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Primary VTE Prophylaxis Ponlapat Rojnuckarin, MD PhD Chulalongkorn University Bangkok, Thailand

Primary VTE Prophylaxis¸_ พลภัทร... · 2018. 10. 24. · DVT 0.81% 0.38% Mortality 4.5% 4.3% Significant reduction in PE/fatal PE/DVT DVT prophylaxis in high-risk medical

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Text of Primary VTE Prophylaxis¸_ พลภัทร... · 2018. 10. 24. · DVT 0.81% 0.38% Mortality...

  • Primary VTE Prophylaxis

    Ponlapat Rojnuckarin, MD PhDChulalongkorn UniversityBangkok, Thailand

  • A 70-yr-old female before THABMI 31 kg/m2 with varicose veinWhat do you recommend for VTE prevention?A. NoneB. IPCC. ASAD. ASA+ IPCE. DOAC x 5 d then ASA 30 daysF. LMWH x 5 d then ASA 30 days

  • VTE prophylaxis in Thailand

    Lancet 2008; 371: 387

    Thailand

    Patients at risk for VTE

    Prophylaxis given

  • Rationale of VTE prophylaxis Incidence of VTE? Clinically-relevant VTE?

    – Asymptomatic vs. Symptomatic– Proximal vs. Distal– Fatal PE

    Efficacy vs. Safety of prophylaxis?Cost-effectiveness?

  • Incidence of VTE in hip/knee surgery in Asia (N = 2454)

    Publication from 1979 to 2009Total DVT (Venography) 30-40%Proximal VTE 5-10%Symptomatic DVT* 2.8-4.5%Symptomatic PE 0.6%Fatal PE None reported*The limbs with surgery are frequently swollen without

    thrombosis. Meta-analysis Br J Surg 2011; 98: 1356JTH 2005; 3: 2664-70, JTH 2005; 3: 28.

  • Increasing Incidences of VTE in ThailandSettings Year Total

    NumberIncidence Notes

    HIP/KNEE SURGERYHip Surgery1 1984-1986 50 4% Angiography

    Knee Surgery2 2004 67 24% Radionuclide ScanHip Fracture3 2005 96 48% Angiography

    GYNECOLOGICAL CANCER SURGERYGynecologic cancer surgery4 1975 52 3.8% Radionuclide Scan

    (No symptom) Ovarian cancer5 2004-2013 305 5.9% Symptomatic DVT by USGynecologic cancer6 2014 100 7.0% Proximal DVT by US

    1. Atichartakarn et al. Arch Intern Med 1988; 148: 1349 4. Chumnijarakit et al. Lancet 1975; 1: 1357-82. Pookarnjanamorakot et al. J Med Assoc Thai 2004; 87: 869 5. Oranratanaphan et al. Asian Pac J Cancer Prev 2015; 16: 67053. Chotanaphuti et al J Med Assoc Thai 2005; 88 (S3): S159 6. Sermsathanasawadi et al. J Med Assoc Thai. 2014; 97: 153-8

  • VTE in Hip/knee Arthroplasty Siriraj Hospital (N = 896) TKA (714) Supervised calf muscle exercise Early ambulation (Mean: 2 days post -op) Follow-up by phone and imaging for symptoms Symptomatic DVT 2/896 (0.22%): Both of them

    had no risk factor Leg swelling is common after surgery. Diagnosis by

    symptoms is difficult. Some might have been missed?

    Wongprasert C et al. JTH 2015; 13 (Suppl 1): 984.

  • Non-orthopedic surgery

    Chulalongkorn Hospital, Thailand 2009General and gynecologic surgeryAge > 40 yr and Major surgery (GA or > 1 hr)(Moderate risk, ACCP recommends heparin)N=1432Symptomatic VTE 11 (0.77%)Most of VTE had cancer.

    Yongkasem Vorasettakarnkij et al.

  • VTE in Thai surgical ICUDoppler Ultrasonography in all casesRamathibodi Hospital (Surgical ICU) 2005-2006 10.5% (20/190) DVT KCMH (Surgical ICU) 2011-2012 3.6% (11/305) DVT (2 with PE)Risk factors: Previous VTE (OR 34.3),

    Orthopedics group (OR 27.2) and female sex (OR 14.3)

    Wilasrusmee et al. Asian J Surg 2009;32:85Prichayudh et al. J Med Assoc Thai. 2015; 98: 472

  • Medical patientsChulalongkorn Hospital, 2007-2008 (N = 7126) Admit > 3 d, No active VTE on admission 42/7126 (0.59%) symptomatic VTE Arthritis (7.7%), Cancer (1.8%), Ventilator (1.5%) 23/42 (55%) symptomatic PE 10 (0.14%) fatal PE (41.7% of PE) 2 deaths from anticoagulants

    Aniwan & Rojnuckarin. Blood Coagul Fibrinolysis 2010; 21: 334

  • High-risk medical patientsChulalongkorn Hospital, 2007-2008 7.7% (2/26) of arthritis of lower limbs 4.7% (3/64) of SLE 1.8% (22/1211) of active cancer 1.5% (5/543) of mechanical ventilation 0.5 % (1/204) of congestive heart failure 0.4% (1/240) of acute stroke

  • High-risk medical patients (N = 1290)(Western risk scores: Not working)

    6

    11

    1

    1

    1

    Total VTE = 27 (2.1%) Rojnuckarin et al. Thromb Haemost 2011; 106: 1103

  • VTE in Thailand

    The incidence of Symptomatic VTE in High-risk patients is NOT LOW.– Major Hip and Knee Surgery: 0.22-4.5%– Active cancer patients: 2-3%

    Over 50% of all VTE are attributed to hospitalization or cancer. The prevention will be helpful for public health.

  • Hospitalization and cancer attributed to over half of VTE in population

    Arch Intern Med 2002; 162: 1245Admission within 3 months

  • Perioperative heparin reduced Mortality

    Heparin Control

    Non Fatal PE 1.3% 2.0% p

  • No Anticoagulant Anticoagulant

    Any PE 0.49% 0.20%Fatal PE 0.39% 0.14%DVT 0.81% 0.38%Mortality 4.5% 4.3%

    Significant reduction in PE/fatal PE/DVT

    DVT prophylaxis in high-risk medical patients

    Ann Intern Med. 2007;146:278-88. Meta-analysis, N=19 958Symptomatic only

    NNT=400

  • Anticoagulant Prophylaxis increased risk of major bleeding.

    J Thromb Haemost 2008; 6: 405–14Are there other choices of prophylaxis?

  • Pathogenesis of VTE

    Anesth Analg 2017; 125: 403.

  • Intermittent Pneumatic Compression

  • Intermittent Pneumatic Compression (IPC) for VTE prophylaxis

    Meta-analysis of 70 trials (N =16 164) Surgical or Medical Hospitalized patientsDVT :RR 0.43 (p

  • IPC in Orthopedic and Neurological surgeryDVT

    Ann Surg 2016; 263: 888

  • IPC in Critically-ill patientsNetwork meta-analysis

    J Korean Med Sci 2016; 31: 1828

  • Pathogenesis of VTE: Platelets

    Anesth Analg 2017; 125: 403.

  • Hip/Knee SurgeryDVT rate: ASA vs. Anticoagulant

    J Hosp Med 2014; 9: 579

  • Hip/Knee SurgeryPE rate: ASA vs. Anticoagulant

    J Hosp Med 2014; 9: 579

  • Bleeding ASA vs. Anticoagulant

    J Hosp Med 2014; 9: 579

  • THA or TKA Rx Rivaroxaban 5 daysRivaroxaban vs. ASA for total of 30 or 14 d

    N Engl J Med 2018; 378: 699

  • Meta-analysis: ASA in THA and TKA

    Retro-/Prospective/RCT: Symptomatic eventsYear 1976-2014 (39 studies)DVT 1.2% (N = 59,273)PE 0.6% (N = 61,315)Major bleeding 0.3% (N = 54,255)Year 2014-2017 (7 studies)DVT 0.66% (N = 43,012)

  • Thai Society of HematologyGuideline: Hip/Knee surgery THA/TKA: LMWH, fondaparinux, LDUH, DOACs,

    warfarin, or aspirin (คุณภาพหลกัฐาน ก๑ นํ้าหนกัคาํแนะนาํ +) or IPC (คุณภาพหลกัฐาน ข๑ นํ้าหนกัคาํแนะนาํ +)

    Hip fracture: LMWH, fondaparinux, LDUH, warfarin or aspirin (คุณภาพหลกัฐาน ก๑ นํ้าหนกัคาํแนะนาํ +) or IPC (คุณภาพหลกัฐาน ข๑ นํ้าหนกัคาํแนะนาํ +)

    High risk for bleeding: IPC (คุณภาพหลกัฐาน ง๑ นํ้าหนกัคาํแนะนาํ +)

    Thai Society of Hematology Guideline 2017

  • Caprini score for surgical patients

    ACCP guideline, Chest 2012; 141: e227SCalculator is available online.

  • Abdominal or pelvic surgeryRisk Caprini

    scoreVTE risk Methods

    Very low 0

  • Risk Factors in Cancer patients

    Thromb Res 2015; Suppl 1: S8 Breast and prostate CA have low-risk.

  • Thai Society of HematologyGuideline: Medical inpatients All require VTE risk assessment (คุณภาพหลกัฐาน ง๑

    นํ้าหนกัคาํแนะนาํ +)

    Select appropriate VTE prevention for each patient (คุณภาพหลกัฐาน ง๑ นํ้าหนกัคาํแนะนาํ +)

    High risk VTE (Padua score ≥4): LMWH, LDUH or fondaparinux (คุณภาพหลกัฐาน ก๑ นํ้าหนกัคาํแนะนาํ +/-)

    High risk for bleeding: IPC (คุณภาพหลกัฐาน ค๑ นํ้าหนกัคาํแนะนาํ +)

    Thai Society of Hematology Guideline 2017

  • How to improve VTE preventionMultidisciplinary action

    Surgeon concernsGynecological OncologistsOrthopedists, Surgeons, AnesthesiologistsProfessional societiesOpen guidelines with choices

    Raise the concernEarly ambulationMechanical prophylaxisPharmacological prophylaxis(LMWH or SH)

  • Rationale of VTE prophylaxis Incidence of VTE Clinically relevant VTE

    – Asymptomatic vs. Symptomatic– Distal vs. Proximal– Fatal PE

    Efficacy vs. Safety of prophylaxis(Mechanical or ASA prophylaxis)

    Cost-effectiveness analysis (ASA in Hip/knee surgery)

  • A 70-yr-old female before THABMI 31 kg/m2 with varicose veinWhat do you recommend for VTE prevention?A. NoneB. IPCC. ASAD. ASA+ IPCE. DOAC x 5 d then ASA 30 daysF. LMWH x 5 d then ASA 30 days

  • Summary

    All doctors need to be aware of and assess the VTE risks of patients.

    Consider prophylaxis in very high risk– Caucasian patients – History of previous VTE– Hip and knee surgery (Consider ASA) – High-risk Cancer undergoing Major Surgery

    Non-pharmacological or Pharmacological prophylaxis, e.g. IPC in ICU patients