Venous Thromboembolism Prophylaxis for Medical Inpatients

Heather Hofmann, rev. 4/18/14DSR2 Mini Lecture

Objectives

• Recognize that VTE carries high morbidity and mortality

• Determine VTE risk for nonsurgical inpatient

• Select VTE prophylaxis for the non-surgical inpatient

Background

Most medical inpatients are at risk for VTE.– 25% of all VTE cases occur in the hospital– 50-75% occur on medicine– 5-10% of inpatient mortality are due to PE

Heparin ppx– does NOT decrease inpatient mortality risk– DOES decrease PE incidence

VTE Venous Thromboembolism

DVT Deep vein thrombosisPE Pulmonary embolism

Determine Prophylaxis

Determine ProphylaxisVTE Risk Stratification

Low If all 3: < 40yo Mobile No VTE risk factors (next slide)

Moderate All other patients.High ICU patients.

Bleeding Risk StratificationLow Limited validated definitions; can

determine “IMPROVE” riskModerateHigh Active GI bleed

Bleed (GI, CVA…) < 3mos agoPlatelets < 50K

Risk Factors for VTE• Obesity: BMI > 30• Smoking• Immobility• Malignancy• Previous VTE• Presence of central venous catheter• Inherited or acquired hypercoagulable states• Oral contraceptives/Hormone replacement therapy/tamoxifen• Admission diagnosis of:

– Congestive heart failure (NYHA III/VI)– Acute COPD exacerbation– Acute infectious disease or sepsis– Acute myocardial infarction– Stroke with lower limb paralysis– Inflammatory bowel disease*

Non-Pharmacologic Prophylaxis

• AMBULATION– Use if low VTE risk!

• MECHANICAL– Use if moderate-high VTE risk but high bleeding risk– Intermittent pneumatic compression (/SCDs/Sequentials)

• Contraindicated in leg ischemia from PVD– Options ineffective in prevention of VTE:

• Graduated compression stockings• Venous foot pumps

Pharmacological VTE Prophylaxis

Medication Dose

HeparinUnfractionated (UFH)

5,000 units SQ q8h5,000 units SQ q12h if elderly

Enoxaparin (Lovenox)Low Molecular Weight

(LMWH)

30-40mg SQ dailyContraindicated if CrCl < 30 mL/min

What VTE prophylaxis would you use?

62 yo F is admitted for community acquired pneumonia.No prior history of VTE, bleeding, hepatic, or renal failure.Her platelet count is 200.

VTE Risk?

Bleeding Risk?

VTE PPx:

Moderate

Low

UFH or LMWH

What VTE prophylaxis would you use?

35 yo M is admitted for acute gout. He is ambulatory. He has no prior VTE, GI bleed, thrombophilia, or malignancy. BMI 23. His platelet count is 240.

VTE Risk?

Bleeding Risk?

VTE PPx:

Low

Low

Early ambulation

What VTE prophylaxis would you use?

21 yo F admitted to ICU for DKA from poor insulin compliance. She is ambulatory. She has no prior VTE, GI bleed, thrombophilia, or malignancy. Platelet count is 300.

VTE Risk?

Bleeding Risk?

VTE PPx:

High

Low

UFH or LMWH

What VTE prophylaxis would you use?

65 yo F is admitted for treatment of an active malignancy. CrCl is 20 ml/min. She has a history of prior VTE but no history of bleeding, hepatic failure. Her platelet count is 250.

VTE Risk?

Bleeding Risk?

VTE PPx:

Moderate

Low

UFH

Determine Prophylaxis

Determine ProphylaxisVTE Risk Stratification

Low If all 3: < 40yo Mobile No VTE risk factors (next slide)

Moderate All other patients.High ICU patients.

Bleeding Risk StratificationLow Limited validated definitions; can

determine “IMPROVE” riskModerateHigh Active GI bleed

Bleed (GI, CVA…) < 3mos agoPlatelets < 50K

Summary

• Recognize VTE risk in all hospitalized patients.• Assess VTE risk with every admission• Use pharmacologic prophylaxis for patients with moderate to

high risk of VTE• If pharmacologic prophylaxis is contraindicated due to high

risk of bleeding, use ICD’s; do not use compression stockings.

• AMBULATION for all at low risk of VTE.

References

Guyatt GH, et al. Executive Summary : Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141;7S-47S.

Francis, CW. Prophylaxis for Thromboembolism in Hospitalized Medical Patients. N Engl J Med 2007;356:1438-44.

Pineo GF. Prevention of venous thromboembolic disease in medical patients. UpToDate, Mar 2012.

Qaseem A, et al. Venous Thromboembolism Prophylaxis in Hospitalized Patients: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2011;155:625-632.

Decousus, H., Tapson, V. F., Bergmann, J.-F., Chong, B. H., Froehlich, J. B., Kakkar, A. K., … IMPROVE Investigators. (2011). Factors at admission associated with bleeding risk in medical patients: findings from the IMPROVE investigators. Chest, 139(1), 69–79. doi:10.1378/chest.09-3081

Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep vein thrombosis after stroke (CLOTS trial 1): a multicentre, randomised controlled trial. (2009). The Lancet, 373(9679), 1958–1965. doi:10.1016/S0140-6736(09)60941-7