Download Prophylaxis of Venous Thromboembolism

Prophylaxis of Venous
Thromboembolism
Dr Galila Zaher
Consultant Hematologist
MRCPATH
VTE in medical patients
• 600,000 patients / year are hospitalized
for DVT. symptomatic PE 600,000
patients and causes .
• contributes to death 200,000 annually.
• Most fatal PE occur in medical patients.
• A small number of randomised trials compared
with that of surgical patients.
• Meta-analyses in MI ,stroke and other medical
patients have clarified the benefits of thromboprophylaxis .
• 85% of all medical patients admitted
to an acute care hospital are eligible
and/or suitable for DVT prophylaxis
ACUTE MYOCARDIAL
INFARCTION
• Prior to the introduction of routine
antithrombotic therapy .
• Acute MI had a risk of asymptomatic
DVT of 24%, and PE of 2-9%.
• The risk increases with age and in
the presence of heart failure.
MECHANICAL
PROPHYLAXIS
• GENERAL MEASURES .
• Compression stockings especially
when heparin prophylaxis is
contraindicated.
(grade A)
ASPIRIN AND THROMBOLYTIC
THERAPY
• Strongly recommended that all patients
with acute MI should be given aspirin
(150-300 mg) .
(grade A)
• Strongly recommended that all patients
with acute MI should be considered for
thrombolytic therapy.
(grade A)
ANTICOAGULANTS
• Heparin not routinely in addition to
aspirin in acute MI, but reserved
for patients at increased
thromboembolic risk
(grade A)
High risk of thromboembolism
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Large anterior Q-wave infarction.
Severe left ventricular dysfunction.
Congestive heart failure.
History of systemic or PE or thrombophilia.
Echo evidence of mural thrombus.
Persistent AF.
Prolonged immobilization.
Marked obesity
(grade A)
ANTICOAGULANTS
• Full-dose heparin , followed with warfarin
for up to three months.
• Bleeding risks outweigh the benefits,
thrombo-prophylaxis low-dose SC heparin
(7,500 IU 12-hourly) for seven days or until
ambulant.
(grade A)
Acute stroke
• Asymptomatic DVT 50% of acute
hemiplegic stroke.
• Clinically apparent DVT or PE <5%.
• PE may account for up to 25% of
early
General measures
• Early mobilization and hydration .
• Meta-analysis of haemodilution : VTE
was reduced, despite lack of overall
benefit.
MECHANICAL
PROPHYLAXIS
• Graduated compression stockings justified for
high risk patients.
(grade C)
• Compression stockings are preferred
haemorrhagic stroke.
(grade D)
• Intermittent pneumatic compression no evidence
effective .
• Intermittent pneumatic compression is effective
in patients undergoing neurosurgery .
ASPIRIN
• Significant decrease in death or
dependency.
• Aspirin significantly reduced PE from 0.5%
to 0.3%.
• Aspirin is started as soon as ICH is
excluded by CT or MRI.
(grade A)
• Aspirin can be given by NG tube or rectally
: unable to swallow.
ANTICOAGULANTS
• Systematic reviews RCTs .
• Heparin reduces asymptomatic DVT after
stroke.
• Prevention of DVT& PE is offset by an increase in
haemorrhagic complications.
• The bleeding risk is dose-related.
• If heparins are to be used , low dose should be
selected
• LMWH preferred due to a lower risk of bleeding.
• UFH (5,000 IU SC BID) .
• LMWH .
ACUTE MYOCARDIAL
INFARCTION
• aspirin (150-300 mg).grade A
• thrombolytic therapy. Grade A.
• Heparin should not be used routinely but
reserved for patients at increased
thromboembolic risk grade A.
• Compression stockings especially when
heparin prophylaxis is contraindicated
grade A
Acute stroke
• graduated compression stockings may be
justified for some high risk patients. Grade C
• Compression stockings are preferred for
patients with haemorrhagic grade D
• Aspirin as soon as intracranial haemorrhage is
excluded by CT or MR brain scanning. Grade A
• Aspirin can be given by nasogastric tube or
rectally for those who are unable to swallow.
• UFH or a LMWH at higher than average risk of
VTE . Grade A
Other medical patients
• low dose UFH or LMWH should be
considered. grade A
• LMWH carries a lower risk of
bleeding. grade A
• heparin prophylaxis is
contraindicated, GECS may be
considered grade C
Cancer patients
• Minidose warfarin (1 mg/day, no INR
monitoring) with central venous
catheters. Grade A
• Low-dose warfarin (target INR 1.6, range
1.3-1.9) during chemotherapy in stage IV
breast cancer. Grade A
ANTICOAGULANTS
• In patients with ischaemic stroke at
higher than average risk of VTE :
• History of previous VTE.
• known thrombophilia .
• Active cancer.
• Lower than average risk of haemorrhagic
complications.
(grade A)
Other medical patients
• Autopsy : PE cause of deaths in immobilized
patients in medical wards.
• Heparin :56% decrease in asymptomatic DVT &PE
• The reduction in mortality was not statistically
significant .
• The risk of major bleeding was higher
• LMWH as effective as UFH in reducing DVT, PE
and mortality; lower risk of major bleeding.
Thrombo-prophylaxis in
medical patients
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Heart failure.
Respiratory failure .
Infections. (chest infections).
Diabetic coma.
Inflammatory bowel disease.
Nephrotic syndrome.
Intensive care patients.
 Low dose UFH or LMWH .
 LMWH lower risk of bleeding.
(grade A)
MECHANICAL
METHODS
• Significant risk of VTE :prophylaxis
is contraindicated, GECS may be
considered.
(grade C)
Cancer patients
• Cancer patients have an increased
risk of VTE.
• Central venous line thrombosis .
• Chemotherapy-induced thrombosis.
• Immobilised cancer in medical or
surgical wards should be considered
for prophylaxis.
ANTICOAGULANTS
• Minidose warfarin: (1 mg/day, no INR
monitoring) in cancer patients with central
venous catheters.
(grade A)
• Low-dose warfarin (target INR 1.6) during
chemotherapy stage IV breast cancer.
(grade A)
• Patients receiving antipsychotic drugs
• The Medenox study clearly
showed a dose-effect
relationship with enoxaparin
and the ineffectiveness of
the lower prophylactic dose
trend toward mortality
reduction with enoxaparin.
did not reach statistical
significance.
• CONCLUSIONS :
• Enoxaparin, given once daily at a dose of 40 mg
subq once daily for 6-14 days reduces the risk of
VTE by 63%,
• without increasing the frequency of hemorrhage.
• Enoxaparin is the only LMWH with an approved,
FDA indication for prophylaxis of DVT in medical
patients.
• should be maintained for at least 7 days,
• The majority of fatal PE have not
undergone recent surgery.
• MEDENOX :confirmed the
effectiveness of enoxaparin in
preventing VTED in medical patients.
• In PRIME: enoxaparin versus heparin
new VTE 0.2% and 1.4% .
• Ageno et al. 112 patients with clinical
indications for VTE prophylaxis
without contraindications to
anticoagulation prophylaxis was
underprescribed.
• only 46.4% received
thromboprophylactic treatment.