Venous Thromboembolism Prophylaxis for Medical Inpatients Heather Hofmann, rev. 4/18/14 DSR2 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 VTEVenous Thromboembolism DVTDeep vein thrombosis PEPulmonary embolism

Determine Prophylaxis VTE riskBleeding risk Patient admitted Determine risk of VTE Low Early ambulation Moderate Or High Determine bleeding risk Low Anticoagulant prophylaxis High Intermittent pneumatic compression

Determine Prophylaxis VTE Risk Stratification LowIf all 3: < 40yo Mobile No VTE risk factors (next slide) ModerateAll other patients. HighICU patients. Bleeding Risk Stratification Low Limited validated definitions; can determine “IMPROVE” risk Moderate HighActive GI bleed Bleed (GI, CVA…) < 3mos ago Platelets < 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 MedicationDose Heparin Unfractionated (UFH) 5,000 units SQ q8h 5,000 units SQ q12h if elderly Enoxaparin (Lovenox) Low Molecular Weight (LMWH) 30-40mg SQ daily Contraindicated 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 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 VTE riskBleeding risk Patient admitted Determine risk of VTE Low Early ambulation Moderate Or High Determine bleeding risk Low Anticoagulant prophylaxis High Intermittent pneumatic compression

Determine Prophylaxis VTE Risk Stratification LowIf all 3: < 40yo Mobile No VTE risk factors (next slide) ModerateAll other patients. HighICU patients. Bleeding Risk Stratification Low Limited validated definitions; can determine “IMPROVE” risk Moderate HighActive GI bleed Bleed (GI, CVA…) < 3mos ago Platelets < 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: Pineo GF. Prevention of venous thromboembolic disease in medical patients. UpToDate, Mar 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: 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: /chest 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– doi: /S (09)