Venous Thromboembolism In Medical Patients Research Articles

The prophylaxis of venous thromboembolism in medical patients: If you do it, do it right

The prophylaxis of venous thromboembolism in medical patients: If you do it, do it right

Prevention of Venous Thromboembolism in Medical Patients with Thrombocytopenia or with Platelet Dysfunction: The Last 10 Years.

Current guideline recommendations for primary prophylaxis of venous thromboembolism (VTE) are based on randomized clinical trials that usually exclude subjects at a potentially high risk of bleeding complications. For this reason, no specific guideline is available for thromboprophylaxis in hospitalized patients with thrombocytopenia and/or platelet dysfunction. However, except in patients with absolute contraindications to anticoagulant drugs, antithrombotic prophylaxis should always be considered, for example, in hospitalized cancer patients with thrombocytopenia, especially in those with multiple VTE risk factors. Low platelet number, platelet dysfunction, and clotting abnormalities are also very common in patients with liver cirrhosis, but these patients have a high incidence of portal venous thrombosis, implying that cirrhotic coagulopathy does not fully protect against thrombosis. These patients may benefit from antithrombotic prophylaxis during hospitalization. Patients hospitalized for COVID-19 need prophylaxis, but frequently experience thrombocytopenia or coagulopathy. In patients with antiphospholipid antibodies, a high thrombotic risk is usually present, even in the presence of thrombocytopenia. VTE prophylaxis in high-risk conditions is thus suggested in these patients. At variance with severe thrombocytopenia (< 50,000/mm3), mild/moderate thrombocytopenia (≥ 50,000/mm3) should not interfere with VTE prevention decisions. In patients with severe thrombocytopenia, pharmacological prophylaxis should be considered on an individual basis. Aspirin is not as effective as heparins in lowering the risk of VTE. Studies in patients with ischemic stroke demonstrated that thromboprophylaxis with heparins is safe in these patients also during antiplatelet treatment. The use of direct oral anticoagulants in the prophylaxis of VTE in internal medicine patients has been recently evaluated, but no specific recommendation exists for patients with thrombocytopenia. The need for VTE prophylaxis in patients on chronic treatment with antiplatelet agents should be evaluated after assessing the individual risk of bleeding complications. Finally, the selection of patients who require post-discharge pharmacological prophylaxis remains debated. New molecules currently under development (such as the inhibitors of factor XI) may contribute to improve the risk/benefit ratio of VTE primary prevention in this setting of patients.

Thrombo-Prophylaxis Prevents Thrombotic Events in Home-Managed Covid Patients a Registry Study

This pilot registry analyzes data from subjects with COVID-19 infection and mild symptoms, followed and treated at home. Antithrombotic prophylaxis was used in all subjects. A comparison was made with comparable cases that had not used prophylaxis. A control group (36 subjects) without prophylaxis was compared to a prophylaxis group (67 subjects using LMWH and 35 using defibrotide). At two weeks, there were no DVTs or thrombotic disease in the prophylaxis groups. Also, the evolution of the main respiratory symptoms was significantly better in the prophylaxis groups (p&lt;0.05). No patients went to ITU: 4 out of 36 patients in the comparative group went briefly to hospitals. In subjects, using LMWH 1 went to hospital as in the defibrotide group. None was put in ventilation. D-dimer values were fluctuating and not usable to define the presence of a thrombotic condition. This aspect is under further evaluation. No significant side effects were observed. Conclusions: Antithrombotic prophylaxis should be started as soon as possible (home patients) and used during all the high-risk conditions. The importance of venous thromboembolism in medical patients with severe respiratory disease (as COVID), even in the early phases, has been stressed and it is well known; it cannot be considered a new observation and requires adequate, immediate prophylaxis.

Comparative Performance of Clinical Risk Assessment Models for Hospital-Acquired Venous Thromboembolism in Medical Patients

Comparative Performance of Clinical Risk Assessment Models for Hospital-Acquired Venous Thromboembolism in Medical Patients

Failure to Validate Padua Score’s Ability to Predict the Risk of Venous Thromboembolism in Medical Patients

Medical patients are at risk of developing venous thromboembolism (VTE) over the course of their hospitalization and for an additional 30 days. One of the widely accepted models to predict the risk of VTE in medical patients is the Padua Prediction Score. In the validation study of the Padua score, 11% of the high risk patients experienced VTE within 90 days as opposed to 0.3% of the low-risk patients. Prophylaxis with anticoagulants for high-risk patients reduced the incidence of VTE to 2.2%. This study was designed to verify the Padua Prediction Score’s ability to predict the risk of VTE in medical patients and show the benefit of prophylactic anticoagulant treatment in high-risk patients. In this retrospective cohort study, data was gathered from a random sampling of medical patients files hospitalized between 1.1.2014-30.6.2014. These patients had a Padua Score of 4 and above, had no other indication or contraindication for enoxaparin treatment. A search for diagnoses of death, PE (pulmonary embolism) or DVT (deep vein thrombosis) occurring over the course of 90 days from the date of hospitalization was conducted on the hospital and HMO information systems, or directly with patient or family doctor. The study included 568 high risk patients with a Padua Score of 4 and above, of whom 284 were treated with prophylactic enoxaparin and 284 were not. There were no VTE events over the course of 90 days in either group. The rate of all-cause mortality and major bleeding did not differ between groups. The incidence of VTE was significantly lower than reported in the Padua study. No association was found between administration of prophylactic enoxaparin and prevention of VTE events. The comprehensive guideline for treating patients with a Padua Score of 4 and above with prophylactic LMWH should be reexamined.

Venous thromboembolism in medical patients during hospitalisation and 3 months after hospitalisation: a prospective observational study

ObjectivesThis study was conducted to assess the incidence and risk factors for venous thromboembolism (VTE) in a cohort of medical patients both during the period of hospitalisation and following discharge.DesignThis...

Estimation of clinical and economic effects of prophylaxis against venous thromboembolism in medical patients, including the effect of targeting patients at high-risk.

The clinical and economic effects of medical thromboprophylaxis (MT) using low molecular weight heparin in Australia are unknown. To estimate the effects of MT in Australia. A decision tree model of MT was populated with national data for medical admissions. The Prevention of Recurrent Venous Thromboembolism (PREVENT) trial was chosen as the primary data source because its design uniquely avoided bias caused by treatment of sub-clinical events. Clinical efficacy and costs were estimated compared with no prophylaxis, assuming full compliance and according to three definitions of eligibility. Effectiveness was estimated as thrombotic events saved, mortality from bleeding or pulmonary embolus (PE), cost and $/year of life saved. Model outputs were subjected to sensitivity analysis. MT decreased thrombotic events, and the numbers avoided increased as eligibility broadened (deep vein thrombosis (DVT): 2597, 2771 and 3232 at restricted, intermediate and broad eligibility; PE: 454, 484 and 565 respectively). The annual cost of no prophylaxis was $88.7 m. Costs were reduced at most restricted eligibility (-$7.9 m), but increased by $3.0 and $32.1 m at broader eligibility. PE deaths declined, but this was offset by deaths from haemorrhage, causing a net increase (158, 299 and 672 respectively). Estimates were sensitive to the incidence of venous thromboembolic event (VTE), case-fatality rates for PE and bleeds and the relative risk reduction for PE with prophylaxis. Under PREVENT trial conditions, MT avoids up to 3200 DVT and 565 PE events annually, but may increase mortality.

Validation of a Smartphone Application for Assessment of the Risk of Venous Thromboembolism in Medical Patients

Objective: To validate a smartphone application-based clinical decision support system (CDSS) for risk assessment of venous thromboembolism (VTE) in hospitalized medical patients. Setting: The medical department of a teaching hospital in Jeddah, Saudi Arabia. Participants: 97 patients, admitted to the medical ward during the month of December 2015. Aim of the study: A smart phone application based CDSS was developed to assess the risk of VTE in medical patients. Patient data were collected and risk of VTE was calculated simultaneously by the application and by an expert hematologist. The aim of the study was to determine agreement between both sources. Results: Ninety-seven patients, mean age 50 (19-92) and 51% (50) males were included. Forty-eight percent of patients were stratified as high-risk score based on CDSS compared to forty-seven percent based on expert opinion. There was a strong agreement between the CDSS and the expert hematologist opinion, on the indication and type of prophylaxis suggested for patients with a high-risk score (Chi square 86.7 and 155, p= 0.000, p=0.000, respectively). There was also an agreement with expert hematologist on the need for thromboprophylaxis as well as the type of prophylaxis (Chi square 86.7 and 1.55 respectively). Conclusion: Smartphone application-based CDSS shows a strong agreement with expert opinion for determination of VTE risk score in medical patients. Thus, the smart-phone based CDSS application has the potential to improve physician compliance with guidelines and reduce inappropriate use of thromboprophylaxis, therefore improving clinical care.

Level of concordance between two risk-assessment models for predicting venous thromboembolism in medical patients at admission

ObjectivesTo evaluate the level of concordance between the 2007 PRETEMED guidelines and the 2012 American College of Chest Physicians (ACCP) guidelines in medical patients at admission.MethodsA cross-sectional, observational and descriptive...

Thromboprophylaxie en médecine : quelles modifications avec les nouveaux anticoagulants oraux ?

Thromboprophylaxis with low molecular weight heparin or fondaparinux is associated with a 50% reduction in the risk of venous thrombo-embolism (VTE) in medical patients. Thromboprophylaxis is indicated in the prevention of VTE in medical patients at risk of VTE. Extended thromboprophylaxis with apixaban is associated with a greater reduction in VTE events but also with an increase in bleeding events when compared to standard therapy with enoxaparine. Extended thromboprophylaxis with rivaroxaban is associated with a greater reduction in VTE events but also with an increase in bleeding events, when compared to standard therapy with enoxaparine. Rivaroxaban and apixaban are currently not indicated in medical prophylaxis.

Prophylaxis of venous thromboembolism in medical patients: too much or too little?

Venous thromboembolism (VTE) is a potentially serious complication occurring in 1%–2% of hospitalized medical patients. Despite this low absolute risk, as many as 82% of medical patients are considered to be at increased risk of developing VTE and are eligible for medical thromboprophylaxis. In this commentary, The author will discuss the main findings of a recent paper published in Clinical Epidemiology that questions the large proportion of individuals who are eligible for medical thromboprophylaxis, and also discuss the potential implications for the prevention of VTE. The recent paper demonstrated that when a population is divided into high- and low-risk groups, the maximum absolute risk depends on the inverse of the proportion of patients that is considered to be high risk. Consequently, even an effective treatment will only result in a small reduction in the absolute risk when the high-risk group comprises the largest proportion of this population. For medical thromboprophylaxis, this implies that even patients considered to be at high-risk for developing VTE have a maximum absolute VTE risk of 2% when the overall risk is 1.6%. Therefore, even an effective preventive initiative will only result in a small risk reduction. This small potential benefit should be weighed against potential harms associated with prophylaxis, mainly bleeding events. Still, there may be a reasonable overall balance between prevention of pulmonary embolism and major bleeding, mainly because major bleeding events are rare. Nonetheless, this discussion underscores that future risk prediction models should aim to predict the benefits and harms in individual patients in order to provide optimal care for the right patients.

New Oral Anticoagulants for Venous Thromboembolism: Focus on Factor Xa and Thrombin Inhibitors

Several oral direct anti-Xa agents and one antithrombin agent are currently under clinical development for the prevention and treatment of venous thromboembolism (VTE). The anti-Xa inhibitors rivaroxaban (10 mg once daily) and apixaban (2.5 mg twice daily) as well as the thrombin inhibitor dabigatran (150 or 220 mg once daily) have been recently licensed for the prevention of VTE in total hip or knee replacement. The publication of the results of studies with rivaroxaban and apixaban in the prevention of VTE in medical patients are awaited. Phase III studies on the treatment of VTE showed the non inferiority of rivaroxaban (15 mg twice daily in the first three weeks and 20 mg once daily thereafter) and dabigatran (150 mg twice daily) to standard treatment. The incidence of major or clinically relevant non-major bleeding was similar in patients receiving standard treatment and rivaroxaban or dabigatran. Clinical trials on VTE treatment are currently ongoing with apixaban and edoxaban. A number of phase II clinical trials are currently ongoing with several other antiXa agents in the prophylaxis and treatment of VTE.

Duration of venous thromboembolism risk across a continuum in medically ill hospitalized patients

Patients hospitalized for medical illness are at increased risk of venous thromboembolism (VTE), but the duration of risk is not well understood. To assess incidence and time course of symptomatic VTE following hospitalization for medical illness in a large, real-world patient population. Data were extracted from the Thomson Reuters MarketScan(®) Inpatient Drug Link File. Those hospitalized with cancer, heart failure, severe lung disease, or infectious disease from 2005 to 2008. The cumulative VTE risk over 180 days after admission was calculated using Kaplan-Meier analysis. VTE hazard was calculated on a daily basis and smoothed through LOESS regression. The analysis included 11,139 medically ill patients, 46.7% and 8.8% of whom received pharmacological thromboprophylaxis during hospitalization and after discharge, respectively. The mean duration of prophylaxis during hospitalization was 5.0 days. Of the 11,139 patients, 366 (3.3%) experienced a symptomatic VTE event. VTE events were most frequent during days 0-9 (97 events), followed by days 10-19 (82 events). The mean length of hospital stay was 5.3 days, and 56.6% of all VTE events occurred after discharge. VTE hazard peaked at day 8, with 1.05 events per 1000 person-days. The time course of VTE in medical patients shows that risk of symptomatic VTE is highest during the first 19 days after hospital admission, and extends into the period after discharge. Future research is warranted to investigate risks and benefits of reducing the incidence of VTE after discharge, including the role of improving thromboprophylaxis practices in the inpatient setting and extending thromboprophylaxis after hospitalization.

Prevention of Venous Thromboembolism in Medical Patients with Thrombocytopenia or with Platelet Dysfunction: A Review of the Literature

Current guidelines for venous thromboembolism (VTE) primary prophylaxis are based on randomized clinical trials that exclude subjects at a potentially high bleeding risk. Thus no specific recommendation/algorithm for pharmacological prophylaxis in patients with thrombocytopenia and/or platelet dysfunction is available. Because at least 25% of subjects admitted to medical departments exhibit these conditions, information on this subject is provided here to optimize their VTE prophylaxis. Low platelet number/function and clotting abnormalities are common in patients with liver cirrhosis. However, these patients have a high incidence of portal and idiopathic venous thromboses, implying that cirrhotic coagulopathy does not protect against thrombosis. At variance with severe thrombocytopenia (< 50,000/μL), mild/moderate thrombocytopenia (> 50,000/μL) should not interfere with VTE prevention decisions. In severe thrombocytopenia, prophylaxis should be considered on an individual basis, however. In patients with antiphospholipid antibodies and thrombocytopenia, a thrombotic tendency is usually associated rather than a bleeding risk. VTE prophylaxis in high-risk conditions is thus suggested in these patients. Except in cases with contraindications to anticoagulation, antithrombotic prophylaxis should be always considered in hospitalized cancer patients with thrombocytopenia, especially in those with hematologic malignancies and multiple VTE risk factors. Aspirin treatment is not as effective as heparins in lowering the risk of VTE. Studies in stroke suggest that thromboprophylaxis with heparins is safe in patients with ischemic stroke undergoing aspirin treatment. The need for VTE prophylaxis in patients on chronic treatment with aspirin and/or clopidogrel should be evaluated after assessing the individual risk-benefit ratio.

Venous thromboembolism in medical patients treated in the setting of primary care: A nationwide case-control study in Italy

Objectives The risk of venous thrombotic events (VTE) among medical outpatients is still not clear and it remains to be clarified whether medical diseases involve the same risk if managed at home or in hospital. The aim of this study was to evaluate in the setting of outpatient family medicine the relationship between VTE and medical conditions known to be at risk during a hospital stay. Design and setting The study involved a nationwide retrospective observation according to a nested case-control method; 400 general practitioners throughout Italy constituted the network for data collection. Between 2001 and 2004, all cases recorded as having VTE were entered; ten control patients without VTE, matched by sex, physician, and age, were selected from the database for each case. Results The eligible population comprised 372,000 patients and 1,624 incident VTE were recorded. Univariate analysis indicated hospitalization (OR 5.02; 95% CI 4.01-6.29), cancer (OR 3.06; 95% CI 2.47-3.79), acute infectious disease (OR 2.93; 95% CI 1.94-4.43), neurological disease (OR 2.60; 95% CI 1.56-4.33), congestive heart failure (CHF) (OR 2.48; 95% CI 1.68-3.69), paralysis (OR 1.87; 95% CI 1.51-2.32), COPD (OR 1.58; 95% CI 1.29-1.95), stroke (OR 1.62; 95% CI 1.24-2.12), superficial venous thrombosis (OR 1.51; 95% CI 1.11-2.04, and rheumatic diseases (OR 1.49; 95% CI 1.28-1.74) as significantly associated with an increased risk for VTE. After adjustment, only transient or definitive paralysis, cancer, acute infectious disease, congestive heart failure, neurological diseases, and previous hospitalization remained associated. Conclusions This large study indicates that VTE outpatients seen by general practitioners in Italy have a high prevalence of the same medical diseases associated with VTE among patients treated in hospital.

Prevention of Venous Thrombo-Embolism in Non-surgical Hospitalized Patients

Venous thromboembolism (VTE) is commonly found in hospitalized patients, considered as complication not only in surgical patients but also in medical patients. The vast majority of hospitalized patients with VTE or pulmonary embolism have not undergone any recent surgery. Several large randomized, double-blind, placebo controlled trials including MEDENOX, PREVENT and ARTEMIS have confirmed the efficacy and safety ofVTE thromboprophylaxis for acutely ill medical inpatients, The American College of Chest Physicians (ACCP) Guidelines 2008 recommend a risk assessment at the time hospital admission for every medical patients and VTE prophylaxis using either anticoagulant medications or mechanical prevention should be applied for those who have high risk condition. Other studies showed that many cases of VTE in medical patients occur after hospital discharge, but still no clinical trials and current recommendation evaluating VTE prophylaxis for medical outpatients have been published yet. In this article, we attempt to review the literatures on importance of risk assessment and VTE prophylaxis for hospitalized medical patients. (Med J indones 2010; 19: 71-7)

Risk Factors for Venous Thromboembolism in Medical Patients: Data from the GEMINI and MASTER Registries

In the context of GEMINI, a multivariable analysis has been performed to evaluate the association between some potential risk factors and the occurrence of VTE in the study population. As specified in Table 1, previous VTE and bed resting were significantly associated with the risk of VTE, while a trend for increased risk was documented in cancer patients, in the case of recent surgery, and for obesity. Chronic heart failure and obstructive pulmonary disease appeared inversely related to occurrence of VTE, while a very low number or no VTE events occurred in patients with myocardial infarction and inflammatory bowel disease, so determining extremely wide confidence intervals for odds ratios.

Prevention of venous thromboembolism in medical patients and outpatients

The majority of fatal cases of pulmonary embolism in hospitalized patients occur in acutely ill, medically treated patients. Current guidelines, based on a large number of prospective, randomized, controlled trials evaluating the safety and efficacy of pharmacologic venous thromboembolism (VTE) prophylaxis in medical patients, now recommend using VTE prophylaxis in this population. Unfortunately, prophylaxis rates in medical patients are unacceptably low, despite efforts to develop strategies for improving implementation of prophylaxis regimens. Studies indicate that a substantial proportion of patients with VTE present after hospital discharge, but no clinical trials evaluating VTE prophylaxis for medical outpatients have yet been published. In this Review, we examine the literature on VTE prophylaxis in hospitalized medical patients, and evaluate the available data for the outpatient setting.

Improving the use of anticoagulant therapies in acutely ill medical patients

Assessment of risk for the development of venous thromboembolism (VTE), selection of VTE prophylaxis in medical patients, strategies for improving prescribing practices to prevent VTE, and the impact of pharmacist-managed anticoagulation services are described; case studies are used to illustrate each topic. Assessing risk for VTE is more complicated for acutely ill medical patients than for surgical patients. The risk of VTE in medical patients increases with the number of VTE risk factors the patient has. A number of regimens have demonstrated efficacy in reducing the rate of VTE in medically ill patients. Head-to-head studies suggest that enoxaparin 40 mg daily is at least as effective as unfractionated heparin (UFH) 5000 units three times daily for preventing VTE in acute medically ill patients. Because of greater efficacy, enoxaparin may be preferred over UFH in certain patient populations at particularly high risk for VTE. Although the efficacy of VTE prophylaxis is well documented, most patients at risk still do not receive this therapy. A combination of strategies is more effective than a single strategy for modifying prescribing practices to ensure that optimal VTE prophylaxis is provided when indicated. Pharmacist-managed anticoagulation services improve the appropriate use of anticoagulant agents, shorten hospital length of stay, and reduce mortality, drug-related complications, hospital readmissions for bleeding and thrombosis, and costs. Pharmacists can improve clinical and economic outcomes in acutely ill medical patients who are at risk for VTE through the use of various strategies, including anticoagulation management services.

Risk of Venous Thromboembolism and Efficacy of Thromboprophylaxis in Hospitalized Obese Medical Patients and in Obese Patients Undergoing Bariatric Surgery

Obesity is considered a highly prevalent risk factor for venous thromboembolism (VTE) in hospitalized patients. However, recommendations for VTE prophylaxis in obese patients are not clear. To evaluate obesity as a risk factor for VTE in medical and bariatric patients and the efficacy of VTE prophylaxis, we performed a systematic review in MEDLINE, Cochrane Database of Systematic Reviews and LILACS from 1976 to 2006. Evidence was evaluated independently by 2 authors and presented descriptively. Of the 124 studies found, 87 were excluded based on predefined criteria. There is no consensus among studies, but prospective cohorts show that obesity is associated with a higher risk of VTE in medical patients. There is evidence that the risk of VTE exceeds that attributable to the surgical procedure alone in bariatric surgery. Only 6 studies evaluated prophylactic methods (unfractionated heparin, low molecular weight heparin and sequential compression devices) in obese patients. Although these studies have some methodological flaws, they suggest efficacy of VTE prophylaxis in medical and surgical obese patients. Obesity is a risk factor for VTE in obese medical patients and patients undergoing bariatric surgery. Obesity appears to play an adjuvant role for the development of VTE in hospitalized patients with other risk factors. The small number of prospective trials in this population prevents a definite conclusion about the most effective and safe VTE prophylactic method for obese patients. Thus, randomized clinical trials to compare VTE prophylactic methods in obese patients are still highly warranted.