 2P < 0.00001) and for deaths attributed to pulmonary embolism (0.2% upsilion 0.9%; 2P = 0.0001). There was a slight but non - significant excess of deaths from other causes (1.0% upsilion 0.7%), which made the difference in total mortality non-significant, though still favourable (1.2% upsilion 1.5%). Information on adding antiplatelet therapy to heparin was limited but, at least for pulmonary embolism, suggested more protection from the combination than from heparin alone.
Conclusion : It had previously been supposed that antiplatelet therapy did not influence venous thromboembolism, and many surgeons and physicians do not use it routinely for thromboprophylaxis, even for patients who are at substantial risk of deep venous thrombosis or pulmonary embolism. These results indicate that antiplatelet therapy - either alone or, for greater effect, in addition to other proved forms of thromboprophylaxis (such as subcutaneous heparin) - should be considered.

Clinical implications

  • Clinical implications

  • Prolonged general and orthopaedic surgery (as well as other periods of limited mobility) are associated with increased risks of venous thromboembolism

  • A few weeks of antiplatelet therapy roughly halved the risk both of deep venous thrombosis and of pulmonary embolism in a wide range of surgical patients (and the limited evidence in immobilised medical patients was also encouraging)

  • The absolute benefits appeared to be greater for those at higher risk (for example, those undergoing orthopaedic surgery)

  • Antiplatelet therapy can be conveniently continued after discharge from hospital (in contrast with many other forms of prophylaxis) for as long as the risk of thromboembolism is still substantial

  • Antiplatelet therapy - either alone or, for greater effect, in addition to other proved forms of thromboprophylaxis - should be considered for patients at high risk of thromboembolism


Add to CiteULike CiteULike   Add to Complore Complore   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us   Add to Digg Digg   Add to Reddit Reddit   Add to Technorati Technorati    What's this?

Relevant Article

Antiplatelet prophylaxis Combination treatment may cause bleeding
V Seagroatt, C Bulstrode, D W Murray, P H Wittmann, F W Wittmann, R Collins, C Baigent, R Peto, B Farrell, and J L Sullivan
BMJ 1994 308: 651-652. [Extract] [Full Text]

This article has been cited by other articles:

  • Lacut, K., van der Maaten, J., Le Gal, G., Cornily, G., Mottier, D., Oger, E. (2008). Antiplatelet drugs and risk of venous thromboembolism: results from the EDITH case-control study. haematol 93: 1117-1118 [Full text]  
  • Patrono, C., Baigent, C., Hirsh, J., Roth, G. (2008). Antiplatelet Drugs: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 133: 199S-233S [Abstract] [Full text]  
  • Geerts, W. H., Bergqvist, D., Pineo, G. F., Heit, J. A., Samama, C. M., Lassen, M. R., Colwell, C. W. (2008). Prevention of Venous Thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 133: 381S-453S [Abstract] [Full text]  
  • Albers, G. W., Amarenco, P., Easton, J. D., Sacco, R. L., Teal, P. (2008). Antithrombotic and Thrombolytic Therapy for Ischemic Stroke: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 133: 630S-669S [Abstract] [Full text]  
  • Daniel, J., Pradhan, A., Pradhan, C., Ziaee, H., Moss, M., Freeman, J., McMinn, D. J. W. (2008). Multimodal thromboprophylaxis following primary hip arthroplasty: THE ROLE OF ADJUVANT INTERMITTENT PNEUMATIC CALF COMPRESSION. J Bone Joint Surg Br 90-B: 562-569 [Abstract] [Full text]  
  • Blanc, J. J., Almendral, J., Brignole, M., Fatemi, M., Gjesdal, K., Gonzalez-Torrecilla, E., Kulakowski, P., Lip, G. Y.H., Shah, D., Wolpert, C., on behalf of the Scientific Initiatives Committee, (2008). Consensus document on antithrombotic therapy in the setting of electrophysiological procedures. Europace 10: 513-527 [Full text]  
  • Eikelboom, J. W. (2008). Effect of fondaparinux 2.5 mg once daily on mortality: a meta-analysis of phase III randomized trials of venous thromboembolism prevention. Eur Heart J Suppl 10: C8-C13 [Abstract] [Full text]  
  • Francis, C. W., Kakkar, A. K., Levine, M. N., Lyman, G. H. (2008). Prevention of Venous Thromboembolism in Patients with Cancer. Am Soc Clin Oncol Ed Book 2008: 250-256 [Abstract] [Full text]  
  • Dorr, L. D., Gendelman, V., Maheshwari, A. V., Boutary, M., Wan, Z., Long, W. T. (2007). Multimodal Thromboprophylaxis for Total Hip and Knee Arthroplasty Based on Risk Assessment. JBJS 89: 2648-2657 [Abstract] [Full text]  
  • Glynn, R. J., Ridker, P. M, Goldhaber, S. Z., Buring, J. E. (2007). Effect of Low-Dose Aspirin on the Occurrence of Venous Thromboembolism: A Randomized Trial. ANN INTERN MED 147: 525-533 [Abstract] [Full text]  
  • Adams, H. P. Jr, del Zoppo, G., Alberts, M. J., Bhatt, D. L., Brass, L., Furlan, A., Grubb, R. L., Higashida, R. T., Jauch, E. C., Kidwell, C., Lyden, P. D., Morgenstern, L. B., Qureshi, A. I., Rosenwasser, R. H., Scott, P. A., Wijdicks, E. F.M. (2007). Guidelines for the Early Management of Adults With Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists.. Circulation 115: e478-e534 [Abstract] [Full text]  
  • Adams, H. P. Jr, del Zoppo, G., Alberts, M. J., Bhatt, D. L., Brass, L., Furlan, A., Grubb, R. L., Higashida, R. T., Jauch, E. C., Kidwell, C., Lyden, P. D., Morgenstern, L. B., Qureshi, A. I., Rosenwasser, R. H., Scott, P. A., Wijdicks, E. F.M. (2007). Guidelines for the Early Management of Adults With Ischemic Stroke: A Guideline From the American Heart Association/ American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke 38: 1655-1711 [Abstract] [Full text]  
  • Francis, C. W. (2007). Prophylaxis for Thromboembolism in Hospitalized Medical Patients. NEJM 356: 1438-1444 [Full text]  
  • Manini, T. M, Clark, B. C, Nalls, M. A, Goodpaster, B. H, Ploutz-Snyder, L. L, Harris, T. B (2007). Reduced physical activity increases intermuscular adipose tissue in healthy young adults. Am. J. Clin. Nutr. 85: 377-384 [Abstract] [Full text]  
  • Clark, B. C., Fernhall, B., Ploutz-Snyder, L. L. (2006). Adaptations in human neuromuscular function following prolonged unweighting: I. Skeletal muscle contractile properties and applied ischemia efficacy. J. Appl. Physiol. 101: 256-263 [Abstract] [Full text]  
  • Rajkumar, S. V. (2005). Thalidomide Therapy and Deep Venous Thrombosis in Multiple Myeloma. Mayo Clin Proc. 80: 1549-1551  
  • Devereaux, P.J., Goldman, L., Yusuf, S., Gilbert, K., Leslie, K., Guyatt, G. H. (2005). Surveillance and prevention of major perioperative ischemic cardiac events in patients undergoing noncardiac surgery: a review. CMAJ 173: 779-788 [Abstract] [Full text]  
  • Agnelli, G. (2004). Prevention of Venous Thromboembolism in Surgical Patients. Circulation 110: IV-4-IV-12 [Abstract] [Full text]  
  • Cushman, M., Kuller, L. H., Prentice, R., Rodabough, R. J., Psaty, B. M., Stafford, R. S., Sidney, S., Rosendaal, F. R., for the Women's Health Initiative Investigators, (2004). Estrogen Plus Progestin and Risk of Venous Thrombosis. JAMA 292: 1573-1580 [Abstract] [Full text]  
  • Patrono, C., Coller, B., FitzGerald, G. A., Hirsh, J., Roth, G. (2004). Platelet-Active Drugs: The Relationships Among Dose, Effectiveness, and Side Effects: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 126: 234S-264S [Abstract] [Full text]  
  • Geerts, W. H., Pineo, G. F., Heit, J. A., Bergqvist, D., Lassen, M. R., Colwell, C. W., Ray, J. G. (2004). Prevention of Venous Thromboembolism: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 126: 338S-400S [Abstract] [Full text]  
  • Albers, G. W., Amarenco, P., Easton, J. D., Sacco, R. L., Teal, P. (2004). Antithrombotic and Thrombolytic Therapy for Ischemic Stroke: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 126: 483S-512S [Abstract] [Full text]  
  • Kyrle, P. A., Minar, E., Bialonczyk, C., Hirschl, M., Weltermann, A., Eichinger, S. (2004). The Risk of Recurrent Venous Thromboembolism in Men and Women. NEJM 350: 2558-2563 [Abstract] [Full text]  
  • Vilahur, G., Baldellou, M. I., Segales, E., Salas, E., Badimon, L. (2004). Inhibition of thrombosis by a novel platelet selective S-nitrosothiol compound without hemodynamic side effects. Cardiovasc Res 61: 806-816 [Abstract] [Full text]  
  • Kearon, C. (2003). Natural History of Venous Thromboembolism. Circulation 107: I-22-30 [Abstract] [Full text]  
  • O'Donnell, M., Linkins, L.-A., Kearon, C., Julian, J., Hirsh, J. (2003). Reduction of Out-of-Hospital Symptomatic Venous Thromboembolism by Extended Thromboprophylaxis With Low-Molecular-Weight Heparin Following Elective Hip Arthroplasty: A Systematic Review. Arch Intern Med 163: 1362-1366 [Abstract] [Full text]  
  • Nugent, H. M., Edelman, E. R. (2003). Tissue Engineering Therapy for Cardiovascular Disease. Circ. Res. 92: 1068-1078 [Abstract] [Full text]  
  • Adams, H. P. Jr, Adams, R. J., Brott, T., del Zoppo, G. J., Furlan, A., Goldstein, L. B., Grubb, R. L., Higashida, R., Kidwell, C., Kwiatkowski, T. G., Marler, J. R., Hademenos, G. J. (2003). Guidelines for the Early Management of Patients With Ischemic Stroke: A Scientific Statement From the Stroke Council of the American Stroke Association. Stroke 34: 1056-1083 [Full text]  
  • Dalen, J. E. (2002). Pulmonary Embolism: What Have We Learned Since Virchow?: Treatment and Prevention. Chest 122: 1801-1817 [Full text]  
  • Weisman, S. M., Graham, D. Y. (2002). Evaluation of the Benefits and Risks of Low-Dose Aspirin in the Secondary Prevention of Cardiovascular and Cerebrovascular Events. Arch Intern Med 162: 2197-2202 [Abstract] [Full text]  
  • Sobieszczyk, P., Fishbein, M. C., Goldhaber, S. Z. (2002). Acute Pulmonary Embolism: Don't Ignore the Platelet. Circulation 106: 1748-1749 [Full text]  
  • Califf, R. M., DeMets, D. L. (2002). Principles From Clinical Trials Relevant to Clinical Practice: Part I. Circulation 106: 1015-1021 [Full text]  
  • Alonso-Ortiz del Rio, C., Romero-Alonso, A., Marin-Leon, I., Rincon-Gomez, M., Geerts, W. H. (2002). Strength of Evidence for Low-Molecular-Weight Heparin. Chest 121: 2078-2079 [Full text]  
  • Turek, J. W., Halmos, T., Sullivan, N. L., Antonakis, K., Le Breton, G. C. (2002). Mapping of a Ligand-binding Site for the Human Thromboxane A2 Receptor Protein. J. Biol. Chem. 277: 16791-16797 [Abstract] [Full text]  
  • Sculco, T. P., Colwell, C. W. Jr., Pellegrini, V. D. Jr., Westrich, G. H., Bottner, F. (2002). Prophylaxis Against Venous Thromboembolic Disease in Patients Having a Total Hip or Knee Arthroplasty. JBJS 84: 466-477 [Full text]  
  • Dormandy, J.A. (2002). Antiplatelet therapy in patients with claudication: lessons from large trials. Eur Heart J Suppl 4: B55-B57 [Abstract]  
  • Collaboration, A. T. (2002). Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ 324: 71-86 [Abstract] [Full text]  
  • Eriksson, B. I., Bauer, K. A., Lassen, M. R., Turpie, A. G.G., the Steering Committee of the Pentasaccharide in H, (2001). Fondaparinux Compared with Enoxaparin for the Prevention of Venous Thromboembolism after Hip-Fracture Surgery. NEJM 345: 1298-1304 [Abstract] [Full text]  
  • Jin, F., Chung, F. (2001). Minimizing perioperative adverse events in the elderly{dagger}. Br J Anaesth 87: 608-624 [Abstract] [Full text]  
  • Kelly, J., Rudd, A., Lewis, R.R., Hunt, B.J. (2001). Screening for subclinical deep-vein thrombosis. QJM 94: 511-519 [Full text]  
  • Sandercock, P., Dennis, M., Kelly, J., Rudd, A., Lewis, R., Hunt, B.J. (2001). Venous Thromboembolism After Acute Stroke Response. Stroke 32 : 1443-1448 [Full text]  
  • Gillespie, W. J. (2001). Extracts from "Clinical Evidence": Hip fracture. BMJ 322: 968-975 [Full text]  
  • Thomas, D. P (2001). Thromboprophylaxis after replacement arthroplasty. BMJ 322: 686-687 [Full text]  
  • Ravn, H B, Hjortdal, V E, Stenbog, E V, Emmertsen, K, Kromann, O, Pedersen, J, Sorensen, K E (2001). Increased platelet reactivity and significant changes in coagulation markers after cavopulmonary connection. Heart 85: 61-65 [Abstract] [Full text]  
  • Kelly, J., Rudd, A., Lewis, R., Hunt, B. J. (2001). Venous Thromboembolism After Acute Stroke. Stroke 32: 262-267 [Abstract] [Full text]  
  • Patrono, C., Coller, B., Dalen, J. E., FitzGerald, G. A., Fuster, V., Gent, M., Hirsh, J., Roth, G. (2001). Platelet-Active Drugs : The Relationships Among Dose, Effectiveness, and Side Effects. Chest 119: 39S-63S [Full text]  
  • Geerts, W. H., Heit, J. A., Clagett, G. P., Pineo, G. F., Colwell, C. W., Anderson, F. A. Jr., Wheeler, H. B. (2001). Prevention of Venous Thromboembolism. Chest 119: 132S-175S [Full text]  
  • Rai, R., Backos, M., Baxter, N., Chilcott, I., Regan, L. (2000). Recurrent miscarriage--an aspirin a day?. Hum Reprod 15: 2220-2223 [Abstract] [Full text]  
  • Wahl, D. G., Bounameaux, H., de Moerloose, P., Sarasin, F. P. (2000). Prophylactic Antithrombotic Therapy for Patients With Systemic Lupus Erythematosus With or Without Antiphospholipid Antibodies: Do the Benefits Outweigh the Risks? A Decision Analysis. Arch Intern Med 160: 2042-2048 [Abstract] [Full text]  
  • Davenport, R., Dennis, M. (2000). Neurological emergencies: acute stroke. J. Neurol. Neurosurg. Psychiatry 68: 277-288 [Abstract] [Full text]  
  • SALVATI, E. A., PELLEGRINI, V. D., SHARROCK, N. E., LOTKE, P. A., MURRAY, D. W., POTTER, H., WESTRICH, G. H. (2000). Symposium - Recent Advances in Venous Thromboembolic Prophylaxis During and After Total Hip Replacement. JBJS 82: 252-70 [Full text]  
  • de Swiet, M. (1999). Review Article: Management of pulmonary embolus in pregnancy. Eur Heart J 20: 1378-1385  
  • Yusuf, S. (1999). Randomised controlled trials in cardiovascular medicine: past achievements, future challenges. BMJ 319: 564-568 [Full text]  
  • Avidan, M S, Hunt, B J, Soar, J., Howell, S. J, Sonksen, J., Gray, R., Hutton, P. (1999). Safer non-cardiac surgery for patients with coronary artery disease. BMJ 319: 320-320 [Full text]  
  • NURMOHAMED, M T, LEMS, W F, DIJKMANS, B A C (1999). Risk of post-discharge venous thromboembolism in patients with rheumatoid arthritis undergoing knee or hip arthroplasty. Is prolonged thromboprophylaxis warranted or dangerous?. Ann Rheum Dis 58: 392-395 [Full text]  
  • Cesarone, M.R., Laurora, G., DeSanctis, M.T., Incandela, L., Fugazza, L., Girardello, R., Poli, A., Peracino, L., Ambrosoli, L., Belcaro, G. (1999). Effects of Triflusal on Arteriosclerosis Progression Assessed with High-Resolution Arterial Ultrasound. ANGIOLOGY 50: 455-463 [Abstract]  
  • Verstraete, M. (1999). Prevention and treatment of venous thromboembolism after major trauma. Trauma 1: 39-51 [Abstract]  
  • Dormandy, J. A (1998). Rationale for antiplatelet therapy in patients with atherothrombotic disease. Vasc Med 3: 253-255 [Abstract]  
  • Goldhaber, S. Z. (1998). Pulmonary Embolism. NEJM 339: 93-104 [Full text]  
  • Hull, R. D., Pineo, G. F. (1998). Prophylaxis of Deep Vein Thrombosis and Pulmonary Embolism: Current Recommendations. CLIN APPL THROMB HEMOST 4: 96-104 [Abstract]  
  • Ronning, O. M., Guldvog, B. (1998). Stroke Units Versus General Medical Wards, I: Twelve- and Eighteen-Month Survival : A Randomized, Controlled Trial. Stroke 29: 58-62 [Abstract] [Full text]  
  • Hennekens, C. H., Dyken, M. L., Fuster, V., Fuster, V. (1997). Aspirin as a Therapeutic Agent in Cardiovascular Disease : A Statement for Healthcare Professionals From the American Heart Association. Circulation 96: 2751-2753 [Full text]  
  • Petticrew, M., Kennedy, S. C (1997). Detecting the effects of thromboprophylaxis: the case of the rogue reviews. BMJ 315: 665-668 [Full text]  
  • Cappelleri, J. C., loannidis, J. P. A., Schmid, C. H., de Ferranti, S. D., Aubert, M., Chalmers, T. C., Lau, J. (1996). Large Trials vs Meta-analysis of Smaller Trials: How Do Their Results Compare?. JAMA 276: 1332-1338 [Abstract]  
  • Collins, R., MacMahon, S., Flather, M., Baigent, C., Remvig, L., Mortensen, S., Appleby, P., Godwin, J., Yusuf, S., Peto, R. (1996). Clinical effects of anticoagulant therapy in suspected acute myocardial infarction: systematic overview of randomised trials. BMJ 313: 652-659 [Abstract] [Full text]  
  • Prandoni, P., Goldhaber, S. Z., Piccioli, A., Girolami, A. (1996). State-of-the-Art Review : Prevention of Venous Thromboembolism in Major Orthopedic Surgery. CLIN APPL THROMB HEMOST 2: 153-157 [Abstract]  
  • (1996). Advising patients about air travel. DTB 34: 30-32 [Abstract] [Full text]  
  • Prystowsky, E. N., Benson, D. W. Jr, Fuster, V., Hart, R. G., Kay, G. N., Myerburg, R. J., Naccarelli, G. V., Wyse, D. G. (1996). Management of Patients With Atrial Fibrillation : A Statement for Healthcare Professionals From the Subcommittee on Electrocardiography and Electrophysiology, American Heart Association. Circulation 93: 1262-1277 [Full text]  
  • Greenfield, L. J., Proctor, M. C. (1996). Diagnosis and Management of Pulmonary Embolism. Ann. Thorac. Surg. 61: 1037-1037 [Full text]  
  • Gent, M., Hirsh, J., Ginsberg, J.S., Powers, P.J., Levine, M.N., Geerts, W.H., Jay, R.M., Leclerc, J., Neemeh, J.A., Turpie, A.G.G. (1996). Low-Molecular-Weight Heparinoid Orgaran Is More Effective Than Aspirin in the Prevention of Venous Thromboembolism After Surgery for Hip Fracture. Circulation 93: 80-84 [Abstract] [Full text]  
  • Pratico, D., FitzGerald, G. A. (1995). Testosterone and Thromboxane : Of Muscles, Mice, and Men. Circulation 91: 2694-2698 [Full text]  
  • Baker, W. F. JR (1995). Outcome Analysis for Treatment in 100 Patients with Deep Vein Thrombosis. CLIN APPL THROMB HEMOST 1: 39-48 [Abstract]  
  • Weinmann, E. E., Salzman, E. W. (1994). Deep-Vein Thrombosis. NEJM 331: 1630-1641 [Full text]  
  • Cohen, A T, Skinner, J A, Kakkar, V V (1994). Antiplatelet treatment for thromboprophylaxis: a step forward or backwards?. BMJ 309: 1213-1215 [Full text]  
  • Collins, R, Baignent, C, Sandercock, P, Peto, R (1994). Antiplatelet therapy for thromboprophylaxis: the need for careful consideration of the evidence from randomised trials. BMJ 309: 1215-1217 [Full text]  
  • Barbui, T., Finazzi, G. (1994). Clinical Trials on Antiphospholipid Syndrome: What is Being Done and What is Needed?. Lupus 3: 303-307  
  • Bounameaux, H, Baigent, C, Collin, R, Peto, R, Bell, P, Sandercock, P (1994). Trails of antiplatelet therapy. BMJ 308: 1371-2 [Full text]  
  • Patrono, C. (1994). Aspirin as an Antiplatelet Drug. NEJM 330: 1287-1294 [Full text]  
  • Seagroatt, V, Bulstrode, C, Murray, D W, Wittmann, P H, Wittmann, F W, Collins, R, Baigent, C, Peto, R, Farrell, B, Sullivan, J L (1994). Antiplatelet prophylaxis. Consider the protective effect of blood loss from the gut.. BMJ 308: 651-652 [Full text]  
  • (1994). ANTIPLATELET THERAPY AND VENOUS THROMBOSIS. JWatch General 1994: 2-2 [Full text]  
Access jobs at BMJ Careers
Whats new online at Student BMJ