Abstract
Venous thromboembolism (VTE) is the commonest cause of preventable death in hospitalized patients. Elderly patients have higher risk of VTE because of the high prevalence of predisposing co-morbidities and acute illnesses. Clinical diagnosis of VTE in the elderly patient is particularly difficult and, as such, adequate VTE prophylaxis is of pivotal importance in reducing the mortality and morbidities of VTE. Omission of VTE prophylaxis is, however, very common despite continuous education. A simple way to overcome this problem is to implement universal VTE prophylaxis for all hospitalized elderly patients instead of selective prophylaxis for some patients only according to individual's risk of VTE. Although pharmacological VTE prophylaxis is effective for most patients, a high prevalence of renal impairment and drug interactions in the hospitalized elderly patients suggests that a multimodality approach may be more appropriate. Mechanical VTE prophylaxis, including calf and thigh compression devices and/or an inferior vena cava filter, are often underutilized in hospitalized elderly patients who are at high-risk of bleeding and VTE. Because pneumatic compression devices and thigh length stockings are virtually risk free, mechanical VTE prophylaxis may allow early or immediate implementation of VTE prophylaxis for all hospitalized elderly patients, regardless of their bleeding and VTE risk. Although the cost-effectiveness of this Multimodality Universal STat (‘MUST’) VTE prophylaxis approach for hospitalized elderly patients remains uncertain, this strategy appears to offer some advantages over the traditional ‘selective and single-modal’ VTE prophylaxis approach, which often becomes ‘hit or miss’ or not implemented promptly in many hospitalized elderly patients. A large clustered randomized controlled trial is, however, needed to assess whether early, multimodality, universal VTE prophylaxis can improve important clinical outcomes of hospitalized elderly patients.
Highlights
Venous thromboembolism (VTE) is the commonest cause of preventable death in hospitalized patients
Ho KM et al Venous thromboembolism in hospitalized elderly patients may have different normal values for different age groups and they may not be reliable for patients who have a high pre-test probability of VTE.[12,13]
These results suggest that the current strategy to improve implementation of VTE prophylaxis by continuous education is insufficient
Summary
Venous thromboembolism (VTE) is a global public health problem and is the commonest cause of preventable hospital death in many developed countries.[1,2] The latest data showed that VTE affects over 900 000 patients and causes over 100 000 to 300 000 deaths in the USA each year.[2,3] The total burden of VTE in the European Union countries was estimated to exceed 1.6 million events, comprising 0.7 million cases of deep vein thrombosis (DVT), 0.4 million cases of non-fatal pulmonary embolism (PE), and 0.5 million VTE-related deaths.[4 ]. The risk of developing VTE exceeds 0.6% per year for the general population who are older than 80 years old (Figure 1).[6] The risk of VTE is high among hospitalized elderly patients because of the associated risk factors (Figure 2). Many of these acute and chronic risk factors interact with each other and are responsible for the dramatic increase in the overall risk of VTE in hospitalized elderly patients. Will discuss some limitations of the existing VTE prophylaxis strategy for hospitalized elderly patients
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