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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.

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Prophylaxis of Venous Thromboembolism

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  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.

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