IMPROVING PATIENT SAFETY Preventing & Managing Venous Thromboembolism Session 8 Data Driving Strategies for VTE Prevention and Management 3/30/2012; 15.35-15.55 Symptomatic Venous Thromboembolism after Total Hip/Knee Replacement: A Population-based Taiwan Study Pao-Hsien Chu, M.D., F.C.C.P., F.A.C.C., F.E.S.C. Department of Cardiology, Chang Gung Memorial Hospital School of Medicine, Chang Gung University Taipei, Taiwan
A Population-based Taiwan Study Incidence of the VTE in Asia Symptomatic VTE after Total Hip/Knee Replacement
Symptomatic VTE Venous Thromboembolism (VTE) Deep vein thrombosis (DVT) Pulmonary embolism (PE) Diversity of methodologies Symptomatic Asymptomatic
Prevention and Treatment Circulation 2010, 121:2146-2150; Thromb Haemost 2010; 104: 432 439
Prevention and Treatment Anticoagulant deficiencies Factor V Leiden Prothrombin 20210A Genes + + Intrinsic Thrombosis Risk Acquired Risk Factors Age Previous VTE Cancer Obesity Varicose Veins Hormone Treatments Prophylaxis VTE + Triggering Factors Pregnancy Surgery Immobilization Trauma Air Travel Thrombosis Threshold Circulation 2010, 121:2146-2150; Thromb Haemost 2010; 104: 432 439
Thromboembolism Differences between West and East In Western countries the incidence of VTE 71 117 per 100,000 each year Much lower in Taiwanese populations of VTE 15.9 per 100,000 each year Circ J. 2011 Jul 25;75(8):1998-2004; J Thromb Haemost. 2010;8:1515-1523; J Thromb Haemost. 2005;3:2664-2670
Thromboembolism Differences between West and East Short-term mortality rates were still high in specific populations. The overall 1-month mortality rate 8.8% 7.1% in deep venous thrombosis 12.9% in pulmonary embolism Circ J. 2011 Jul 25;75(8):1998-2004; J Thromb Haemost. 2010;8:1515-1523; J Thromb Haemost. 2005;3:2664-2670
Thromboembolism Differences between West and East Prognosis in Taiwan Independent predictors of 1-month death pulmonary embolism cancer neurologic disease with extremity paresis or paralysis older age longer hospital stay major abdominal and thoracic surgery within the 3 months Circ J. 2011 Jul 25;75(8):1998-2004
Incidence of VTE in Asia Trauma studies Author/Year People Nature Diagnostic modality DVT, % Symptomatic PE Hip fractures Prospective Venography 47.9 0 Traumatic fracture- Tianjin Ortho Hosp Prospective Duplex 12.4 ND Pelvi-acetabular fracture Prospective Venography/ CTPA 28.6 17.9 Asian VTE guidelines: Prevention of Venous Thromboembolism (VTE)
Incidence of VTE in Asia General surgery and colorectal surgery Author/Year People Liew, 2003 Asia Sakon, 2006 Japan Oh, 2008 Asia Lee, 2001 Chinese Shukla, 2008 Japan Nature Diagnostic modality DVT, % Symptomatic PE Review Venography 3-28 - Duplex Prospective Venography 23.7 0.6 MCT (2.9) Retrospective Duplex 5.3 - CTA Symptomatic Prospective Duplex 41.7 0 2 Symptomatic Prospective Duplex Control-0 0 RCT Dalteparin-0 Asian J Surg 2003; 26: 154 158. Asian VTE guidelines: Prevention of Venous Thromboembolism (VTE)
Incidence of VTE in Asia Intensive care studies Author/Year Nature Diagnosis DVT, % Symptomatic PE Joynt, 2009 Chines, HK Prospective Duplex 19.0 0 Wilasrusmee, 2009 Thailand Prospective Duplex 10.5 0 Asian VTE guidelines: Prevention of Venous Thromboembolism (VTE)
Incidence of VTE in Asia Gynaecology and Obstetrics studies Author Year Chan, 2001 Hong Kong Chan, 2002 Hong Kong Chisaka, 2004 Japan Chan, 2005 Hong Kong Nature Diagnostic modality DVT Symptomatic PE Retrospective Duplex, 1.88/1000 0.02/1000 Venogram, Autopsy Retrospective Duplex, 5.1/1000 0.03/1000 Venogram Retrospective V/P scan, ND 0.03/1000 Pulmonary arteriography, Autopsy Prospective Duplex 0 0 Asian VTE guidelines: Prevention of Venous Thromboembolism (VTE)
Incidence of VTE in Asia Medical patients Author/Year People Nature Diagnostic modality DVT, % Symptomatic PE Cheng, 2004 Chinese, HK Leung, 2006 HK Aniwan, 2010 Thailand Sharma, 2009 India Ng, 2009 Singapore Cheng, 2011 Chinese, HK Retrospective Duplex 0.3 ND Retrospective Duplex 0.3 ND Prospective Duplex 0.59 0.28 Prospective Duplex 3.1 0 Review Duplex 0.45 - Retrospective Duplex 1.7-2.0 - Asian VTE guidelines: Prevention of Venous Thromboembolism (VTE)
Incidence of VTE in Asia Orthopaedic epidemiology studies Name Nature Diagnostic modality DVT, % Symptomatic PE, % Critical appraisal Review Venogram, 10-60 - Duplex Overview Review Venogram, THR-16, 1.4 Duplex TKR-50 SMART Prospective Venogram *0.9 0.3 SMART venography study AIDA Korean CTPA /CTV Prospective MC study Venogram THR-16.4 TKR-49.0 Prospective MC study Venogram THR-25.6 TKR-58.1.0 Prospective CTPA/CTV 1THR-8.7 TKR-40.4 Asian VTE guidelines: Prevention of Venous Thromboembolism (VTE) 0 0.5 1.1
Asians should be considered for VTE prophylaxis? A recent meta-analysis of the rate of postoperative VTE in orthopaedic surgery all-site, proximal, distal and isolated distal DVT to be 31.7%, 8.9%, 22.5% and 18.8% ultrasonography, the respective rates were 9.4%, 5.9%, 5.9% and 5.8% Br J Surg 2011;98:1356-64.
Asians should be considered for VTE prophylaxis? After total hip replacement (THR) venography, the pooled rates of all-site and proximal DVT were 25.8% and 9.6% ultrasonography, the respective rates were 10.8% and 7.2%. Br J Surg 2011;98:1356-64.
Asians should be considered for VTE prophylaxis? In total knee replacement (TKA) using venography pooled rates of all-site and proximal DVT were 42.5% and 8.7% with ultrasonography, the respective rates were 9.5% and 5.2% Br J Surg 2011;98:1356-64.
Incidence of VTE in Asia Orthopaedic thromboprophylaxis Author/ year Nature Diagnosis Drugs DVT, % DVT Drugs, % Fuji /2008 RCT Venography Fondaparinux THR-33.8, TKR-65.3 THR-14.3, TKR-9.5 Fuji/2008 RCT Venography Edoxaban TKR-48.3 TKR-9.1 Housan RCT Venography Rivaroxaban THR-13.1, TKR-24.2 THR-0.8, TKR-12.7 Chin PL 2009 Nakase 2009 RCT Duplex Enoxaparin TKR-22 GCS-13, *IPC-8, #Enoxa-6 RCT Venography Danaparoid THR-31 THR-6 Asian VTE guidelines: Prevention of Venous Thromboembolism (VTE)
Asians should be considered for VTE prophylaxis? The overall pooled rates of symptomatic DVT and PE were 4.5% and 0.6%. Br J Surg 2011;98:1356-64.
Low incidence of VTE in Asia Secondary to the difference in body mass index (BMI) Inherent blood components that rendered Asians less thrombogenic following surgery. However, the substantial double digit incidence in high risk surgeries and intensive care Circulation 2009;120;360-363;
National Health Insurance Research Database (NHIRD) This is a nationwide population-based retrospective cohort study using the claim database of National Health Insurance Research Database (NHIRD) in Taiwan. Currently, the National Health Insurance (NHI) program covers nearly all Taiwan s population (more than 99%). Stroke 2009;40:1162-1168 Am J Cardiol. 2011;107(2):325-30.
Longitudinal Health Insurance Database (LHID) NHIRD containing all the original claims data of one million randomly sampled insured from 27 million people http://nhird.nhri.org.tw/en/data_subsets.html
VTE after TKR/THR Enrolling Totally 11 millions randomly samples A TKR/THR in 2000-2010 (n=7,921) Excluded n=575 Incorrect insurance data (n=322) No birthday data (n=10) Previous VTE (n=243) Results A TKR/THR in 2000-2010 (n=7,346) Follow-up (1 month or 3 months) Events DVT (n=34, 1-month; n=48, 3-month) PE (n=6, 1-month; n=7, 3-month) http://nhird.nhri.org.tw/en/data_subsets.html
VTE after THR/TKR The incidence rate of symptomatic DVT and PE was 4.628 and 0.953 per 1,000 patients respectively within 3 months. THR: 2.519 and 0.42 per 1,000 TKR: 8.589 and 1.171 per 1,000
Baseline of TKR/THR group VTE within 1 or 3 month VTE No VTE Hospital days 12.39 8.90 P<0.05 ICU days 48.50 27.24 P<0.05 Times of OPD 10.68 8.60 P<0.05 http://nhird.nhri.org.tw/en/data_subsets.html
VTE after TKR The rate of using anticoagulation or antiplatelet treatment was only 20.011 per 1,000 patients. The longer average staying days in hospital or in intensive care unit of symptomatic VTE patients comparing to without events.
Asians should be considered for VTE prophylaxis? These data confirmed the epidemiological findings that the rate of VTE in Asia is only 10% lower than the reported incidence in the Caucasians
Prevention and Treatment Pharmacologic and mechanical approaches are available heparin new anticoagulants that inhibit factor Xa and thrombin graduated compression stockings. Am J Surg. 2010 Jan;199(1 Suppl):S11-20
Acknowledgement Chang Gung Memorial Hospital Lung-Sheng Wu, MD, Yu-Heng Chang, MD, PhD; Mel S. Lee, MD, PhD Chang Gung Memorial Hospital Pi-Hua Liu, PhD Standford University Christopher Mow, MD; Ann Weinacker, MD Circulation 2009;120;360-363;