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In aspirin-treated patients with acute coronary syndromes without ST-segment elevation unfractionated heparin (UFH) or low molecular weight heparin (LMWH) treatment < 7 days significantly reduce the risk of acute myocardial infarction (AMI), and LMWH furthermore reduces revascularisation. There is a non-significant effect on mortality compared with placebo and an insignificantly increased risk of haemorrhagic complications. No net clinical benefit of LMWH was found compared to UHF, but LMWH has pharmacokinetic advantages. The optimal duration of heparin treatment remains controversial.

In aspirin-treated patients with acute coronary syndromes without ST-segment elevation unfractionated heparin (UFH) or low molecular weight heparin (LMWH) treatment < 7 days significantly reduce the risk of acute myocardial infarction (AMI), and LMWH furthermore reduces revascularisation. There is a non-significant effect on mortality compared with placebo and an insignificantly increased risk of haemorrhagic complications. No net clinical benefit of LMWH was found compared to UHF, but LMWH has pharmacokinetic advantages. The optimal duration of heparin treatment remains controversial.

Superficial thrombophlebitis is a common disease. Recently, a relatively high incidence of concomitant venous thromboembolism has been found. Graduated compressing stockings and low-molecular heparin subcutaneously in weight-based therapeutic doses for 10-30 days are considered the best treatment. Non-steroidal-anti-inflammatory drugs or local treatment with heparinoid may reduce the pain. A new Cochrane analysis concludes that the existing studies do not demonstrate strong recommendations for any treatment. Ongoing trials will add to our knowledge about optimal treatment of ST.

The pathogenesis of deep vein thrombosis (DVT) involves vascular changes or injury, stasis and alterations in the blood composition. The risk increases with age; however, important risk factors are cancer, surgery, immobilisation and hormone therapy. DVT most often appears in the crural veins. The diagnosis is based on ultrasound, d-dimer and clinical examination. Correct treatment requires gradient compression hosiery, low-molecular heparins and anticoagulant therapy. Duration of treatment depends on the individual risk of recurrence.

Acute manifestations of atherosclerosis, e.g. myocardial infarction and ischaemic stroke, are among the most common causes of death in the western part of the world. Rupture of an atherosclerotic plaque results in activation, adhesion and aggregation of platelets. Antithrombotic treatment has shown to reduce mortality and morbidity and is used in both primary and secondary prevention. The thienopyridine Clopidogrel specifically and irreversibly inhibits the binding of ADP to platelet surface ADP-receptors, thereby inhibiting platelet activation and aggregation. In this publication the pharmacological background and clinical documentation for the use of Clopidogrel both as monotherapy and in combination with Acetylicsalisylic acid are reviewed.

In 1998, the sale of vitamin K antagonists (VKA) in Denmark corresponded to the amount used for treatment of more than 20,000 patients for one year. This is more than three times more than ten years earlier. The reasons for the increasing use of VKA are new indications for permanent anticoagulant treatment, especially chronic atrial fibrillation and venous thromboembolism associated with permanent thromboembolic risk factors. The risk of bleeding is higher in the introductory phase of anticoagulant treatment than later on. It is now recommended to commence anticoagulant therapy without a loading dose. This seems to hasten a good estimate of the maintenance dose. The metabolism of VKA depends on a number of genetic and acquired factors. Knowledge of these factors is crucial for optimal regulation of the treatment, and it is important that patients at start of treatment are thoroughly informed about these factors in order to minimize the risk of complications.

During the last 10 years anticoagulant (AC) therapy and thrombolytic treatment of venous thromboembolism (VT) have been evaluated in randomized studies. Adjusted subcutaneous (s.c.) heparin and low molecular weight heparin (LMWH) are found at least as effective as intravenous (i.v.) infusion of heparin in deep venous thrombosis (DVT) without an increased bleeding risk. In pulmonary embolism (PE) randomized trials assessing the efficacy of s.c. heparin and LMWH are missing. Oral AC-treatment can be initiated from the first or second day in VT. The recommended duration is three months for medical patients, and 4 weeks seem appropriate for surgical patients that are completely mobilized and without persisting predisposing factors. Long-term efficacy of thrombolytic treatment of DVT has only been assessed in small trials showing a trend towards reduced risk of developing chronic venous insufficiency. Short-term thrombolytic treatment of DVT is evaluated in ongoing trials. In the treatment of PE short-term thrombolysis with either t-PA or urokinase is found to be as effective as long-term thrombolytic treatment with a reduced bleeding risk. Thrombolytic therapy rapidly reduces embolic mass and stabilizes haemodynamics, but mortality and long-term efficacy of thrombolysis and AC-treatment versus AC-treatment alone in PE are being assessed in ongoing studies.

Intracoronary thrombus formation is the essential pathogenic substrate for the development of the acute ischaemic coronary syndromes (unstable angina pectoris (UAP), acute myocardial infarction (MI) and sudden cardiac death). Rupture of an atherosclerotic plaque has been shown to be of major importance for initiation of the thrombogenic process, but the reactivity of the circulating platelets and their interaction with the coronary vessel wall are also important for the formation and propagation of the intracoronary thrombus. The evidence favouring the role of platelets is: 1) the aggregability of platelets is increased in the morning where the incidence of MI and sudden cardiac death has been shown to be high, 2) shortened bleeding time and increased mean platelet volume in the acute phase of MI, 3) the synthesis of proaggregatory thromboxane A2 is increased in the acute phase of MI and in UAP, 4) a high platelet count and an increased ADP-induced platelet aggregation predispose to MI and death in healthy males, 5) high mean platelet volume and increased spontaneous platelet aggregation are risk factors for MI and death in patients with a recent MI, 6) the platelet inhibitor, acetylsalicylic acid, has been shown to reduce the incidence of MI and mortality in patients with silent myocardial ischaemia, stable and unstable angina pectoris and in patients with MI.

The study was conducted in order to describe the extent and content of advice on common ailments in pregnancy given by doctor or midwife during prenatal visits and to describe the frequency of ailments in the period before the visits. The design was a nationwide cross-sectional study based on questionnaires completed by pregnant women who had seen a general practitioner (GP), midwife or hospital doctor for prenatal care. Ailments and advice in connection with one specific visit were reported. The questionnaires were completed by 517 women after a prenatal visit to their GP (92% of eligible), by 514 women after a prenatal visit to the midwife (91% of eligible), and by 203 women after a prenatal visit to a doctor in the maternity department in pregnancy week 16-18 (84% of eligible). The results showed that nausea, pollakisuria, tiredness and heartburn had been present during the period before the visit in about half the women. Between a third and a fourth of the women had been discomforted by back pain, discharge or cramps. From 15 to 58 percent had been given advice, depending on the symptom. The advice was of many different kinds. To a large extent the women wanted to talk to the health professionals about the ailments, and most often they wanted to talk to a midwife about the ailments. We conclude that common ailments of pregnancy are frequent and they should be investigated more. Nearly all pregnant women want to talk about the subject during prenatal visits. The objectives of giving advice should be clearer, and clinical studies of the effectiveness of the advice are needed.

In Denmark, pregnant women are offered antenatal care in a nationwide programme. This programme is organized around health examinations in general practice, hospital outpatient departments and at midwives' centres. During winter 1986-1987, a nationwide investigation of antenatal care was carried out. A random sample of approximately 1/3 of the general practitioners, all of the midwives who had antenatal consultations and the medical staffs of 26 departments of obstetrics and gynaecology received a questionnaire about content of a definite antenatal examination. 62% of the general practitioners, 63% of the doctors at the place of delivery and 86% of the midwives replied. Among the pregnant women, 92% replied from general practice, 84% from hospital outpatient departments and 91% from midwives' centres. The interviews about date of delivery and genetic counselling at early visits in general practice, hospital outpatient departments and at midwives' centres were in agreement with the nationwide guidelines. Employment of routine ultrasound scanning was not associated with less detailed history taking by the doctors at hospital outpatient departments, where ultrasound scanning was employed only on special indications. It was concluded that there was a considerable overlap between the interview about the date of delivery and genetic counselling at early visits in general practice and in hospital outpatient departments and, to some extent, at the midwives' centres. The sharing of responsibility for care of pregnant women by three professional groups requires specification of the content of the consultation. Official guidelines should be more specific about this point.

A clinical investigation was undertaken to assess the agreement between serum potassium (S-K) (1) in the peripheral venous blood and S-K in ten samples of 2 ml blood taken via a central venous catheter (2) where fluid containing potassium had been infused prior to taking the blood-samples (3). The results revealed that in order that S-K in 95% (twice the SD) of the samples taken from the central venous catheter is to fall within +/- 0.5 mmol/l as compared with S-K in the peripheral blood, it is necessary to discard the first 12 ml of blood withdrawn.

On account of immigration there are now groups in the Danish population, which should be tested for sickle-cell disorders before anaesthesia. In certain other countries patients of negro or arabian anchestry are sickle tested. Specific diagnosis of sickle-cell disorders is made only by haemoglobin electrophoresis. Sickle-cell crises are commonly precipitated by infection, dehydration, cold, hypoxia and acidosis. Before anaesthesia the patient must be free from intercurrent infection and well hydrated. During anaesthesia it is important to avoid hypoxia, hypotension, cold and venous stasis. Either general or regional anaesthesia may be used. Controlled oxygen therapy must be continued well into the postoperative period.

A review of the literature is undertaken to account for the current status of acetylsalicylic acid (ASA) in the treatment of patients with arterial thrombo-embolic conditions. Employment of ASA monotherapy has been documented to be effective in clinically controlled investigations in patients with unstable angina pectoris, transient cerebral ischaemia, coronary by-pass and femoro-popliteal endarterectomy and introduction of vascular prostheses and, in addition, in primary and secondary prophylaxis of acute myocardial infarction (AMI). In combination with dipyridamol, ASA has been found to be effective in secondary AMI prophylaxis, coronary by-pass operation and in peripheral arteriosclerosis. In patients with cardiac valvular prostheses, conventional anticoagulation therapy must still constitute the basic treatment but dipyridamol may be employed to increase the antithrombotic efficacy of the treatment. The dosage of ASA in the majority of works has been about 1,000 mg daily while isolated investigations have shown good effect from doses as low as 60 mg daily. It appears to be important for the efficacy of the treatment with platelet inhibitors in the above-mentioned conditions that treatment is instituted rapidly and, in connection with operative intervention, preferably preoperatively. In other clinical conditions such as preeclampsia, hypertension in pregnancy, diabetic angiopathy and nephropathy, membranoproliferative glomerulonephritis and arterio-venous shunts with haemodialysis, treatment with ASA appears to be effective but documentation in extensive clinically-controlled investigations is not yet available. The duration of treatment with ASA in arterial thrombo-embolic disease does not appear to be illustrated unanimously in the articles published but, as the atherosclerotic lesion is not influenced by ASA, there are indications for life-long therapy.

An account is presented of the problems which occur on reperfusion of the myocardium in connection with fibrinolytic treatment and the present day possibilities for reducing the complications. Restenosing is mentioned in particular. The advantages and disadvantages of the individual fibrinolytic preparations are illustrated. The clinical investigations available demonstrate that the higher frequencies of reperfusion for "fibrin selective" plasminogen activator are observed mainly in patients with durations of AMI symptoms for more than three hours before the commencement of thrombolytic treatment. In a comparison between t-PA and streptokinase investigations regardless of the time of inclusion no difference could be demonstrated in the effect on the left ventricular function, lethality after 12 months and the risk of haemorrhage. Employing APSAC and streptokinase, significant reduction in the one year lethality was found and, where streptokinase was concerned, on treatment up to 24 hours after the commencement of symptoms. Acetylsalicylic acid has an additive effect, possibly as a result of the reduced risk for rethrombosing among other things. The current data provide, however, no final explanation of the relative efficacy of the individual fibrinolytic drugs because the various investigations have had different forms of selection of patients, initiation of treatment and parallel medication. Attempts will be made to elucidate these in future investigations where ISIS-3 compares t-PA, streptokinase and APSAC while GISSI-2 will compare t-PA and streptokinase. Simultaneously, the value of heparin will be investigated in connection with fibrinolytic therapy.

A questionnaire about the content of a concrete antenatal examination and their own qualifications was sent to a random sample consisting of 1/3 of general practitioners in Denmark, all of the midwives who had antenatal consultations, the medical staffs of 26 departments of obstetrics and gynaecology and 26 surgical departments with more than 100 deliveries in 1985. The medical staffs could describe three different types of antenatal examinations depending upon the place and function. The percentages of replies received were 62 for general practice, 86 for midwives and 63, 69 and 55 for the medical staffs of the institutions involved. 49% of the general practitioners had worked in departments of obstetrics and gynaecology for at least six months. 62% of the doctors who described antenatal examination in week 16-18 were house officers or registrars and 28% were specialists. Among the medical staff who described an antenatal examination of a woman with an at risk pregnancy, 61% were consultants or senior registrars and 49% were specialists. The commonest goal for postgraduate training where non-specialists were concerned was general practice. Supervision in one form or another was possible in all of the departments participating, as a rule because an experienced colleague was present in the outpatient department. Supervision may be improved by alterations in the working arrangements.