MEDICAL THROMBOPROPHYLAXIS

MEDICAL THROMBOPROPHYLAXIS:A CASE &DISCUSSIONANDOur experienceof Established DVT&VTEDrH.GANESHHOD(Dept. of Med.)ESIHospital,KKNagar,Chennai : 

MEDICAL THROMBOPROPHYLAXIS:A CASE &DISCUSSIONANDOur experienceof Established DVT&VTEDrH.GANESHHOD(Dept. of Med.)ESIHospital,KKNagar,Chennai

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Madhavan 72 yr male admitted on 24/9/07 Known case of HT/COPD for 10 years on Rx Presented with h/o of giddiness,followed by fall followed by weakness of R Half of the body. He also c/o of ing breathlessness,cough with greenish sputum and low grade fever for 2days. Following the fall he sustained multiple minor scratch injuries over his shoulders and knees.

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No other relevant facts in the present,past,family history. He was a smoker for about 15 yrs and quit smoking 3 years back.

O/E : 

O/E Afebrile Dyspneic BP:140/90 P/R:100/mt,reg. RR:34 Chest:B/L AirEntry,low pitched rhonchi,crepts in scattered areas. CNS:Concious,oriented;HMF,Cranial Ns:WNL, Motor exam:power:Rt Hemiplegia with 1/5 power and Rt Plantar extensor All other relevant examination did not reveal any abnormal findings.

:Rt Hemiparesis( ?infarct)/A/E of COPD,Chest infectionHT( Controlled) : 

:Rt Hemiparesis( ?infarct)/A/E of COPD,Chest infectionHT( Controlled) VTE RISK FACTORS FOR THIS PATIENT (IUA) RISK SCORE AGE >65 2 STROKE WITH POSSIBLE IMMOBILITY>4 DAYS 3 INFECTION 1 A/E ON COPD 2 Total Score 8

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Routine blood investigations :WNL CXR consistent with COPD ECG :WNL CT Brain:A small infarct in Lt Corona Radiata;no edema/mass effect. O2 SATURATION:93%

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After R/O Hemmorrhage,Massive infarction in CT Scan(which only showed a small infarct in Lt CoronaRadiata) and the other contra-indications ,medical thromboprophylaxis started on D3 with Inj Dalteparin 2500 u s/c od.,along with Rx for the other medical conditions.

WHAT IS Medical Thromboprophylaxis? : 

WHAT IS Medical Thromboprophylaxis? ACCP CONSENSUS CONFERENCE 2004 “In acutely ill medical patients admitted with Congestive Heart Failure or Severe Respiratory Disease or who are confined to bed AND have one or more additional risk factors including Active cancer,Previous DVT,Acute Neurological Disease or Inflammatory Bowel Disease

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PROPHYLAXIS WITH Unfractionated Heparin(UHF)-(Grade-IA) or Low MolecularWeight(LMWH)-(Grade-IA) is recommended. In whom there is contra-indication to pharmocological prophylaxis, use of mechanical prophylaxis with Graduated Compression Stockings(GCS) or Intermittent Pneumatic Compression(IPC)-(Grade-IC+) is recommended.”

WHAT ARE THE MECHASNISMS OF VTE IN MEDICAL PATIENS : 

WHAT ARE THE MECHASNISMS OF VTE IN MEDICAL PATIENS Congestive Heart Failure: Passive congestion in veins and venous stasis, Use of diuretics viscosity Severe Infections: Activation of complement cascade leading to a hypercoagulable state, Thrombocytosis, AntiThrombin III

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Acute MI : Activation of coagulation system, immobilisation, venous stasis Cancer : Tissue Factor expression, Cancer Procoagulant , Platelet Activation, Inflammatory response:complement Immobilisation >72hours : venous stasis venous dialation blood viscosity activation coagulation factors

IN PRACTICE : 

IN PRACTICE All the admitted medical patients, who are likely to be bed ridden for at least 4daysin are to be considered for TP,in the absence of absence of absolute contra-indications.

RISK ASSESMENT(IUA 2006) : 

RISK ASSESMENT(IUA 2006)

PREDISPOSING RISK(Score) : 

PREDISPOSING RISK(Score)

MEDICAL TP IS RECOMMENDED if : 

MEDICAL TP IS RECOMMENDED if TOTAL SCORE IS6 with at least 3 from exposing risk category.

THRIFT II GUIDELINES : 

THRIFT II GUIDELINES MAJOR MEDICAL ILLNESS: SEVERE HEART DISEASE/LUNG DISEASE/INFLAMMATORY BOWEL DISEASE;ACTIVE CANCER DVT:10-40%, PROXIMAL DVT :1-10% FATAL PE: 0.1-1.0% DVT PROPHYLAXIS DEFINETELY INDICATED

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MAJOR ILLNESS +THROMBOPHILIA/PREVIOUS DVT/PE ABSOLUTE INDICATION FOR PT

WHY is thromboprophylaxis important in seriously ill medical patients : 

WHY is thromboprophylaxis important in seriously ill medical patients TO PREVENT PULMONARY EMBOLISM WHICH IS A CAUSE OF DEATH IN 10% OF SUCH PATIENTS 75% OF FATAL PULMONARY EMBOLI OCCUR IN MEDICAL(ie Non Surgical)CASES MANY OF THESE DEATHS ARE PREVENTABLE

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THE CAUSE OF THIS PE IS VENOUS THROMBOSIS WHOSE INCIDENCE IS REPORTED TO BE AS HIGH AS 13.6% AT DAY21 IN UNTREATED PATIENTS IN ONE STUDY(MEDENOX 2004) THE PATIENTS WHO DEVELOP VTE FOLLOWING AN ACUTE MEDICAL DISEASE(AS COMPARED TO SURGICAL PATIENTS) HAVE MORE SEVERE PRESENTATION AND A SIGNIFICANTLY WORSE OUTCOME(MONREAL ,JOTH 2005)

HOW HAS MEDICAL TP HELPED IN THESE SICK PATIENTS : 

HOW HAS MEDICAL TP HELPED IN THESE SICK PATIENTS INCIDENCE OF DVT (SYMPTOMATIC& ASYPMTOMATIC) p value <0.001 (PREVENT,MEDENOX,EXCLAIM STUDIES) .INCIDENCE OF PE (SYMPTOMATIC&ASYMPTOMATIC) pvalue >0.05 (PREVENT,MEDENOX)

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MORTALITY.p value<0.001 (AJHS STUDY 2006)

PREVENT STUDY(2004)NO OF PATIENTS(2991) : 

PREVENT STUDY(2004)NO OF PATIENTS(2991) MEDICAL CONDITIONS INCLUDED CONGESTIVE HEART FAILURE (CLASSIII/IV)-52% ACUTE RESPIRATORY FAILURE -30% ACUTE CONDITIONS INFECTIOUS DISEASES 36% INFL. BOWEL DISEASE,RHEUM.DIS. LUMBAR PAIN , ARTHRITS OF LEGS ETC 4%

MEDENOX STUDYNO.OF PATIENTS:722 : 

MEDENOX STUDYNO.OF PATIENTS:722 MEDICAL CONDITIONS INCLUDED Congestive Heart Disease Class III/IV -34% Acute Respiratory Failure -53.5% Ac.Infectious Diseases -53.1% Inf. Bowel Disease -0.5% Rheumatic Disorders -9.1%

PREVENT STUDYInj Dalteparin 5000U-104DAYS : 

PREVENT STUDYInj Dalteparin 5000U-104DAYS

MEDENOX STUDYINJ. ENOXAPARIN 40MG -72DAY : 

MEDENOX STUDYINJ. ENOXAPARIN 40MG -72DAY

Thromboprophylaxis in Medically Ill Patients at risk of VenousTE(Am.J of HealthSyst.PharmacologyDec2006) : 

Thromboprophylaxis in Medically Ill Patients at risk of VenousTE(Am.J of HealthSyst.PharmacologyDec2006) RETROSPECTIVE STUDY 2367362 ELIGIBLE MEDICAL CASES DISCHARGE SUMMARIES FROM 500 HOSPITALS IN US; MORTALITY &COST BENEFITS COMPARED BETWEEN THE GROUP THAT HAD RECEIVED Medical TP vs No Prophylaxis

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ONLY 30.3% OF ELIGIBLE PATIENTS RECEIVED TP MORTALIY BENEFITS SEEN ACROSS ALL LISTED CONDITIONS. IN ISCHEMIC STROKE ,MORTALITY BENEFITS DON’T REACH SIGNIFICANT LEVELS VERY LARGE STUDY WITH SIGNIFICANT IMPLICATIONS:IT ESTABLISHES MORTALITY BENEFITS

OTHER STUDIES : 

OTHER STUDIES EXCLAIM: Extended TP –287DAYS ,Enox,to late onset VTE ARTEMIS:TP with Fondaparinux VTE PRIME :Hemorrhagic complications less with LMWH(Enox.) than UFH

CONTRAINDICATIONS TO TP : 

CONTRAINDICATIONS TO TP Active GI Bleed Cerebral Hemorrhage/Very Large Infarct Advanced CKD Hepatic Insufficiency BleedingDisorder/Thrombocytopenia Malignant HT/ Recent Injury/operation in HEENT HT/DM Retinopathy Bact.Endocarditis/HIV

RECOMMENDED DRUGS : 

RECOMMENDED DRUGS COMMONLY USED UHF 5000U S/C TDS ENOXAPARIN 40 mg S/C OD DALTEPARIN 5000U S/C OD OTHERS FONDEPARINUX PARNAPARIN

DURATION : 

DURATION MOST STUDIES RECOMMEND 104Days EXCLAIM STUDY: 28 7Days

BLEEDING COMPLICATIONS OF THERAPY vs PLACEBO : 

BLEEDING COMPLICATIONS OF THERAPY vs PLACEBO PREVENT STUDY: MAJOR BLEED :0.49% vs 0.16% MINOR BLEED :1.03% vs 0.55% MEDENOX STUDY: MAJOR BLEED: 1.17%vs 1.1% MINOR BLEED:10.9% vs 7.5%

Bleeding complications of LMHW vs UFH : 

Bleeding complications of LMHW vs UFH PRIME STUDY: MAJOR BLEED:0.4% vs 1.5% ALL BLEED: 3.1% vs 7.1%

HOW MANY ELIGIBLE PATIENTS RECEIVE TP : 

HOW MANY ELIGIBLE PATIENTS RECEIVE TP MERE 27-32% EVEN IN US DVT REGISTRY(JTH 2003): <1/3 MEDICAL PATIENTS RECEIVED TP IMPROVE 2(JTH 2004) : MOST ACUTELY ILL MEDICAL PATIENTS DO NOT RECEIVE TP AJHSP 2006 STUDY: ONLY 30.3% OF ELIGIBLE PTS RECEIVED TP

WHAT ARE THE REASONS FOR THE POOR IMPLEMENTATION OF TP : 

WHAT ARE THE REASONS FOR THE POOR IMPLEMENTATION OF TP 1.Lack of awareness and incorrect belief that VTE is uncommon and anticoagulation is unwarranted.The reason for this misconception is VTE in a majority of cases is silent and hence underdiagnosed. 2.UndueAnxiety about bleeding complications. 3.Costs:Since this a primarily a preventive measure,there is a misconception that this cost of TP is unnecessary.

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4.Multiplicity of medical conditions along with contraindications in the same patient make the choice of TP difficult.25% of the indicated patients eliminate themselves because of compelling contraindications. 5.Different studies have included different inclusion criteria .For example AcMI included in AJHSP Study but not in PREVENT or MEDENOX Studies or in the ACCP Guidelines. 6.Incidence of VTE is heterogenous in that:stroke :56%,spinal cord disease:75%,cancer:50%,MI:25%,OTHERS:15%

WHAT IS THE MESSAGE : 

WHAT IS THE MESSAGE IN THE INDICATED PATIENTS WHO ARE LIKELY TO BE BEDRIDDEN FOR AT LEAST 4DAYS WITHOUT CONTRA INDICATIONS MEDICAL THROMBOPROPHYLAXIS IS RECOMMENDED AND THE ANXIETY OF THE PHYCISION ABOUT BLEEDING COMPLICATIONS IN THIS SELECTED SET OF PATIENTS NEEDS TO BE ALLAYED IN THE LIGHT OF EVIDENCE AVAILABLE .

What we plan to follow : 

What we plan to follow IUA 2006 RISK ASSESMENT GUIDELINES UHF/DALTEPARIN/ENOXAPARIN for 7-14days in indicated medical patients

Our Experience of Established DVT & VTE(2007-08) : 

Our Experience of Established DVT & VTE(2007-08) 5 CASES OF DVT 2 CASES OF ?PE FOLLOWING DVT DUE TO PUTTUR KATTU 2 CASES OF CORTICAL VEIN THROMBOSES :ONE PUERPARIUM RELATED,ONE DUE TO PROTEIN S DEFICIENCY

PROTOCOL FOLLOWED FOR VTE (STANDARD) : 

PROTOCOL FOLLOWED FOR VTE (STANDARD) DVT(ACUTE/ SUBACUTE PHASE):HEPARIN 10000 STAT S/C,5000 QID ALONG WITH ACITROM 4MG OD. PT(INR)/APTT DONE ON DAY 3 ; INR2-3:HEPARIN STOPPED.ADJUST DOSE OF ACITROM TO ACHIEVE THIS. CHRONIC :CONTINUE ACITROM WITH DOSE ADJUSTMENTS TO MAINTAIN INR:2-3 FOR A PERIOD OF 6 WKS-3MONTHS.

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MASSIVE DVT/PE:IV HEPARIN 10000U STAT FOLLOWED BY IV INFUSION 1000-1500U/HR –5-7DAYS.

INVESTIGATIONS( usually after 3 months;acitrom stopped during investigations) : 

INVESTIGATIONS( usually after 3 months;acitrom stopped during investigations) Coagulation Screen:APL,ACL,ANA,HOMOCYSTEINE Cancer screening Detailed family history

Special situations : 

Special situations PREGNANT:CONTINUE UFH AS ACITROM IS CONTRAINDICATED. SITUATIONAL:6WKS TO 3 MONTHS THROMBOPHILIA: LIFELONG RECURRENT DVT: MINIMUM 1 YR PE: MINIMUM 6 MONTHS MASSIVE PE: LIFELONG CKD ADVANCED:UFH PREFERRED ACTIVE CANCER:HEPARINS PREFERRED