Optimal Strategies for DVT Prophylaxis: Translating Evidence into Practice Samuel Z. Goldhaber, MD...
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Optimal Strategies for DVT Optimal Strategies for DVT Prophylaxis: Translating Evidence Prophylaxis: Translating Evidence into Practice into Practice Samuel Z. Goldhaber, MD Samuel Z. Goldhaber, MD Cardiovascular Division Cardiovascular Division Brigham and Women’s Hospital Brigham and Women’s Hospital Professor of Medicine Professor of Medicine Harvard Medical School Harvard Medical School DVT-WRAP SlideCAST DVT-WRAP SlideCAST
Optimal Strategies for DVT Prophylaxis: Translating Evidence into Practice Samuel Z. Goldhaber, MD Cardiovascular Division Brigham and Women’s Hospital
Optimal Strategies for DVT Prophylaxis: Translating Evidence
into Practice Samuel Z. Goldhaber, MD Cardiovascular Division
Brigham and Womens Hospital Professor of Medicine Harvard Medical
School Samuel Z. Goldhaber, MD Cardiovascular Division Brigham and
Womens Hospital Professor of Medicine Harvard Medical School
DVT-WRAP SlideCAST
Slide 2
The Challenge DVT/ PE are rampant but often preventable.
Hospitalized patients are at risk, but prophylactic measures are
often omitted. Behavior Modification and Quality Improvement
strategies: - Electronic, Human alerts - 3-screen alert with
default prophylaxis - Continuum of Care (ensure prophylaxis from
admission to discharge, to SNF, and at home) DVT/ PE are rampant
but often preventable. Hospitalized patients are at risk, but
prophylactic measures are often omitted. Behavior Modification and
Quality Improvement strategies: - Electronic, Human alerts -
3-screen alert with default prophylaxis - Continuum of Care (ensure
prophylaxis from admission to discharge, to SNF, and at home)
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Lung with PE
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PE SXS/ Signs (PIOPED II) Dyspnea (79%) Tachypnea (57%)
Pleuritic pain (47%) Leg edema, erythema, tenderness, palpable cord
(47%) Cough/ hemoptysis (43%) Dyspnea (79%) Tachypnea (57%)
Pleuritic pain (47%) Leg edema, erythema, tenderness, palpable cord
(47%) Cough/ hemoptysis (43%) Stein PD. Am J Med 2007; 120:
871-879
Slide 7
Incidence 900,000 PEs/ DVTs in USA in 2002. Estimated 296,000
PE deaths: 7% treated, 34% sudden and fatal, and 59% undetected.
Heit J. ASH Abstract 2005 -----------------------------------------
762,000 PEs/ DVTs in EU in 2004. Thromb Haemostas 2007; 98:
756
Slide 8
The high death rate from PE (exceeding acute MI!) and the high
frequency of undiagnosed PE causing sudden cardiac death emphasize
the need for improved preventive efforts. Failure to institute
prophylaxis is a much bigger problem with Medical Service patients
than Surgical Service patients. The high death rate from PE
(exceeding acute MI!) and the high frequency of undiagnosed PE
causing sudden cardiac death emphasize the need for improved
preventive efforts. Failure to institute prophylaxis is a much
bigger problem with Medical Service patients than Surgical Service
patients.
Slide 9
Annual # At-Risk for VTE: US Hospitals 7.7 million Medical
Service inpatients 3.4 million Surgical Service inpatients Based
upon ACCP guidelines for VTE prophylaxis Anderson FA Jr, et al. Am
J Hematol 2007; 82: 777-782 7.7 million Medical Service inpatients
3.4 million Surgical Service inpatients Based upon ACCP guidelines
for VTE prophylaxis Anderson FA Jr, et al. Am J Hematol 2007; 82:
777-782
Slide 10
Malignant Gliomas (N=9,489) and VTE California Cancer Registry
2-year VTE Incidence: 7.5% 16 VTE events per 100 person-years
during 1 st 6 months Risk factors: older age, neurosurgery VTE: 30%
increased risk of death California Cancer Registry 2-year VTE
Incidence: 7.5% 16 VTE events per 100 person-years during 1 st 6
months Risk factors: older age, neurosurgery VTE: 30% increased
risk of death J Neurosurg 2007; 106: 601-608
Slide 11
Outpatient and Inpatient VTE are Linked 74% of VTEs present in
outpatients. 42% of outpatient VTE patients have had recent surgery
or hospitalization. Only 40% had received VTE prophylaxis. 74% of
VTEs present in outpatients. 42% of outpatient VTE patients have
had recent surgery or hospitalization. Only 40% had received VTE
prophylaxis. Spencer FA, et al. Arch Intern Med 2007; 167:
1471-1475
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ICOPER Cumulative Mortality Mortality (%) Days From Diagnosis
17.5% 0 5 10 15 20 25 714306090 Lancet 1999; 353: 1386-1389
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Progression of Chronic Venous Insufficiency From UpToDate
2006
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Risk Factors Linking Venous and Arterial TE: Biologically
Plausible 1.Activation of platelets and coagulation proteins
2.Increased fibrin turnover 3.Inflammation 4.Lipid profiles
1.Activation of platelets and coagulation proteins 2.Increased
fibrin turnover 3.Inflammation 4.Lipid profiles
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Dabish 20-Year Cohort: VTE, Subsequent CV Events Assessed risk
of MI, Stroke 25,199 with DVT 16,925 with PE 163,566 population
controls Assessed risk of MI, Stroke 25,199 with DVT 16,925 with PE
163,566 population controls Sorensen HT. Lancet 2007; 370:
1773-1779
Slide 17
RR CV Event in PE Patients CV Event 1 Year RR 2-20 Year RR
Acute MI 2.61.3 Stroke2.91.3 Sorensen HT. Lancet 2007; 370:
1773-1779
Slide 18
Cardiovascular Risk Factors and VTE (N=63,552 meta-analysis)
RFRR Obesity2.3 Hypertension1.5 Diabetes1.4 Cigarettes1.2 High
Cholesterol1.2 RFRR Obesity2.3 Hypertension1.5 Diabetes1.4
Cigarettes1.2 High Cholesterol1.2 Ageno W. Circulation 2008; 117:
93-102
Slide 19
Risk Factors Meta-Analysis Implications 1.RFs for
atherothrombosis are also associated with VTE 2.Cardiovascular RFs
may be involved in pathogenesis of VTE 3.Atherosclerosis and VTE
are not completely distinct entities. 1.RFs for atherothrombosis
are also associated with VTE 2.Cardiovascular RFs may be involved
in pathogenesis of VTE 3.Atherosclerosis and VTE are not completely
distinct entities. Ageno W. Circulation 2008; 117: 93-102
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Obesity and VTE: NHDS AGE RR (PE) RR (DVT) < 40 y 5.25.2 All
Ages 2.22.5 Stein PD. Am J Med 2005; 118: 978-980
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Steffen LM. Circulation 2007;115:188-195 Eat Veggies and Lower
VTE Risk; Careful with Red Meat Adjusted Hazard Ratios (Quintiles)
2345p Fruits, veggie 0.730.570.47 0.59 0.03 Fish 0.580.600.55 0.70
0.30 Red Meat 1.241.211.09 2.01 0.02
VTE Prophylaxis in 19,958 Medical Patients/ 9 Studies
(Meta-Analysis) 62% reduction in fatal PE 57% reduction in fatal or
nonfatal PE 53% reduction in DVT 62% reduction in fatal PE 57%
reduction in fatal or nonfatal PE 53% reduction in DVT Dentali F,
et al. Ann Intern Med 2007; 146: 278-288
Slide 26
Intermittent Pneumatic Compression Meta-Analysis in Postop
Patients 2,270 patients in 15 randomized trials IPC devices reduced
DVT risk by 60% (Relative Risk 0.40, 95% CI 0.29-0.56, p< 0.001)
2,270 patients in 15 randomized trials IPC devices reduced DVT risk
by 60% (Relative Risk 0.40, 95% CI 0.29-0.56, p< 0.001)
Urbankova J. Thromb Haemost 2005; 94: 1181-5
Slide 27
The Amin Report: Prophylaxis Rates in the US Studied 196,104
Medical Service discharges from 227 hospitals (Premier database).
VTE prophylaxis rate was 62%. ACCP-deemed appropriate prophylaxis
rate was 34%. Studied 196,104 Medical Service discharges from 227
hospitals (Premier database). VTE prophylaxis rate was 62%.
ACCP-deemed appropriate prophylaxis rate was 34%. J Thromb
Haemostas 2007; 5: 1610-6
Slide 28
Medical Patient Prophylaxis in Canada Studied 1,894 Medical
Service discharges from 29 hospitals. VTE prophylaxis was indicated
in 90% of patients. ACCP-deemed appropriate prophylaxis rate was
16%. Studied 1,894 Medical Service discharges from 29 hospitals.
VTE prophylaxis was indicated in 90% of patients. ACCP-deemed
appropriate prophylaxis rate was 16%. Thrombosis Research 2007;
119: 145-155
Slide 29
ENDORSE : WORLDWIDE (Lancet 2008; 371: 387-394) 68,183
patients; 32 countries; 358 sites First patient enrolled August 2,
2006;Last patient enrolled January 4, 2007
Slide 30
42% at Risk for VTE Medical 40% receive ACCP Rec. Px 64% at
Risk for VTE 59% receive ACCP Rec. Px Surgical Worldwide
Prophylaxis Status for 68,183 Patients 52% at Risk for VTE (50%
receive ACCP recommended prophy)
Slide 31
We have initiated trials to change MD behavior and improve
implementation of VTE prophylaxisnot trials of specific types of
prophylaxiseAlert RCT, eAlert cohort, human Alert, 3-screen
eAlert.
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Quality Improvement Initiative to Improve Clinical Practice
Randomized controlled trial to issue or withhold electronic alerts
to MDs whose high-risk patients were not receiving DVT prophylaxis.
Kucher N, et al. NEJM 2005;352:969-977
Randomization VTE risk score > 4 No prophylaxis N = 2,506
INTERVENTION: Single alert N = 1,255 CONTROL No computer alert N =
1,251 Kucher N, et al. NEJM 2005;352:969-977
Primary End Point Intervention Control Number at risk
1255977900853 1251976893839 Intervention Control Time (days)
0306090 %Freedom from DVT/ PE 90 92 94 96 98 100 Kucher N, et al.
NEJM 2005;352:969-977
Slide 45
Purpose: To evaluate use of the VTE risk score and eAlert
system in real world setting To validate the efficacy of continued
use of the eAlert after discontinuing randomization To determine
whether VTE prophylaxis prescribing changed following NEJM
publication Purpose: To evaluate use of the VTE risk score and
eAlert system in real world setting To validate the efficacy of
continued use of the eAlert after discontinuing randomization To
determine whether VTE prophylaxis prescribing changed following
NEJM publication J Thromb Thrombolysis 2008;25: 146-50 Electronic
Alert Cohort
Slide 46
We identified 866 consecutive patients between January 2004 and
July 2006 following completion of original study All patients met
same inclusion/ exclusion NEJM eAlert criteria Rules for generating
alerts remained identical to original VTE eAlert study We
identified 866 consecutive patients between January 2004 and July
2006 following completion of original study All patients met same
inclusion/ exclusion NEJM eAlert criteria Rules for generating
alerts remained identical to original VTE eAlert study Baroletti S
et al. J Thrombosis Thrombolysis 2008; 25: 146-50)