1 / 29

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.

kermit-cameron
Download Presentation

Prophylaxis of Venous Thromboembolism

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Prophylaxis of Venous Thromboembolism Dr Galila Zaher Consultant Hematologist MRCPATH

  2. 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 thrombo-prophylaxis .

  3. 85% of all medical patients admitted to an acute care hospital are eligible and/or suitable for DVT prophylaxis

  4. 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.

  5. MECHANICAL PROPHYLAXIS • GENERAL MEASURES . • Compression stockings especially when heparin prophylaxis is contraindicated. (grade A)

  6. 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)

  7. ANTICOAGULANTS • Heparin not routinely in addition to aspirin in acute MI, but reserved for patients at increased thromboembolic risk (grade A)

  8. High risk of thromboembolism • 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)

  9. 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)

  10. Acute stroke • Asymptomatic DVT 50% of acute hemiplegic stroke. • Clinically apparent DVT or PE <5%. • PE may account for up to 25% of early

  11. General measures • Early mobilization and hydration . • Meta-analysis of haemodilution : VTE was reduced, despite lack of overall benefit.

  12. 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 .

  13. ASPIRIN • Significant decrease in death or dependency. • Aspirin significantly reduced PE from 0.5% to 0.3%. • Aspirinis 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.

  14. 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 .

  15. 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

  16. 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 • Aspirinas 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

  17. 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

  18. 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

  19. 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)

  20. 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.

  21. Thrombo-prophylaxis in medical patients • 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)

  22. MECHANICAL METHODS • Significant risk of VTE :prophylaxis is contraindicated, GECS may be considered.  (grade C)

  23. 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.

  24. 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

  25. 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.

  26. 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,

  27. The majority of fatal PE have not undergone recent surgery.

  28. MEDENOX :confirmed the effectiveness of enoxaparin in preventing VTED in medical patients. • In PRIME: enoxaparin versus heparin new VTE 0.2% and 1.4% .

  29. Ageno et al. 112 patients with clinical indications for VTE prophylaxis without contraindications to anticoagulation prophylaxis was underprescribed. • only 46.4% received thromboprophylactic treatment.

More Related