Venous Thromboembolism Prophylaxis for Medical Inpatients

1. Venous Thromboembolism Prophylaxis for Medical Inpatients Dennis Whang 4/2/12 DSR2 Mini Lecture

2. Objectives • Recognize the morbidity and mortality with venous thromboembolism of inpatients • Determine the risk of VTE for each nonsurgical inpatient admitted • Decide the VTE prophylaxis for each nonsurgical inpatient admitted

3. Background • Most medical inpatients are at risk for venous thromboembolism (VTE): • Deep venous thrombosis (DVT) • Pulmonary embolus (PE) • 25% of all VTE cases occur during hospitalization • 50-75% of VTE cases occur on medical service • 5-10% of inpatient deaths are due to PE • Heparin prophylaxis has NOT shown to decrease risk for inpatient mortality • However it has shown to decrease the incidence of PE

4. Deciding VTE Prophylaxis • Must weigh TWO factors before deciding ppx • VTE Risk • Bleeding risk

5. VTE Prophylaxis Guideline • Risk of VTE • Low risk if all 3: • Younger than 40 • Mobile • No thrombotic risk factors • Moderate risk: All other patients • High risk: ICU patients • High Bleeding Risk • Active gastroduodenal bleed • Bleeding within 3 months prior to admission • Platelet count of < 50

6. Thrombotic Risk Factors for VTE • Obesity: BMI > 30 • Smoking • Immobility • Malignancy • Previous VTE • Placement 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

7. Mechanical VTE Prophylaxis • Intermittent pneumatic compression • Contraindicated in leg ischemia from peripheral vascular disease • Ineffective in prevention of VTE • Graduated compression stockings • Venous foot pumps

8. Pharmacological VTE Prophylaxis • Low dose unfractionated heparin (UFH) • 5,000 units SQ TID • Low molecular weight heparin (LMWH) • Enoxaparin (Lovenox) 40 mg SQ daily • Do NOT use if CrCl < 30 ml/min

9. What VTE prophylaxis would you use? • A 62 yo F is admitted for community acquired pneumonia. No prior history of VTE, bleeding, hepatic, or renal failure. Her platelet count is 200. • Moderate risk of VTE • Low risk of bleeding • VTE ppx: unfractionated heparin or enoxaparin

10. What VTE prophylaxis would you use? • A 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. • Low risk of VTE • Low risk of bleeding • VTE ppx: early ambulation

11. 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. • High risk of VTE • Low bleeding risk • VTE ppx: unfractionated heparin or enoxaparin

12. What VTE prophylaxis would you use? • A 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. • Moderate risk for VTE • Low bleeding risk • VTE ppx: unfractionated heparin

13. VTE Prophylaxis Guideline • Risk of VTE • Low risk if all 3: • Younger than 40 • Mobile • No thrombotic risk factors • Moderate risk: All other patients • High risk: ICU patients • High Bleeding Risk • Active gastroduodenal bleed • Bleeding within 3 months prior to admission • Platelet count of < 50

14. Summary • Be aware of VTE in all hospitalized patients • Assess risk of VTE with every admission • Use pharmacologic prophylaxis with heparin for patients with moderate to high risk of VTE • If pharmacologic prophylaxis is contraindicated due to high risk of bleeding, use intermittent pneumatic compression • Do not use compression stockings

15. References • Guyatt GH, et al. Executive Summary : AntithromboticTherapyandPreventionofThrombosis, 9th ed: American College ofChestPhysiciansEvidence-Based Clinical Practice Guidelines. Chest 2012;141;7S-47S. • Francis, CW. ProphylaxisforThromboembolism in Hospitalized Medical Patients. N Engl J Med 2007;356:1438-44. • Pineo GF. Preventionofvenousthromboembolicdisease in medicalpatients. UpToDate, Mar 2012. • Qaseem A, et al. VenousThromboembolismProphylaxis in HospitalizedPatients: A Clinical Practice Guideline Fromthe American College ofPhysicians. Ann Intern Med. 2011;155:625-632.