Venous Thromboembolism Prophylaxis - Why Should We Care? Harry Gibbs FRACP FCSANZ Vascular Physician The Alfred Hospital

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1 Venous Thromboembolism Prophylaxis - Why Should We Care? Harry Gibbs FRACP FCSANZ Vascular Physician The Alfred Hospital

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4 VTE is common and dangerous

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6 VTE is Common VTE Incidence: 1.5 / 1000 per year 2/3 DVT; 1/3 PE Prevalence of 1% by age 40 years

7 PE is Dangerous Pulmonary embolism 25% sudden death 5% further 7 day mortality with anticoagulation 30% 1 week mortality

8 All autopsies at University of Michigan Medical Center from 1964 to % autopsy rate; 4600 autopsies Relationship to Death PE found in 12.3% Sole immediate cause 4.4% Contributory 2.7% Minor 5.3%

9 DVT is Dangerous Post thrombotic syndrome 60% following symptomatic DVT 10% with disabling symptoms 4% develop venous ulcers

10 VTE Treatment is Dangerous 3 months of anticoagulation for provoked VTE LMWH or UFH followed by warfarin Major bleeding in 5% Inconvenient Costly

11 VTE Cases Working age 43% Deaths 5285

12 Access Economics 2008

13 VTE is Common and Dangerous Pulmonary embolism most deaths occur before treatment can be started Post thrombotic syndrome high incidence in spite of anticoagulation Treatment Potentially dangerous and difficult VTE prevention is the only way to reduce its complications

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16 VTE is Preventable

17 VTE prophylaxis Identify those at risk and prescribe prophylaxis for them

18 VTE Attributable Risk Spencer Arch Int Med 2007 Heit Clin Chest Med 2003

19 Risk Factors for VTE Disease or surgery related Patient related Risk factors are additive

20 Surgical VTE Rates Incidence of symptomatic venous thromboembolism after different elective or urgent surgical procedures White Thromb Haemost ,653,275 cases undergoing 76 different surgical procedures 3 month rate of VTE recorded

21 Symptomatic VTE in Surgery Procedure Lower limb embolectomy or endarterectomy VTE Rate 2.8% Hip arthroplasty 2.4% Invasive neurosurgery 2.3% Knee arthroplasty 1.7% 56% of VTE cases occurred after hospital discharge White Thromb Haemost 2003

22 VTE and Malignant Surgery Procedure VTE Rate Radical cystectomy 3.7% Invasive neurosurgery 3.6% Hip arthroplasty 3.1% Internal fixation femur 3.0% Partial hip arthroplasty 2.8% Permanent colostomy 2.6% White Thromb Haemost 2003

23 Disease Related Risk Factors Condition VTE rates Active cancer 60% Stroke 56% Decompensated heart failure 26% Myocardial infarction 26% Acute respiratory disease 25% Acute rheumatic disease 20% Acute infectious disease 16% Myeloproliferative disorders? Inflammatory bowel disease?

24 Patient Related Risk Factors Risk Factor Odds ratio Prior VTE 15 Immobilisation 6 Varicose veins 5 OCP / HRT 3 Obesity 2 Advanced age 2

25 VTE and Hospitalisation VTE is a common complication of hospitalisation Hospitalisation is the commonest cause of VTE VTE prevention should be optimised during hospitalisation

26 VTE Prevention VTE is preventable Prophylaxis reduces VTE

27 VTE Prophylaxis Types of prophylaxis Pharmacological Aspirin Graduated compression stockings Unfractionated heparin Intermittent pneumatic compression Low molecular weight heparin device Warfarin Foot compression device Danaparoid Lepirudin Fondaparinux Rivaroxaban Dabigatran Apixaban Mechanical

28 Efficacy of Anticoagulant Prophylaxis Collins R, et al. N Engl J Med 1988,318:

29 Efficacy of GCS

30 Goals Risk assess all adult, medical and surgical acute care patients Prescribe appropriate prophylaxis

31 First the patient must recover from the disease, then he must recover from the medicine - Osler

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33 Appropriate Prophylaxis Prescription of prophylaxis appropriate to patient risk, and presence of contra-indications

34 Appropriate Prophylaxis High risk surgical Anticoagulant and mechanical, or Anticoagulant if contra to mechanical, or Mechanical if contra to anticoagulant, or Nothing if contra to anticoagulant and mechanical High risk medical Anticoagulant, or Mechanical if contra to anticoagulant, or Nothing if contra to anticoagulant and mechanical

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36 Study Population Number Baseline audit 4399 Post intervention audit 4375 Total 8774

37 Appropriate Prophylaxis In High Risk Patients Appropriate Prophylaxis Baseline 38% Post intervention 54% Absolute improvement 16% (12 21%) p <0.001

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39 There are more things in Heaven and Earth, Horatio, Than are dreamt of in your philosophy

40 There is a lot more to understand and do

41 Some Challenges Better risk identification?genetic testing?racial differences?biomarkers?other things

42 VTE In Asia Racial differences may exist due to Differences in the incidence of VTE Differences in the risk of bleeding Due to Genetic, Dietary, Environmental and/or Social factors

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44 Bleeding In Asians Higher rate of bleeding with warfarin VKORC1 polymorphism More bleeding with heparin for PCI in Asians

45 Am J Cardiol 2010

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48 Jupiter healthy subjects LDL <3.4 and elevated CRP Randomised to rosuvastatin or placebo Median follow-up 1.9 years

49 Jupiter Rosuvastatin Placebo HR Unprovoked VTE Provoked VTE All VTE

50 Novel Risk Factors Depression Body height Leg length Diet Coffee

51 25,964 subjects aged years Enrolled ; followed to 2007 VTE incidence 1.56 / 1000 per year HR Often depressed 1.59 ( ) Often happy 0.60 ( ) Often lonely 1.29 ( )

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55 VTE - Why should we care Common and dangerous Preventable The challenge to improve knowledge and practice