Venous thromboembolism, age and hospitalisation: A potentially deadly combination

Abstract

Venous thromboembolism (VTE) is a common complication of hospitalisation and is associated with morbidity and mortality (1, 2). The annual incidence of VTE increases sharply with age (3). Thus, as the population ages the health burden associated with VTE is expected to grow dramatically. Many studies have identified highrisk groups of surgical and acutely ill medical patients who benefit from antithrombotic prophylaxis (4). Despite this, there seems to be fairly variable and often suboptimal application of appropriate thromboprophylaxis (5, 6). Randomised controlled trials (RCTs) and meta-analyses have shown that unfractionated heparin (UFH), low-molecularweight heparin (LMWH) or fondaparinux reduce symptomatic deep-vein thrombosis (DVT), and symptomatic and fatal pulmonary embolism (PE) in selected medical patients (7). Other studies have found similar results in patients undergoing hip or knee replacement, and cancer surgery (4, 8, 9). As a result of this, evidence-based guidelines recommended the use of antithrombotic prophylaxis in acutely ill high risk medical and surgical patients (4, 10). Few studies have evaluated the risk of thromboembolic events and the role of antithrombotic prophylaxis during stays in facilities including convalescent homes and other forms of extended duration skillednursing facilities caring for patients who are no longer in the acute phase of an illness but who require a level of care higher than that provided in long-term care institutions. Although not well studied, a substantial proportion of all VTE events occur in patients in such facilities (11, 12). The reported incidence of symptomatic and ultrasonography detected VTE in postacute care patients ranges from 5% to 18% (11). In a population-based, nested, casecontrol study, 13% of all incident VTE cases occurred in residents of post-acute care inpatient facilities (12). Risk factors for the development of VTE in patients in post-acute care facilities remain largely undefined. Appropriate VTE risk stratification may be especially critical for these patients, many of whom are elderly with multiple co-morbidities and complex medication regimens. These characteristics may increase the risk of both VTE and complications of VTE prophylaxis. Age, previous history of VTE, regional or metastatic-stage cancer, dependence in more than three activities of day living, and pressure ulcers were significantly associated to the occurrence of VTE during hospitalisation in post acute facilities in a previous study (13). Recent studies have shown that development of VTE is associated with an increased mortality in elderly patients and that treatment of VTE is complicated by a not negligible incidence of major bleeding complications in a community setting (14, 15). Unfortunately, despite the frequency of VTE in subacute care facilities, rigorous scientific data providing evidence of the efficacy of prophylaxis in these patients are currently lacking. There is wide hospital-to-hospital variation in the provision of prophylaxis (16) and patients with risk factors for VTE may not receive antiCorrespondence to: Francesco Dentali Department of Clinical Medicine, University of Insubria Viale Borri 57, 21100, Varese, Italy E-mail: fdentali@libero.it or Mark Crowther Department of Medicine and Pathology and Molecular Medicine McMaster University and St Joseph’s Hospital 50 Charlton Ave East, Hamilton Ontario, L8N 4A6, Canada E-mail: crowthrm@mcmaster.ca