June 25, 2016 Maryland AFP Annapolis, MD. Venous Thromboembolism BEAT THE CLOT

Transcription

1 June 25, 2016 Maryland AFP Annapolis, MD Venous Thromboembolism BEAT THE CLOT

2 Faculty and curriculum development team Our faculty and planners have completed disclosure of interest statements. Drs. Olson and Dressner, and Mss. Shelly Rodrigues, Jerri Davis and Mary Ales declare that in the past 12 months neither they nor any members of their families have had a financial interest in organizations supporting this activity. Dr. Flores declares that in the past 12 months he has David Garcia, MD Hematology and Internal Medicine Professor of Medicine, Division of Hematology University of Washington School of Medicine Christopher Flores, MD Family Medicine Faculty, Loma Linda University School of Medicine Mark Dressner, MD Family Medicine Long Beach, CA Cheri Olson, MD Family Medicine Faculty, La Crosse Mayo Family Medicine Residency Program received Advisory Board honoraria from Aerocrine and ResMed. Dr. Garcia declares that in the past 12 months he has served as a consultant for Boehringer Ingelheim, Bristol Myers Squibb, Daiiichi Sankyo and Pfizer and received research support from Daiichi Sankyo and Janssen. CAFP s Committee on Continuing Professional Development reviews and resolves all COI disclosures.

3 Today s faculty Cheri Olson, MD Family Medicine Associate Director La Crosse Mayo Family Medicine Residency Program Dr. Olson declares that in the past 12 months neither she nor any members of her family have had a relevant financial interest in entities or companies supporting this topic.

4 Sponsors and support This activity is sponsored by the California Academy of Family Physicians. It has been developed as part of the work of the TEAM A Partnership, a 10 organization collaboration seeking to improve the care of patients with AFib and VTE conditions. This initiative is supported by an unrestricted educational grant from Bristol Meyers Squibb/Pfizer.

5 VTE: Beat the Clot Online VTE community for you facilitated by us Private! Secure! Interact, share, learn REQUEST an invitation to join via CME Type yammer in subject line

6 The activity is easy to use, simple to navigate, available in English and Spanish, and offers patients practical information, printable resources and even note taking options! FREE. You simply prescribe EMMI by sending your patients to Interstate Postgraduate Medical Association and CAFP are thrilled to offer you and YOUR patients a terrific VTE education tool. This FREE 15 minute online activity, developed and hosted by EMMI Solutions, is designed by your colleagues to assist patients in understanding, managing and preventing VTEs.

7 Why this topic? Clinicians say they Are uncertain about identifying at risk patients Are concerned about the risk for bleeding Lack complete understanding of the administration of thromboprophylaxis Have challenges with elderly and obese patients Need help individualizing therapy Have questions about length of anticoagulation after an unprovoked VTE

8 Questions for today 1. How do I complete the initial assessment and management? 2. How long do I treat? 3. What about peri operative and peri procedural care?

9 At the end of today you should be able to: 1. Define the short term and long term goals of anticoagulation for VTE. 2. Determine the optimal length of therapy based on clinical factors. 3. Manage anticoagulation around medical procedures and special situations.

10 Why this topic? Think of your last patient with a DVT/PE... A call to action... Cushman M, Creager M. Improving Awareness and Outcomes related to Venous Thromboembolism. JAMA 314(18) Avail at:

11 Initial Assessment and Management

12 Meet Claire Claire is a 49 year old woman She develops unilateral leg pain and swelling 4 days after completing a 10.5 hour air flight. Her heart rate is 86 and her blood pressure is normal. Arterial oxygen saturation is 97 percent on room air (by pulse oximetry).

13 Wells Criteria for DVT Clinical Feature Points Active Cancer 1 Leg paralysis 1 Bedridden > 3 days 1 Local vein tenderness 1 Entire leg swollen 1 Unilateral swelling > 3 cm 1 Unilateral pitting edema 1 Superficial veins 1 Likely alternative 2 s criteria for dvt/ Patients Risk 3 High 75% 1 2 Moderate 17% 0 Low 3%

14 Assuming Claire s diagnosis is correct: The most important next step in the management of this patient is: A. Measure d dimer concentration B. Perform CT angiogram (helical/spiral CT) of the chest C. Administer anticoagulation (in therapeutic doses) D. Administer systemic thrombolysis (IV tissue plasminogen activator) E. Perform pharmaco mechanical thrombolysis (local therapy)

15 As you continue to treat Claire: Which of the following would NOT be an indication for treatment over and above anticoagulation? A. Pulmonary embolism with systemic hypotension and tachycardia, but normal arterial oxygen saturation B. Iliac vein thrombosis with phlegmasia cerulea dolens (possibly compromised circulation) C. Common femoral vein thrombosis greater than 6 cm in length D. Pulmonary embolism with biochemical and echocardiographic evidence of right ventricular strain

16 In case you ve never seen it This is phlegmasia cerulea dolens

17 Distal DVT: What would you do about it? Do you treat the distal DVT? Yes, if: Severe symptoms extends distally extends to proximal veins Has risk factors for extension, or Serial imaging (2 weeks) Risk factors for extension include: Positive d dimer Extensive size (>5cm, multiple veins, >7 mm in diameter) Close to proximal Unprovoked Active cancer History of DVT Inpatient status

18 DVT/PE treatment options You have many options for treatment You must consider the best option for your patient on a case by case basis. Guidelines define acute, long term therapy (3 mo), and extended anticoagulant therapy (indefinite) Acute Phase Thrombolysis and IV Heparin IV Heparin SC LMWH SC UFH Chronic Phase 3 months Warfarin LMWH Direct oral anticoagulants SC fondaparinux Direct oral anticoagulants IVC Filter

19 What are the ACCEPTED indications for... IVC placement? Recent DVT/PE with absolute contraindication to anticoagulants Meyer et al. N Engl J Med 2014;370: Konstantinides S. N Engl J Med 2008;359: tpa in PE? Hypotension, not corrected with volume resuscitation Deterioration (falling BP, increased HR or O 2 requirement) despite AC therapy? Evidence of RV strain ;? Elevated troponin Enden et al. Lancet Jan 7;379(9810):31 8. Vedantham et al. Am Heart J Apr;165(4): tpa in DVT? Compromise of tissue perfusion (dusky, painful, swollen extremity)?ilio femoral thrombosis? long term follow up data suggest reduction of post thrombotic syndrome) More data to come from the ATTRACT trial

20 Does Claire have a PE? Wells Criteria for PE Present Score Clinical Signs and Symptoms of DVT? 3 PE is No. 1 Dx or Equally likely Dx 3 Heart Rate > Immobilization at least 3 days, or Surgery in 1.5 the Previous 4 weeks Previous, objectively diagnosed PE or DVT? 1.5 Hemoptysis? 1 Malignancy with treatment within 6 months, 1 or palliative? Score Risk > 4 PE likely Consider diagnostic imaging 4 or less PE unlikely Consider D dimer to rule out PE hp#pe

21 AC alone vs. AC + filter for a patient with PE A study done by Mismetti et al. JAMA. 2015;313(16): , showed: Clinical Outcomes for Patients with at Least 1 Event in the PREPIC2 Trial Group, No. with Events (%) Clinical Outcomes Filter Group n=200 Control Group n=199 At 3 Months Recurrent pulmonary embolism (primary efficacy outcome) c 6 (3.0) 3 (1.5) Fatal 6 (3.0) 2 (1.0) Nonfatal 0 (0.0) 1 (0.5) Recurrent deep vein thrombosis 1 (0.5) 1 (0.5) Recurrent venous thromboembolism 7 (3.5) 4 (2.0) Major bleeding 8 (4.0) 10 (5.0) Death 15 (7.5) 12 (6.0) At 6 Months Recurrent pulmonary embolism c 7 (3.5) 4 (2.0) Fatal 6 (3.0) 3 (1.5) Nonfatal 1 (0.5) 1 (0.5) Recurrent deep vein thrombosis 1 (0.5) 2 (1.0) Recurrent venous thromboembolism 8 (4.0) 6 (3.0) Major bleeding 13 (6.5) 15 (7.5) Death 21 (10.6) 15 (7.5) 399 Patients randomized 200 Randomized to the retrievable inferior vena cava plus the anticoagulation group (filter group) 199 Randomized to the anticoagulation group alone (control group)

22 Claire Does this information change your treatment of Claire? She has a diagnosis of VTE Is Claire at risk for complications of pulmonary embolism? Can she be treated out of the hospital? Would you assign her high or low risk?

23 What does this mean for Claire? Class 1 Low risk Class 5 Jump on this right now! In a study reported by Jimenez et al Chest 2007 vol. 132(1):P 7 8, of 10,354 patients with 30 day PE risk stratification, 953 died: Class Death PESI I 1.1 ( ) PESI II 3.1 ( ) PESI III 6.5 ( ) PESI IV 10.4 ( ) PESI V 24.5 ( ) The Pulmonary Embolism Severity Index (PESI) Score Multiple screening tools exist to assist you in assigning risk. Predictors B Coefficients Points Assigned (95% C1) Demographic characteristics Age, per year 0.03 ( ) Age, in years Male sex 0.17 (( ) + 10 Co morbid conditions Cancer 0.87 ( ) + 30 Heart failure 0.31 ( ) + 10 Chronic lung disease 0.30 ( ) + 10 Clinical findings Pulse > 110/min 0.60 ( ) + 20 Systolic blood pressure < 100mm Hg 0.86 ( ) + 30 Respiratory rate > 30/min 0.41 ( ) + 20 Temperature <36 C 0.42 ( ) + 20 Altered mental status 1.50 ( ) + 60 Arterial oxygen saturation <90% 0.58 ( ) + 20 Point total and risk classes: < 65=Class I, 66 85=Class II, =Class III, Class IV, >125=Class V Aujesky, D. et al J Respir Crit Care Med. 2005;172,

24 Low risk PE may be treated out of hospital Outcome 90 day Event Rate (95% CI) Recurrent VTE 1.47% (0.47 to 3.0%) Fatal PE 0.47% (0.16 to 1.0%) Major Bleeding 0.81% (0.37 to 1.42%) Fatal ICH 0.29% (0.06 to 0.68%) Pooled analysis of > 1,200 patients with acute low risk PE All were treated as outpatients; 11 studies. Overall Mortality 1.58% (0.71 to 2.80%) Piran et al. Thromb Res Nov;132(5):515 9.

25 Treat PE at Home?? You can treat PE at home when: The patient is clinically stable with good cardiopulmonary reserve (low PESI score) And they DO NOT have: Hypoxia BP <100 systolic Recent bleeding Severe CP Platlet <70,000 PE on anticoagulation medications Severe liver or kidney disease Patients treated at home need: Good social support Ready access to medical care / phone access Well maintained living conditions To be compliant and willing to follow up Feel well enough to manage

26 Is anticoagulation sufficient? Yes/No, why? Can I treat Claire outside the hospital? If Yes. Why, and how? If No. What are the situations that merit in hospital treatment? Discussion questions

27 True positive subsegmental PE High quality CT angiogram Multiple intraluminal defects More proximal subsegmental arteries Defects on more than one image More than one projection Surrounded by contrast rather than adhered Symptomatic vs. incidental High clinical pre test High d dimer

28 Of the following treatments for acute DVT/PE, which does not require an antecedent course of heparin (i.e. can be given as monotherapy from the outset)? A.Dabigatran 150 PO BID B.Rivaroxaban 15 mg PO BID C.Edoxaban 5 mg PO QD D.Warfarin 5 mg PO QD What medication should I prescribe?

29 Traditional Preferred Treatment Plan for Most Patients * Prescribe 5 7 days of injectable anticoagulant (e.g. LMWH 1 mg/kg BID) Prescribe 7 days of warfarin (e.g. 5 mg daily) Arrange appropriate follow up appointments, care and activities *Long term LMWH preferred for cancer associated VTE

30 NOACs for Venous Thrombosis Rivaroxaban Dabigatran Apixaban Edoxaban XARELTO PRADAXA ELIQUIS SAVAYSA 15 mg b.i.d. for 3 weeks then 20 mg once daily Can be used WITHOUT parenteral heparin treatment first 150 mg b.i.d. 5 days of parenteral treatment needed before dabigatran 10 mg b.i.d. for 7 days then 5 mg b.i.d. Can be used WITHOUT parenteral heparin treatment first Daily (60 mg; or 30 mg for renal impairment or low weight) 5 days parenteral (LMWH) treatment needed before edoxaban FDA Approval Status (for VTE) Approved Nov 2012 Approved Apr 2014 Approved Aug 2014 Approved Jan 2015

31 Reasons NOT to treat acute PE/DVT with NOACs Severe renal insufficiency (Cr Cl < 30 ml/min) Weight > 120 kg (264 lbs) or < 50 kg (110 lbs) tpa use contemplated PATIENT CANNOT AFFORD MEDICATION No reversal agent in the case of severe/life threatening bleed Known pro thrombotic state HIT, cancer, antiphospholipid syndrome New Info Clinicians own discomfort using NOACs can also be a barrier to prescribing these agents to patients.

32 Just Approved Reversal Agents Praxbind (idarucizumab) (reverses dabigatran) ncements/ucm htm On fast track for approval: Andexanet Alfa (antidote to factor Xa inhibitors; rivaroxaban, apixaban, edoxaban)

33 Challenges with Warfarin Are there similar challenges with the NOACS? Aspirin? Clopidogrel? Delayed onset/offset Unpredictable dose response Narrow therapeutic range Drug drug, drug food interactions Problematic monitoring INR should be determined at least weekly during initiation and at least monthly when INR is in range and stable Slow reversibility Ansell J, et al. Chest. 2001;119(1 Suppl):22S 38S. Hirsh J, et al. Chest. 2001;119(1 Suppl):64S 94S. January CT, et al. J Am Coll Cardiol. 2014;64(21):e1 76. doi: /j.jacc Epub 2014 Mar 28.

34 Warfarin and the new oral anticoagulants Target Warfarin Coumadin VKORC1 Factors II, VII, IX, X Dabigatran 1 Pradaxa Rivaroxaban 2 Xarelto Apixaban 3 Eliquis Edoxaban 4 Savaysa Thrombin Factor Xa Factor Xa Factor Xa T (max) hours 2 hours hours 3 hours 2 3 hours Half life Monitoring Administration Metabolism Assay 40 hours hours 5 9 hours healthy, 9 13 hours elderly Every 4 weeks or PRN 8 15 hours 8 10 hours Not needed Not needed Not needed Not needed Once daily Twice daily Once daily Twice daily Once daily Cytochrome P450 PT/INR 80% renal, 20% fecal Ecarin clotting time, thrombin time 35% renal 25% renal 35% renal Anti Xa activity Anti Xa activity Anti Xa activity Quick Comparison 1. Connolly SJ, et al. N Engl J Med. 2009;361(12): Patel MR, et al. N Engl J Med. 2011;365(10): Granger CB, et al. N Engl J Med. 2011;365(11): Giugliano RP, et al. N Engl J Med. 2013;369(22):

35 Limitations and concerns Warfarin Dabigatran Rivaroxaban Apixaban Edoxaban Continuous monitoring X Heparin overlap often necessary X Limited experience with reversal X X X X Accumulation in renal dysfunction X X +/ X Lack of experience treating bleeding Limited experience in elderly, obese X X X X X X X X High acquisition cost X X X X Wartak SA, Bartholemew JR. Cleve Clin J Med. 2011;78(10): ; Gulseth MP, et al. Pharmacotherapy. 2011;31(12): ; Patel JP, et al. Br J Haematol. 2011;155(2): ; Connolly SJ, et al. N Engl J Med. 2011;364(9): ; Granger CB, et al. N Engl J Med. 2011;365(11): ; Giugliano RP, et al. N Engl J Med. 2013;369(22):

36 NOACs: Comparing risk of bleeding among different anticoagulant medications This is for Afib, but the bottom line is important! 30 day event rates (%) Trial RE LY ROCKET AF ARISTOTLE Stroke or systemic embolism dabigatran warfarin rivaroxaban warfarin apixaban warfarin Major bleed Healey et al. Circulation Sherwood et al. Circulation Garcia et al. Blood

37 What about increased major bleeding risk? Concomitant Antiplatelet and other meds Advanced Age Prior Major Bleeding Anemia Uncontrolled Hypertension INR variability and target range Alcohol Predominantly derived from data in patients with Atrial Fibrillation. Lip et al. Thrombosis and Hemostasis, :

38 Assessing Bleeding Risk: HAS BLED Score 3 is highly predictive of bleeding events HAS BLED is recommended by major international guidelines HAS BLED Score Bleeds/100 Patients* Any score 1.56 Hypertension Abnormal liver/renal function Stroke history Bleeding predisposition Labile INRs Elderly (>65) Drugs/alcohol use *p=.007 for trend of increasing bleeding risk with increasing score. Lip GY, et al. J Am Coll Cardiol. 2011;57(2): , Omran H, et al. Thromb Haemost. 2012;108(1): Camm AJ, et al. Europace. 2010;12(10): , Caims JA, et al. Can j Cardiol. 2011;27:74 90.

39 In Summary Assess risk Assess bleeding risk Treat as outpatient? How to choose a regimen...

40 Treatment Duration: who needs extended anticoagulant therapy

41 Claire Her original clot was provoked by travel You ve prescribed rivaroxaban She s been under your care for 2 months She s asked how long she has to remain on the medication

42 Clots: provoked or unprovoked Provoked blood clot Unprovoked clot Management and workups different because the RISK is different NO difference any more between treatment lengths for PE or DVT; NO difference based on size of clot

43 Provoked Clots are associated with: Claire s clot caused by extended air travel is a provoked clot. Surgery Estrogen therapy Pregnancy Leg injury Flights of >8 hours Provoked Clots : Better in near term mortality and in long term limb health Little work up or additional testing is needed Stop anticoagulation after the appropriate duration

44 Unprovoked Clots Fare poorly / limb threatening Commonly associated with an underlying condition Need work up According to Bagin, Lancet, 2000, unprovoked clots are nearly 2x more likely to recur as provoked clots. According to Kearon et al. Annals of Internal Medicine, males are at higher risk for recurrence than females.

45 100 patients with first unprovoked DVT

46 One year off anticoagulation medications = recurrent VTE Kearon, et al. NEJM 1999, vol 340. Agnelli, et al. Ann Int Med 2003, vol 139. Ridker, et al. NEJM April, 2003

47 Two years off anticoagulation medications = recurrent VTE Kearon, et al. NEJM 1999, vol 340. Agnelli, et al. Ann Int Med 2003, vol 139. Ridker, et al. NEJM April, 2003.

48 Thrombophilia testing Does testing improve our chance of assessing VTE recurrence? Acquired and inherited factors Acute clot not the time to test Homocysteine level, prothrombin gene mutation, and Factor V Leiden okay Organized approach when stopping antithrombotic agent or soon thereafter.

49 The Thrombophilias Acquired Post operative state/immobilization States associated with increased estrogen Cancer Antiphospholipid antibodies (APLA) Homocysteine (HCY) Paroxysmal noctural hemoglobinuria (PNH) JAK2 mutation Other rare conditions Congenital Factor V Leiden (FVL) Prothrombin gene mutation (PGM) Deficiencies of Protein C, Protein S and Antithrombin III Hyperhomocysteinemia Elevated coagulation factors Dysfibrinogenemia Dysplasminogemia Heparin Cofactor II deficiency (HCII) Platelet receptor polymorphisms Various Single nucleotide polymorphisms (SNP) of unknown function

50 Why should we test? 1. Because the results will influence the intensity of anticoagulation? No evidence in any setting 2. Because the results will influence the duration of anticoagulation? Little evidence, except for specific circumstances 3. Because it might influence future decisions for the patient or their family? Selected patients 4. Curiosity? A legitimate reason IF the patient is fully aware of the implications 5. Because we can or we didn t bother to think about it? The most frequent reason, unfortunately

51 You ve got an APA test how do you interpret it? 1. Most important are those with an LAC + ACA + antiβ2 gpi 2. IgM ACA and IgG ACA are problematic poor laboratory standardization positive predictive value for APS disputed low titer positives are frequent and probably not of clinical significance 3. LAC is a functional assay warfarin and (especially) NOACs can cause false positive Why is this important? In many cases our thrombophilia tests may be inaccurate, particularly in the setting of the use of anticoagulants. Patients/physicians are often falsely re assured by a negative comprehensive thrombophilia panel. Multiple testing positives may mean you should seek a consult for interpretation. False positives in infections, cancer, aging, medications, autoimmune states

52 Want to learn more?

53 Thrombophilia summary Antiphospholipid antibody testing is probably appropriate for many patients with unprovoked VTE More comprehensive testing may be indicated with strong family history Testing may be indicated for selected patients with a high risk of recurrence For example, in some patients with prior VTE who are planning pregnancy

54 Treat Proximal DVT or PE (unprovoked) at least 3 months A Suggested Approach Ensure the patient is up to date on age appropriate cancer screening and perform careful physical exam and review of systems. More extensive testing is not helpful. Discuss risks/benefits of extended anticoagulant therapy with all patients. Encourage extended anticoagulant therapy for patients who: are male have had previous VTE had PE (rather than DVT) as their index event have poor cardiopulmonary reserve have low risk of AC related bleeding Test young patients for antiphospholipid syndrome before permanently discontinuing. Consider d dimer testing if other factors equivocal, patient is female, etc.

55 All cause death no different: 24 Placebo; 21 ASA Becattini et al. N Engl J Med. 2012; 366: Brighton et al. N Engl J Med 2012; 367:

56 WARFASA and ASPIRE: Study designs Median Follow up: 2 years in WARASA 3 years in ASPIRE Study period First ever idiopathic VTE Stop R ASA 100 mg o.d 6 18 months Primary endpoint: Symptomatic recurrent VTE: DVT, fatal or non fatal PE: 0 14 days Placebo Randomized, double blind studies

57 Among patients who have a first unprovoked DVT/PE, the annual risk of recurrence is 8 12% during the first 2 3 years after stopping warfarin. Compared to no treatment, low dose aspirin can reduce the risk of recurrence. Well controlled anticoagulation significantly eliminates the risk of recurrence in patients without cancer. Summary of treatment duration

58 Peri Operative and Peri Procedural Care

59 Claire She s been under your care for 2.5 months She is still taking the AC medication as prescribed She recently had a gall bladder attack She is now scheduled to have the gallbladder removed

60 What is Claire s bleed risk? Is Claire at HIGH risk for a bleed during the procedure? Higher risk surgeries for bleed Urological Pacemaker Large colonic polyps Bowel Extensive tissue injury Pericardial/intracerebral/epidural Lower risk surgeries for bleed Minor dental Derm Cataract

61 Risk for VTE High Risk Recent VTE 0 3 months Severe thrombophilia Moderate Risk VTE 3 12 months Non severe thrombophilia Recurrent VTE Active cancer Low Risk VTE > 12 months and no other risk factors

62 For patients on Warfarin Most can simply interrupt without bridging Bridging increases the risk of bleeding and likely has no benefit for any patient except those at the highest risk of thrombosis Clark NP. JAMA Intern Med Jul;175(7): Douketis J. NEJM (this is a study of AF pts but shows that bridging clearly increases the risk of post procedure bleeding)

63 Is bridging necessary? These questions are important as family physicians complete pre op physicals. Should I consider alternative anticoagulants during the postoperative period when risk of bleeding is high or if postoperative bleeding occurs? How long do I hold patients on anticoagulation medications? Some patients may need bridging AFTER but not BEFORE... Less bridging with NOACs due to shorter half life. Half life Warfarin Coumadin Dabigatran 1 Pradaxa Rivaroxaban 2 Xarelto 40 hours hours 5 9 hours healthy, 9 13 hours elderly Apixaban 3 Eliquis Edoxaban 4 Savaysa 8 15 hours 8 10 hours

64 Many procedures can be performed safely without NOAC interruption Need more data to select patients and procedures For patients whose procedure requires interruption hours likely sufficient if renal function normal Longer interruptions if renal impairment and/or high risk procedure More data anticipated from P.A.U.S.E.* Prospective cohort study with standardized interruption schedule Individualized decision making required! Procedures and interruptions summary * NCT

65 She had an uncomplicated provoked DVT. She was treated with a NOAC for three months. During her treatment she had her gallbladder removed with no issues. Claire is no longer taking AC medications and is flying to Barcelona to meet her family for her 50 th birthday celebration! Claire has ongoing questions about DVTs and is excited to use the EMMI Solutions resource recommended by her family physician to learn more about prevention. How is Claire?

66 Tools and resources are available January 07, 2016 Kearon C, Akl EA, Ornelas J, et al. Antithrombotic Therapy For VTE Disease: Chest Guideline Published online. doi: /j.chest

67 VTE: Beat the Clot Online VTE community for you facilitated by us Private! Secure! Interact, share, learn REQUEST an invitation to join via CME Type yammer in subject line

68 The activity is easy to use, simple to navigate, available in English and Spanish, and offers patients practical information, printable resources and even note taking options! FREE. You simply prescribe EMMI by sending your patients to Interstate Postgraduate Medical Association and CAFP are thrilled to offer you and YOUR patients a terrific VTE education tool. This FREE 15 minute online activity, developed and hosted by EMMI Solutions, is designed by your colleagues to assist patients in understanding, managing and preventing VTEs.

69 Thank you