Venous Thromboembolism Prophylaxis for the Medical Patient

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Venous Thromboembolism Prophylaxis for the
Medical Patient
John A. Heit, MD Professor of Medicine Director,
Coagulation Laboratories Coagulation
Clinic Consultant, Cardiovascular Diseases and
Hematology Research Mayo Clinic College of
Medicine Rochester, MN
CP1069179-1
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Annual Incidence of VTEin Olmsted County, MN
1966-1995By Age and Gender
Men
Annual incidence/100,000
Women
?
Age group (yr)
CP1198340-1
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Risk Factors for DVT or PENested Case-Control
Study (n625 case-control pairs)
Surgery Trauma Inpatient Malignancy with
chemotherapy Malignancy without
chemotherapy Central venous catheter or
pacemaker Neurologic disease Superficial vein
thrombosis Varicose veins/age 45 yr Varicose
veins/age 60 yr Varicose veins/age 70 yr CHF, VTE
incidental on autopsy CHF, antemortem VTE/causal
for death Liver disease
0
5
10
15
20
25
50
Odds ratio
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Overall and by Location in Community at Onset
Incidence of VTE in Olmsted County, MN 19661990
Location at onset
Overall/100,000 person-years
In-hospital/100,000bed-years
Community/100,000person-years
Population

• Overall 117 9,605 71
• Men 130 12,780 77
• Women 110 6,586 65
• Deep vein thrombosis 48 4,593 36
• Pulmonary embolism 69 5,012 35

Adjusted to age and sex distribution of 1980 US
whites. Adjusted to age distribution of 1980
US whites.
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VTE Risk Factors Medical Patients
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VTE Risk Factors Medical Patients
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Independent Risk Factors for VTE after
Hospitalization for Acute Medical
IllnessOlmsted County 1988-97 (n198)
Controlled for Active Cancer and Event
Year Heit, et al. J Thromb Haemost 2005
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Relative Risk of VTE by Tumor Site
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VTE Risk Factors Nursing Home Residents
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Parenteral Pharmacologic Prophylaxis

• Unfractionated (Standard) Heparin (UFH)
• Low-Molecular-Weight Heparin (LMWH)
• enoxaparin sodium (Lovenox)
• dalteparin sodium (Fragmin )
• (tinzaparin sodium Innohep )

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Pharmacologic Prophylaxis

• Parenteral-Indirect Factor Xa Inhibitor
• fondaparinux (Arixtra)
• Parenteral-Direct Thrombin (IIa) Inhibitor
• lepirudin (Refludan)
• argatroban
• bivalirudin (hirulog)
• Oral-warfarin sodium

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Mechanical Prophylaxis

• Intermittent Pneumatic Compression (IPC)
• calf only, or calf thigh IPC
• venous foot pump
• Graduated Compression Stockings (GCS)
• (Inferior Vena Cava IVC Filter)

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Prophylaxis RecommendationsAcutely Sick Medical
Inpatients

• UFH 5000 units subcutaneously three times daily,
  or
• LMWH according to recommended dose and dose
  schedule.
• GCS or IPC when anticoagulant prophylaxis is
  contraindicated.
• 7th ACCP Consensus Conference. Chest 2004