Caprini Score Update 2019

1. Caprini Score Update 2019 Joseph A. Caprini, MD, MS, FACS, RVT, DVSVS Emeritus, NorthShore University Health System, Evanston, IL Senior Clinician Educator, Pritzker School of Medicine, Chicago, IL

2. Risk Assessment In Clinical Practice:Guiding Principles • Evidence-Based Guidelines • Just a start (CHEST 2012) last surgical prophylaxis guidelines • Subsequent literature since the last Guideline • Critically important additional data (2012 to present) • Clinical registries and databases • RIETE worldwide database (80,000 DVT patients) • Validated risk assessment tools • From group identity to individual patient identity • Tailored VTE prophylaxis based on individual risk factors • Clinical experience and judgment • Vital piece of the puzzle

3. Academic Guidelines Vs. Clinical Realities Risk Assessment More than Just Following Guidelines THE NEXT TIME THIS SURGEON SEES A SIMILAR PATIENT DO YOU THINK OUTPATIENT PROPHYLAXIS WHILE AWAITING SURGERY WOULD BE STRONGLY CONSIDERED TO AVERT A REPEAT FATAL EMBOLUS?? • Patient was a 37 yr. old female, BMI 38(4 children) fell at work, • fractured kneecap and placed in a leg brace in FULL EXTENSION • Plan to operate in 2 weeks after swelling subsided • Aunt had history of major PE (second degree relative) • Surgeon thought PE history was not pertinent in a second degree relative • No prophylaxis since according to the surgeon CHEST guidelines do not recommend routine prophylaxis • Nine days later she suffered a fatal PE following tourniquet application during surgery

4. VTE Risk is Underestimated by Chart Reviews • Christopher Pannucci MD MS, Kory Fleming MPH, Journal of vascular surgery Venous and lymphatic disorders. 2018;6(3):304-11

5. Validation of a Patient-Completed Caprini Risk Assessment Tool for Venous Thromboembolism Risk Assessment  Caprini, J., et al; TH Open, 2017. 01(02): p. e106-e112. .

6. Pitfalls Using The Patient Completed Form • Patients often fail to answer family history question correctly • Often do not understand BMI • Overlook pitting edema without finger pressure by examiner • History of obstetrical complications not fully understood • Patients may be carriers of the ACA, Beta2 glycoprotein, or Lupus AC Healthcare provider reviews the patient form and makes sure the above factors are properly documented and a final admission score calculated

7. Varicose Veins 1 Point Visible bulging veins Not spider veins

8. Swollen legs (current)1 point • Pretibial pressure- 2seconds • Indentation of the skin (pitting edema) • Loss of definition of the bony prominences • Obscured surface foot veins • Indentation of the leg when a stocking is removed Normal Note foot veins Pittting Edema

9. Completing The Score Dynamic Instrument • Initial form completed by the patient • Healthcare professional checks form • Calculates initial score • Score revised during hospital stay reflecting – • Reoperation • Infection • Central lines • Cancer diagnosed during stay • FINAL SCORE CALCULATED AT DISCHARGE

10. Effects Of Anesthesia Replicate Virchow’s Triad Definition Of Major Surgery As A Thrombosis Risk Factor Venous stasis due to calf muscle paralysis (1) Venous over-distension producing endothelial cracks (2) Hypercoagulability secondary to surgical stress, retained metabolites, and underlying pathology (3) Time of anesthesia intensifies these effects IPC during surgery critical to minimize these changes

11. Immobilization = 2 Points • *Amin A. et al:ThrombHaemost 2010; 104: 955–961 • Patient confined to bed < 72 hours = 1point • Patient confined to bed over 72 hours • includes being up in the chair and going to the bathroom in the room • Unable to walk in the hospital hall for a sustained distance of 32 feet (10 meters)* • The rate of VTE in non-ambulatory medical patients without prophylaxis was 19.7% compared to 10.6% in those walking 30 feet* (Amin et al) • ADD2 2 MORE POINTS • Any device placed on the leg of the patient that prevents normal contractions of the calf muscle • Plaster cast, walking boot, leg brace, posterior mold, and crutches with toe touch

12. Familial Risk of Venous Thromboembolism in Relatives* • This study shows an increased VTE risk among not only first-degree relatives but also second- and third-degree relatives and non-biologic relatives • The genetic component of the familial clustering of VTE is strong • Family history is potentially useful for clinical VTE risk assessment, even in second- and third degree-relatives. *(183,515 INDIVIDUALS) ThrombHaemost 2013;109(3)458-63

13. The Value Of Family History As A Risk Indicator For Venous Thrombosis Arch Intern Med. 2009;169(6):610-615 • Relative risk of thrombosis increased with the number of risk factors identified • A combination of a genetic and acquired risk factor resulted in a risk 60- fold higher than for those with no known risk factor and a negative family history • Study showed a positive family history increased the risk of venous thrombosis more than 2-fold, regardless of the risk factors precipitating the thrombosis

14. Usefulness Of Clinical Predictors ForPreoperative Screening Of Deep VeinThrombosis In Hip Fractures Luksameearunothai et al. BMC Musculoskeletal Disorders (2017) 18:208 DOI 10.1186/s12891-017-1582-5 • Prospective study in 92 hip fracture patients screened preoperatively with duplex scans, Caprini score, Wells score, and d-dimer. • The incidence of preoperative DVT was 16.3% (n = 15). • DVT group had a significantly higher Wells and Caprini score compared to the non-DVT group (p < 0.05 all). • Sensitivity and specificity of Wells score ≥ 2, and Caprini score ≥12 points were 47 and 81, and 93 and 35%, respectively. • Sensitivity and specificity of Caprini score ≥ 13 points were 60 and 73%.

15. Usefulness Of Clinical Predictors ForPreoperative Screening Of Deep VeinThrombosis In Hip Fractures Luksameearunothai et al. BMC Musculoskeletal Disorders (2017) 18:208 DOI 10.1186/s12891-017-1582-5 Active smoking, swollen legs or pitting edema were also statistically significant predictors for DVT but not D-dimer (p<0.05) The authors recommend that patients with Caprini score ≥ 12 should be screened with doppler ultrasonography preoperatively. Those with Wells score 0–1 had low risk for preoperative DVT, so the surgery could perform without delay.

16. Validation of the Caprini Risk Assessment Model in the Arthroplasty Patient Study involved 1078 patients having total joint replacement over a 15 month period and were treated according to a Department-wide protocol. Department protocol considered high-risk patients to have one or more of the following criteria: VTE within prior year, morbid obesity (BMI>40) with additional comorbidities, active malignancy, bilateral staged total joint replacement, and inherited or acquired thrombophilia Krauss E.S., et al: ClinApplHemostThromb. 2019, in press

17. Validation of the Caprini Risk Assessment Model in the Arthroplasty Patient Low risk patients were treated postoperatively with aspirin while those considered at high risk received conventional anticoagulation with a DOAC postoperatively. Retrospective Caprini scores were calculated at the end of the study and compared to the results of the Department protocol. Krauss E.S., et al: ClinApplHemostThromb. 2019, in press

18. Validation of the Caprini Risk Assessment Model in the Arthroplasty Patient The 2013 version of the Caprini RAM correctly identified seven of the eight arthroplasty patients who developed a clinical VTE event. The Department protocol correctly identified 1/8 VTE events. This approach was abandoned going forward and the Caprini score adopted department-wide Caprini scores of 10+ merit conventional postoperative anticoagulation, while those patients with a Caprini score of <10 can safely be treated with aspirin postoperatively Krauss E.S., et al: ClinApplHemostThromb. 2019, in press

19. Validation of the Caprini Risk Assessment Model in the Arthroplasty Patient Krauss E.S., et al: ClinApplHemostThromb. 2019, in press

20. Validation Of The Caprini Risk Score For Venous Thromboembolism In High Risk Surgical Patients Lobastov K, Barinov V, Schastlivtsev I, Laberko L, Rodoman G, Boyarintsev V. J Vasc Surg: Venous and Lym Dis 2016;4:153-60. P<0,0001 for trend, chi-squared test 65,0% 26,1% 1,9% All patients had from 5 to 15 Caprini scores and were divided in 3 tertiles 5-8 (n=54), 9-11 (n=46) and 12-15 (n=40)

21. VALIDATION OF THE CAPRINI RISK SCORE FOR VENOUS THROMBOEMBOLISM IN HIGH RISK SURGICAL PATIENTS Lobastov K, Barinov V, Schastlivtsev I, Laberko L, Rodoman G, Boyarintsev V. J Vasc Surg: Venous and Lym Dis 2016;4:153-60. The authors found that a score of 11 or more can identify a subgroup of patients at “extremely high risk” that require a more effective prophylactic regimen in order to prevent thrombosis

22. A New Frontier Pirogov Russian National Research Medical University Lobastov K, Dementieva G, SoshitovaN, Bargandzhiya A, Barinov V, Laberko L, Rodoman G TROMBODYNAMICS

23. Utilization Of The Caprini Score Integrated With A Thrombodynamics Test Reduces The Incidence Of Unpredicted, Postoperative Deep Vein Thrombosis Thromodynamic testing (TD) involves a novel global test of hemostasis that studies the spatial-temporal characteristics of clot formation in real time The test demonstrates a high sensitivity for detecting hypercoagulability. This study compared the 2005 Caprini score to a version of the score modified by the results of TD. Positive TD results were scored as 3 points (other thrombophilia) Integrating TD parameters into the Caprini score increases the ability to predict postoperative VTE Lobastov K, Dementieva G, SoshitovaN, Bargandzhiya A, Barinov V, Laberko L, Rodoman G Presented at the AVF 31st Annual Meeting, Rancho Mirage, Ca: February 19 - 22, 2019 Accepted for publication J Vasc Surg: Venous and Lym Dis 2019

24. Utilization Of The Caprini Score Integrated With A Thrombodynamics Test Reduces The Incidence Of Unpredicted, Postoperative Deep Vein Thrombosis It is known that thrombotic tendencies do run in families* Family history is a risk indicator for a first venous thrombosis in a blood relative having surgery* 29.7% of these patients were found to have a genetic risk factorbut what about the rest of the group?* Thromobodynamic testing may prove valuable in identifying susceptible individuals that can be targeted with more intense anticoagulant prophylaxis to prevent postoperative thrombosis Lobastov K, Dementieva G, SoshitovaN, Bargandzhiya A, Barinov V, Laberko L, Rodoman G Presented at the AVF 31st Annual Meeting, Rancho Mirage, Ca: February 19 - 22, 2019 Accepted for publication J Vasc Surg: Venous and Lym Dis 2019 *Arch Intern Med. 2009;169(6):610-615

25. Complete risk assessment avoids your patient being a stranger regarding health issues Then protect your new friend using appropriate “risk score” based thrombosis prophylaxis