Prevention Of Venous Thromboembolic Events Research Articles

Should intermittent pneumatic compression devices be standard therapy for the prevention of venous thromboembolic events in major surgery? Protocol for a randomised clinical trial (IMPOSTERS)

IntroductionVenous thromboembolism (VTE) is a recognised postsurgical risk. Current prevention methods involve low molecular weight heparin (LMWH), graduated compression stockings (GCS), and intermittent pneumatic compression devices (IPCDs). Australian guidelines, commonly...

Chemoprophylactic Anticoagulation After Spine Surgery Does Not Increase Epidural Hematoma Risk: A Propensity-matched Analysis.

A retrospective cohort study. To calculate the magnitude of any increased risk of epidural hematoma (EDH) associated with chemoprophylactic anticoagulation (chemoprophylaxis), if any. Chemoprophylaxis for the prevention of venous thromboembolic events may be associated with an increased risk of EDH after spine surgery. A total of 6869 consecutive spine surgeries performed at our institution were identified, and clinical and demographic data were collected. We identified cases in which symptomatic EDHs were evacuated within 30 days postoperatively. Patients receiving chemoprophylaxis and controls were matched using K-nearest neighbor propensity score matching to calculate the effect of anticoagulation on the rate of postoperative EDH. After propensity score matching, 1071 patients who received chemoprophylaxis were matched to 1585 controls. Propensity scores were well balanced between populations (Rubin B=20.6, Rubin R=1.05), and an 89.6% reduction in bias was achieved, with a remaining mean bias of 3.2%. The effect of chemoprophylaxis on EDH was insignificant ( P =0.294). Symptomatic EDH was independently associated with having a transfusion [odds ratio (OR)=7.30 (1.15, 46.20), P =0.035], having thoracic-level surgery [OR=41.19 (3.75, 452.4), P =0.002], and increasing body mass index [OR=1.44 (1.04, 1.98), P =0.028] but was not associated with chemoprophylaxis. Five out of 13 patients who developed EDH (38.5%) were receiving some form of anticoagulation, including 1 patient on therapeutic anticoagulation, 1 concurrently on aspirin and chemoprophylaxis, and 2 who were also found to have developed thrombocytopenia postoperatively. The median time on anticoagulation before EDH was 8.1 days. A higher proportion of patients who developed EDH also developed venous thromboembolic events than the general population [38.5% vs. 2.4%, OR=25.34 (9.226, 79.68), P <0.0001], and 1 EDH patient died from pulmonary embolism while off chemoprophylaxis. Chemoprophylactic anticoagulation did not cause an increase in the rate of spinal EDH in our patient population.

What has changed over the year in the prevention of venous thromboembolic events in pregnant women and puerperas?

An issue of venous thromboembolic events (VTEs) in pregnant women and puerperas in Russia as well as throughout the world remains relevant. Specialized events with expert’s participation could not be better to promote active discussion and constructive solution of complex problems, which refer to issues of VTEs prevention. Indeed, not disputable issues can be solved, but critical look and reasoned opinion leader presentations in the field undoubtedly improve our understanding and approaches to prevention of threatening complications in pregnant women and puerperas such as VTEs. In addition, actively discussed new data for dosing of low molecular weight heparins (LMWH) in pregnant women will allow to update current clinical guidelines, which would probably improve clinical outcomes of therapy.

Effect of Intermittent Pneumatic Compression in Addition to Pharmacologic Prophylaxis for Thromboprophylaxis in Hospitalized Adult Patients: A Systematic Review and Meta-Analysis.

OBJECTIVES:Venous thromboembolic events (VTE) are frequent complications in hospitalized patients and a leading cause of preventable death in hospital. Pharmacologic prophylaxis is a standard of care to prevent VTE in patients at risk, the additional value of intermittent pneumatic compression (IPC) is uncertain. We aimed to evaluate the efficacy of adding IPC to pharmacologic prophylaxis to prevent VTE in hospitalized adults.DATA SOURCES:We searched the Cochrane Central Register of Controlled Trials, Embase, MEDLINE, Cumulative Index to Nursing and Allied Health Literature, ClinicalTrials.gov, and the International Clinical Trials Registry Platform from inception to July 2022.STUDY SELECTION:We included randomized controlled trials comparing the use of IPC in addition to pharmacological thromboprophylaxis to pharmacological thromboprophylaxis alone in hospitalized adults.DATA EXTRACTION:Meta-analyses were performed to calculate risk ratio (RR) of VTE, deep venous thrombosis (DVT), and pulmonary embolism (PE). We assessed the risk of bias using the Cochrane Risk of Bias Tool for Randomized Trials, Version 2 and the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation approach.DATA SYNTHESIS:We included 17 trials enrolling 8,796 participants. The IPC was mostly applied up to the thigh and pharmacological thromboprophylaxis was primarily low-molecular-weight heparin. Adjunctive IPC was associated with a decreased risk of VTE (15 trials, RR = 0.53; 95% CI [0.35–0.81]) and DVT (14 trials, RR = 0.52; 95% CI [0.33–0.81]) but not PE (seven trials, RR = 0.73; 95% CI [0.32–1.68]). The quality of evidence was graded low, downgraded by risk of bias and inconsistency. Moderate and very low-quality evidence, respectively, suggests that adjunctive IPC is unlikely to change the risk of all-cause mortality or adverse events. Subgroup analyses indicate a more evident apparent benefit in industry-funded trials.CONCLUSIONS:Results indicate low-quality evidence underpinning the additional use of IPC to pharmacological thromboprophylaxis for prevention of VTE and DVT. Further large high-quality randomized trials are warranted to support its use and to identify patient subgroups for whom it could be beneficial.

Prevention of venous thromboembolic events in patients with lower leg immobilization after trauma: Systematic review and network meta-analysis with meta-epsidemiological approach.

BackgroundLower limb trauma requiring immobilization is a significant contributor to overall venous thromboembolism (VTE) burden. The clinical effectiveness of thromboprophylaxis for this indication and the optimal agent strategy are still a matter of debate. Our main objective was to assess the efficacy of pharmacological thromboprophylaxis to prevent VTE in patients with isolated temporary lower limb immobilization after trauma. We aimed to estimate and compare the clinical efficacy and the safety of the different thromboprophylactic treatments to determine the best strategy.Methods and findingsWe conducted a systematic review and a Bayesian network meta-analysis (NMA) including all available randomized trials comparing a pharmacological thromboprophylactic treatment to placebo or to no treatment in patients with leg immobilization after trauma. We searched Medline, Embase, and Web of Science until July 2021. Only RCT or observational studies with analysis of confounding factors including adult patients requiring temporary immobilization for an isolated lower limb injury treated conservatively or surgically and assessing pharmacological thromboprophylactic agents or placebo or no treatment were eligible for inclusion. The primary endpoint was the incidence of major VTE (proximal deep vein thrombosis, symptomatic VTE, and pulmonary embolism-related death). We extracted data according to Preferred Reporting Items for Systematic Reviews and Meta-analyses for NMA and appraised selected trials with the Cochrane review handbook. Fourteen studies were included (8,198 patients). Compared to the control group, rivaroxaban, fondaparinux, and low molecular weight heparins were associated with a significant risk reduction of major VTE with an odds ratio of 0.02 (95% credible interval (CrI) 0.00 to 0.19), 0.22 (95% CrI 0.06 to 0.65), and 0.32 (95% CrI 0.15 to 0.56), respectively. No increase of the major bleeding risk was observed with either treatment. Rivaroxaban has the highest likelihood of being ranked top in terms of efficacy and net clinical benefit. The main limitation is that the network had as many indirect comparisons as direct comparisons.ConclusionsThis NMA confirms the favorable benefit/risk ratio of thromboprophylaxis for patients with leg immobilization after trauma with the highest level of evidence for rivaroxaban.Trial registrationPROSPERO CRD42021257669.

THE EFFICACY AND SAFETY OF DIRECT ORAL ANTI-COAGULANTS IN THE PREVENTION OF CEREBROVASCULAR ACCIDENT AND VENOUS THROMBOEMBOLIC EVENTS IN PATIENTS WHO WEIGH > 120 KG OR BMI > 40 WHEN COMPARED TO WARFARIN IN THE SETTING OF AN URBAN SAFETY-NET HOSPITAL

TOPIC: Pulmonary Vascular Disease TYPE: Original Investigations PURPOSE: In the United States, we use direct oral anticoagulant (DOAC) medications for the treatment and prevention of cerebrovascular accident (CVA) and venous thromboembolic events (VTE): pulmonary embolism (PE) and deep venous thrombosis (DVT). DOACs are a convenient alternative to vitamin K antagonists. However, the Federal Drug Administration (FDA) has approved DOAC usage in patients with body weight less than 120 kilogram (kg) or body mass index (bmi) less than 40. Our clinical observations hypothesize that patients who were outside of the FDA approved weight category, “obese”, would have similar incidences of new CVA and VTE as “normal” weight population. METHODS: All patients using warfarin or DOAC for CVA and VTE prevention seen at MetroHealth Medical Center over a 10-year period were reviewed in this retrospective study. Selection criteria were all males and females greater than the age of 18 on warfarin, rivaroxaban, apixaban or dabigatran. Exclusion criteria were pregnant females, prisoners, and patients who were noncompliant with medications, or lost to follow up. Each chart was reviewed for indication for anticoagulation, if the patient developed a CVA or VTE while on anticoagulation, then grouped by weight class and anticoagulant used. Comparisons were analyzed with chi-square and Cochran-Mantel-Hanenszel calculations. RESULTS: 467 patients were reviewed. 108 of the patients were in the warfarin “normal” and 74 in the warfarin “obese” categories. 209 patients were in the DOAC “normal” and 76 in the DOAC “obese” categories. 54.8% were female (37.6% “normal” weight and 17.2% “obese”) and 45.2 % were male (30.2% “normal” and 15% “obese”). 340 patients on anticoagulation for atrial fibrillation or atrial flutter, 115 patients for VTE, and 12 patients for other indications. New CVA occurrences were evaluated in these four populations in patients with atrial fibrillation or atrial flutter. In the “normal” warfarin category 5% (4/75) of patients had a CVA while on anticoagulation verses 2% (1/41) in the “obese” group (P=0.4631). In the “normal” DOAC category 6% (10/168) of patients had CVA while on anticoagulation verses 2% (1/56) in the “obese” group (P=0.2114). The Cochran-Mantel-Hanenszel calculation when comparing the groups showed P=0.1510, Odds Ratio of 0.3436, CI= 0.075-1.5604. New VTE occurences were reviewed in all patients. In the “normal” warfarin category 6% (7/108) of patients had evidence of new VTE while on anticoagulation verses 12% (9/74 in the “obese” category (P =0.1870). In the “normal” DOAC category 0.5% (1/209) of patients had evidence of new VTE while on anticoagulation verses 5% (4/76) patients (P=0.0064). The Cochran-Mantel-Hanenszel calculation when comparing the three groups against the DOAC “obese” group found to have a P= 0.0153, Odds Ratio of 2.8640, 95% CI = 1.1612-7.0642. CONCLUSIONS: The risk of newly diagnosed VTE is significantly higher in “obese” DOAC patients. No statistically significant difference in the risk of CVA was observed in the “obese” vs “normal”populations. CLINICAL IMPLICATIONS: Our data provides important information on the risk of VTE in obese patients on DOACs. Further research is needed before making the decision to anticoagulated this subgroup of patients with DOACs. DISCLOSURES: No relevant relationships by ASHISH ANEJA, source=Web Response No relevant relationships by Sara Ghoneim, source=Web Response No relevant relationships by Pooja Mishra, source=Web Response No relevant relationships by Srinivasa Potla, source=Web Response No relevant relationships by Charles Thomas, source=Web Response

W13. CLINICAL VALUE OF DIAGNOSTIC WHOLE GENOME/EXOME SEQUENCING IN FAMILIAL AUTISM SPECTRUM DISORDER

A paucity of randomized trials have compared prophylactic dose of unfractionated heparin (UFH) versus low-molecular-weight heparin (LMWH) for the prevention of venous thromboembolic events in spinal surgery. Our objective was to determine the most prevalent chemoprophylactic techniques in spine surgery.The Accreditation Council for Graduate Medical Education was queried for all neurosurgical residency programs, which were subsequently sent an electronic survey about prophylactic UFH versus LMWH in spine surgery for (1) degenerative/deformity, (2) traumatic, and (3) neoplastic pathologies.Of 69 unique responding residencies, the first dose of chemoprophylaxis for degenerative/deformity spinal disease started most commonly on postoperative day (POD) 1 in 75.3% of neurosurgery programs, followed by POD 2 in 10.1% of programs, POD 0 (same day of surgery) in 8.7% of programs, POD 3 in 1.4% of programs, and morning of surgery in 1.4% of programs. Choice of postoperative chemoprophylaxis did not differ statistically significantly between UFH versus LMWH: 56.5% versus 36.2% in degenerative/deformity pathologies (P = 0.080) and 50.7% versus 43.4% in traumatic pathologies (P = 0.535). Three programs (4.3%) in both the degenerative/deformity and trauma groups documented no chemoprophylaxis. Neoplastic pathologies saw a statistically significantly higher proportion of prophylactic UFH (60.8%) compared with prophylactic LMWH (36.2%) (P = 0.037). One program (1.4%) in the neoplastic group did not utilize chemoprophylaxis. Two institutions (2.8%) in the degenerative/deformity cohort and 1 institution (1.4%) in the trauma and cancer cohorts reported “other”.Prophylactic UFH was statistically more common than LMWH in neoplastic spinal surgery, but not in the degenerative/deformity and trauma groups (cohorts). Further trials are warranted.

Thromboprophylaxie pharmacologique chez les patients hospitalisés pour une affection médicale aiguë

Venous thromboembolic events (VTE) occur in approximately 50% of cases during or following hospitalization; VTE are a major cause of morbidity and mortality. Thromboprophylaxis for 6 to 14 days with heparins or fondaparinux has been demonstrated to be effective in VTE prevention in patients hospitalized for acute medical illnesses and reduced mobility. Nevertheless, the level of recommendation has been gradually downgraded as the benefit has been mainly demonstrated on the basis of systematic imaging diagnosed events. Direct oral anticoagulants have been assessed only as an extended prophylaxis, and are currently not recommended in medical thromboprophylaxis. Assessing the risk of VTE and bleeding in medical patients is complex. VTE and bleeding risk assessment scores were constructed but have not been validated. In order to improve the adequacy of prescriptions for thromboprophylaxis, the impact of different interventions has been the subject of several studies but these yielded varying results. The aim of this review is to analyze the indications for thromboprophylaxis in a medical setting with the latest available data.

Consensus on thromboprophylaxis in gynecological surgery

RESUMENObjetivo: Sintetizar la evidencia disponible en torno a las intervenciones para la prevención de eventos tromboembólicos venosos durante el cuidado perioperatorio de las mujeres con patología ginecológica benigna, buscando reducir la morbi-mortalidad asociada a esta condición. Materiales y métodos: El grupo desarrollador estuvo integrado por profesionales de la salud, tomadores decisiones y un representante de las pacientes. Todos los participantes declararon sus conflictos de interés. Se construyeron preguntas clínicas contestables y se realizó la graduación de los desenlaces. Se elaboró la pesquisa de la información en Medline/PubMed, Embase, Epistemonikos y LILACS. La búsqueda también abarcó fuentes de literatura gris y se actualizó el 22 de septiembre de 2020 sin restricciones por fecha o idioma. Se implementó la aproximación GRADE (Grading of Recommendations Assessment, Development and Evaluation) para establecer la calidad de la evidencia y la fuerza de las recomendaciones, se realizó consenso formal acorde con la metodología RAND/UCLA. Previo a la publicación, el documento fue objeto de revisión por pares.Resultados: se presenta la versión corta del consenso "para la prevención de eventos tromboembólicos venosos durante el cuidado perioperatorio de las mujeres con patología ginecológica benigna", junto a su evidencia de soporte y respectivas recomendaciones.Conclusiones: como recomendaciones claves para la implementación, se proponen el uso de la escala de Caprini y el uso de intervenciones acorde con el nivel de riesgo perioperatorio de las pacientes.

Prevention of Venous Thromboembolic Events in Patients with Lower Leg Immobilization after Trauma: Systematic Review and Network Meta-Analysis with Meta-Epidemiological Approach

Prevention of Venous Thromboembolic Events in Patients with Lower Leg Immobilization after Trauma: Systematic Review and Network Meta-Analysis with Meta-Epidemiological Approach

Treatment and Secondary Prevention of Venous Thromboembolic Events in Fragile Patients in a Real-life Practice

Treatment and Secondary Prevention of Venous Thromboembolic Events in Fragile Patients in a Real-life Practice

Venous thromboembolism in orthopaedic oncology.

Malignancy and surgery are risk factors for venous thromboembolism (VTE). We undertook a systematic review of the literature concerning the prophylactic management of VTE in orthopaedic oncology patients. MEDLINE (PubMed), EMBASE (Ovid), Cochrane, and CINAHL databases were searched focusing on VTE, deep vein thrombosis (DVT), pulmonary embolism (PE), bleeding, or wound complication rates. In all, 17 studies published from 1998 to 2018 met the inclusion criteria for the systematic review. The mean incidence of all VTE events in orthopaedic oncology patients was 10.7% (1.1% to 27.7%). The rate of PE was 2.4% (0.1% to 10.6%) while the rate of lethal PE was 0.6% (0.0% to 4.3%). The overall rate of DVT was 8.8% (1.1% to 22.3%) and the rate of symptomatic DVT was 2.9% (0.0% to 6.2%). From the studies that screened all patients prior to hospital discharge, the rate of asymptomatic DVT was 10.9% (2.0% to 20.2%). The most common risk factors identified for VTE were endoprosthetic replacements, hip and pelvic resections, presence of metastases, surgical procedures taking longer than three hours, and patients having chemotherapy. Mean incidence of VTE with and without chemical prophylaxis was 7.9% (1.1% to 21.8%) and 8.7% (2.0% to 23.4%; p = 0.11), respectively. No difference in the incidence of bleeding or wound complications between prophylaxis groups was reported. Current evidence is limited to guide clinicians. It is our consensus opinion, based upon logic and deduction, that all patients be considered for both mechanical and chemical VTE prophylaxis, particularly in high-risk patients (pelvic or hip resections, prosthetic reconstruction, malignant diagnosis, presence of metastases, or surgical procedures longer than three hours). Additionally, the surgeon must determine, in each patient, if the risk of haemorrhage outweighs the risk of VTE. No individual pharmacological agent has been identified as being superior in the prevention of VTE events. Cite this article: Bone Joint J 2020;102-B(12)1743:-1751.

Prevention of venous thromboembolic events occurring in myeloma patients treated with second-generation novel agents.

Thrombosis and neoplasms are strictly linked, and the diagnosis of a malignancy is a relevant risk factor for venous thromboembolism (VTE). In particular, between gammopathies, the VTE risk is known to be increased in both monoclonal gammopathy of uncertain significance and in multiple myeloma, with a 3- and 9-fold increase respectively, when compared to the general population. The risk appears to be further increased in patients treated with immunomodulating drugs, such as thalidomide, especially when in combination with dexamethasone or conventional cytotoxic chemotherapies, and lenalidomide. In 2008 the International Myeloma Working Group put out thrombosis prophylaxis recommendations for myeloma patients treated with IMiDs. Current recommendations for thromboprophylaxis suggest the use of low-dose acetylsalicylic acid in patients with low risk for thrombosis and therapeutic dose anticoagulation with LMWH or warfarin for high-risk patients. However, these recommendations have been frequently not followed in the clinical practice, due to various reasons that involve the patients' will, the level of evidence of the recommendations and some selection biases in the studies that were taken as basis for writing down the indications. The new direct oral anticoagulants have been preliminarily evaluated for the prophylaxis of thrombotic events in IMiDs-treated myelomas, being promising, even if more expensive. Currently, the most reliable tool for a correct thrombotic risk stratification appears to be the complete clinical and anamnestic evaluation of the myeloma patients added to a strong physician awareness of the evidences that the literature contains until now.

Cost-effectiveness of apixaban for prevention of venous thromboembolic events in patients after gynecologic cancer surgery

ObjectiveThe cost-effectiveness of apixaban was compared with enoxaparin for prevention of postoperative venothromboembolic events (VTE) in gynecologic oncology patients. Current guidelines recommend thromboprophylaxis with low molecular weight heparin for 28 days following gynecologic cancer surgery, but recent trials suggest that oral apixaban may be a safe, patient-preferred alternative. Apixaban was superior to enoxaparin in a Canadian cost-effectiveness analysis using orthopedics trial data. MethodsMedication costs, adherence rates, event rates, event costs, and utility decrements were estimated using prior clinical trial data and literature review for input into a short-term decision model to simulate outcomes in a hypothetical cohort of 1000 patients. Incremental cost-effectiveness ratios (ICERs) were calculated as net cost difference per quality-adjusted life year (QALY) gained. Input values at which net costs and QALYs were equivalent and ICERs at upper and lower bounds were evaluated. ResultsUsing aggregated costs, apixaban was less expensive and more effective than enoxaparin, and remained so or had high value in all scenarios on sensitivity analysis. Examining disaggregated ICERs, apixaban was cost-effective for deep venous thrombosis (DVT); of high value for clinically-relevant non-major bleeding (CRNMB) ($411); low value for major bleeding ($183,465), VTE-related death ($2,711,229), and all-cause mortality ($297,522); and not cost-effective for pulmonary embolism prevention. ConclusionsApixaban is more cost-effective than enoxaparin for the prevention of postoperative VTE in patients with gynecologic cancer. This appears to be driven largely by DVT and CRNMB prevention.

Venous thromboembolism prevention compliance: A multidisciplinary educational approach utilizing NSQIP best practice guidelines

BackgroundReview of our institutional National Surgical Quality Improvement Project (NSQIP) data found higher rate of Venous Thromboembolic Events (VTE) (2.5% vs. 1.1%). Compared to the national benchmark. Our goal was to identify opportunities for quality improvement. MethodsWe compared NSQIP general surgery data from January 2015–December 2016 (period 1) to January 2017–December 2018 (period 2). A multidisciplinary committee was developed and patient centered education implemented to enhance VTE compliance. ResultsOver 50% of all the patients who developed VTE were non-compliant with chemical prophylaxis. The majority of non-compliance was due to pain. During period 1 there were 12 VTEs in 482 cases, while in period two, 18 VTEs in 2347 cases (2.5% vs. 0.8%; RR 2.3, 95% CI 1.5–3.7, p < 0.001). Missed chemical prophylaxis decreased from 50 to 17 per week after the intervention. ConclusionA multidisciplinary, patient centered approach to increase VTE prevention decreases VTE rates to below a comparable benchmark.

Rivaroxaban or Enoxaparin in Nonmajor Orthopedic Surgery

BackgroundNonmajor orthopedic surgery of the lower limbs that results in transient reduced mobility places patients at risk for venous thromboembolism. Rivaroxaban may be noninferior to enoxaparin with regard to the prevention of major venous thromboembolism in these patients.MethodsIn this international, parallel-group, randomized, double-blind, noninferiority trial, we randomly assigned adult patients undergoing lower-limb nonmajor orthopedic surgery who were considered to be at risk for venous thromboembolism on the basis of the investigator’s judgment to receive either rivaroxaban or enoxaparin. The primary efficacy outcome of major venous thromboembolism was a composite of symptomatic distal or proximal deep-vein thrombosis, pulmonary embolism, or venous thromboembolism–related death during the treatment period or asymptomatic proximal deep-vein thrombosis at the end of treatment. A test for superiority was planned if rivaroxaban proved to be noninferior to enoxaparin. For all outcomes, multiple imputation was used to account for missing data. Prespecified safety outcomes included major bleeding (fatal, critical, or clinically overt bleeding or bleeding at the surgical site leading to intervention) and nonmajor clinically relevant bleeding.ResultsA total of 3604 patients underwent randomization; 1809 patients were assigned to receive rivaroxaban, and 1795 to receive enoxaparin. Major venous thromboembolism occurred in 4 of 1661 patients (0.2%) in the rivaroxaban group and in 18 of 1640 patients (1.1%) in the enoxaparin group (risk ratio with multiple imputation, 0.25; 95% confidence interval, 0.09 to 0.75; P<0.001 for noninferiority; P=0.01 for superiority). The incidence of bleeding did not differ significantly between the rivaroxaban group and the enoxaparin group (1.1% and 1.0%, respectively, for major bleeding or nonmajor clinically relevant bleeding; 0.6% and 0.7%, respectively, for major bleeding).ConclusionsRivaroxaban was more effective than enoxaparin in the prevention of venous thromboembolic events during a period of immobilization after nonmajor orthopedic surgery of the lower limbs. (Funded by Centre Hospitalier Universitaire de Saint-Etienne and Bayer; PRONOMOS ClinicalTrials.gov number, NCT02401594.)

Call to Action to Prevent Venous Thromboembolism in Hospitalized Patients: A Policy Statement From the American Heart Association.

Venous thromboembolism (VTE) is a major preventable disease that affects hospitalized inpatients. Risk stratification and prophylactic measures have good evidence supporting their use, but multiple reasons exist that prevent full adoption, compliance, and efficacy that may underlie the persistence of VTE over the past several decades. This policy statement provides a focused review of VTE, risk scoring systems, prophylaxis, and tracking methods. From this summary, 5 major areas of policy guidance are presented that the American Heart Association believes will lead to better implementation, tracking, and prevention of VTE events. They include performing VTE risk assessment and reporting the level of VTE risk in all hospitalized patients, integrating preventable VTE as a benchmark for hospital comparison and pay-for-performance programs, supporting appropriations to improve public awareness of VTE, tracking VTE nationwide with the use of standardized definitions, and developing a centralized data steward for data tracking on VTE risk assessment, prophylaxis, and rates.

Review of Therapeutic Options for the Prevention of VTE in Total Joint Arthroplasty.

Hip and knee arthroplasty patients are at high risk of perioperative venous thromboembolic events (VTE). VTE has been well studied in this population and it is recommended that total joint arthroplasty recipients receive chemoprophylactic anticoagulation due to risk factors inherent to the surgical intervention. There are few concise resources for the orthopedic surgeon that summarize data regarding post-operative anticoagulation in the context of currently available therapeutic options and perioperative standards of practice. The periodic reexamination of literature is essential as conclusions drawn from studies predating perioperative protocols that include early mobilization and sequential compression devices as standards of practice in total joint arthroplasty are no longer generalizable to modern-day practice. We reviewed a large number of recently published research studies related to post-operative anticoagulation in total joint arthroplasty populations that received a high Level of Evidence grade. Current literature supports the use of oral aspirin regimens in place of more aggressive anticoagulants, particularly among low risk patients. Oral aspirin regimens appear to have the additional benefit of lower rates of bleeding and wound complications. Less consensus exists among high risk patients and more potent anticoagulants may be indicated. However, available evidence does not demonstrate clear superiority among current options, all of which may place patients at a higher risk of bleeding and wound complications. In this situation, chemoprophylactic selection should reflect specific patient needs and characteristics.

The Development and Application of a Clinical Severity Scoring Model for Post-Operative Venous Thromboembolism (VTE)

Background: In studies evaluating the prevention of venous thromboembolic events (VTE - composite of deep vein thrombosis (DVT) and pulmonary embolism (PE)) following surgery, VTE is considered as a binary event (present or absent). There is no consensus in the literature in determining the clinical severity of a post-operative VTE. The objectives of our study were to derive a severity scoring model for VTE in the post-operative setting and then apply the model to outcomes from a clinical trial evaluating aspirin vs. rivaroxaban for extended prophylaxis following total hip or knee arthroplasty (EPCATII). Methods: Thirty-one clinical scenarios were written, each describing a VTE event after a total hip or knee arthroplasty procedure. Each scenario varied the severity of the patient's presenting symptoms, the extent of thrombosis observed on radiographic studies, and the presence or absence of long-term symptoms. These scenarios were incorporated into a web-based survey sent to thrombosis clinicians. Respondents were asked to score each scenario on a 9-point scale based on perceived clinical severity. Responses from 29 clinicians were analyzed using mixed-effects regression models to determine the weight of each variable on the respondents' overall severity scores. The sum of scores for each weighted factor present based on parameter estimates from the model was calculated to categorize the scenarios into high, moderate, or low clinical severity categories. The VTE clinical severity scoring model was applied independently by two clinicians to the 36 cases of confirmed VTE from the EPCAT II trial. Two further reviewers gave their clinical opinion of each case's severity. Kappa scores for inter-rater reliability, and for agreement between clinical opinion and the model were determined. The proportion of EPCAT II cases rated as mild, moderate and severe by the model were determined for rivaroxaban and aspirin groups and then compared using the Cochran-Armitage test for trend. Results: The following factors shown as parameter estimates were associated with higher levels of clinical severity: moderate (1.28, p&lt;0.0001) or severe (2.61, p&lt;0.0001) radiographic findings; high severity symptoms at initial presentation (0.72, p&lt;0.0001); presence of long-term symptoms (1.01, p&lt;0.0001); and PE compared to DVT (1.49, p&lt;0.0001). Based on these parameters, a scoring model was created using the nearest half point for each doubled parameter estimate for ease of calculation. The model classifies post-operative VTE into mild (score &lt;4.5), moderate (score 4.5-8), or severe (score &gt;8) clinical severity categories. Independent application of the model to the EPCAT II VTE cases had agreement in 33 of 36 cases (κ=0.89). The agreement between the clinical opinion and the model was 28 of the 36 cases (κ=-0.14). In all cases of disagreement, the clinical gestalt was more severe than the model. Cases randomized to rivaroxaban were scored as 10 mild (55.6%), 4 moderate (22.2%), and 4 severe (22.2%). Cases randomized to aspirin were scored as 12 mild (66.7%), 4 moderate (22.2%) and 2 severe (11.1%). There were no differences in severity of VTE between the aspirin and rivaroxaban groups (p=0.38). Conclusion: A clinical severity scoring model for post-operative VTE was created based upon scenarios rated by experienced thrombosis clinicians and validated by applying it to EPCAT II cases of VTE. This model may be useful for categorizing clinical importance of VTE in the post-operative setting. There was no apparent difference in the severity of post-operative VTE following total hip or knee arthroplasty whether aspirin or rivaroxaban was used for extended prophylaxis. Disclosures No relevant conflicts of interest to declare.

Rivaroxaban and Extended Thromboprophylaxis in Acutely Ill Medical Patients with History of Cancer: Insights from the Magellan and Mariner Studies

Rivaroxaban and Extended Thromboprophylaxis in Acutely Ill Medical Patients with History of Cancer: Insights from the Magellan and Mariner Studies