Caprini Rsk Score – Venous Resource Center

Know your Risk for Blood Clots & Save Your Life

Your Total Score:

Your personal identification will not be collected by this site. No record of your responses is preserved.

Planned surgery

MINOR SURGERY
This does not refer to

type of surgery

but rather length of anesthesia < 45 minutes.

 

MAJOR SURGERY
Procedures with

general

Prevention of postoperative deep venous thrombosis and pulmonary emboli with combined modalities

M BorowH J Goldson

PMID: 6195948

Abstract

Worldwide statistics reveal that 25 to 40 per cent of patients who are over the age of 40 years and operated on for 1 or more hours will develop a deep venous thrombosis (DVT). The studies reviewed in this paper were performed to evaluate several modalities and compare their effectiveness in preventing DVT in postoperative patients. In the first study, five modalities plus a control group were evaluated in 562 patients from five surgical specialties. The incidence of DVT in the control group was 35 per cent. Though most of the pharmacologic agents were effective in reducing the incidence of DVT, the antistasis devices (gradient elastic stockings and intermittent pneumatic compression) were most effective. The purpose of the second study was to evaluate the effectiveness of combining a pharmacologic drug with an antistasis modality. Deep venous thrombosis was virtually eliminated in this group of 328 patients. There was only a 1.5 per cent incidence of DVT in the treated population as compared to a 26.8 per cent incidence in the control group. Thus, it seems that combining one antistasis and one pharmacologic agent greatly reduces the incidence of lower extremity thrombi. I-125 fibrinogen scanning was the most sensitive test in detecting DVT and had an accuracy of 97 per cent.

Reference: Am Surg 1983 Nov;49(11):599-605.

 

or regional anesthesia time
>45 minutes

are included. These include open, laparoscopic, or arthroscopic procedures.
Reoperations

Patterns of Failure of a Standardized Perioperative Venous Thromboembolism Prophylaxis Protocol

Michael R Cassidy 1Ryan D Macht 1Pamela Rosenkranz 1Joseph A Caprini 2David McAneny 3

Affiliations expand

PMID: 26821972. DOI: 10.1016/j.jamcollsurg.2015.12.022

Abstract

Background: Venous thromboembolism (VTE) is a leading contributor to morbidity after operations. We previously implemented a standardized VTE risk assessment, based on the Caprini score, along with risk-stratified prophylaxis. This system reduced the odds ratio of a VTE event from 3.02 to 0.75. We investigated patterns of failure to determine characteristics of patients in whom VTE develops despite the protocol.

Methods: We reviewed all nontrauma general surgery patients with evidence of VTE after the inception of a VTE risk assessment and prophylaxis program. Characteristics were recorded, including demographics, diagnoses, operations, risk profile, prophylaxis prescribed, and regimen compliance.

Results: Twenty-seven patients failed the protocol and manifested VTE, representing an overall VTE rate of 0.3%. Of these patients, 63% had emergency operations and 52% underwent multiple operations, compared with 13% and 2.0% of the nontrauma general surgery population in whom VTE did not develop, respectively (p < 0.001). Of patients with VTE, 52% had pre-existing or postoperative infections, 22% had malignancies, but only 15% had missed 1 or more doses of pharmacologic prophylaxis during hospitalization. Five VTEs manifested after discharge; one of those patients was prescribed extended prophylaxis beyond hospitalization, and an extended course was not provided to 3 who were eligible. One patient had underestimation of the Caprini score due to lack of awareness of a family history of VTE.

Conclusions: Emergency and multiple operations seem to confer dramatic hazards for VTE, despite standard prophylaxis. These factors are not currently captured in the Caprini model, but might be significant modifiers of risk that should prompt reassessment, perhaps with a weighted numeric value along with enhanced prophylaxis. It is encouraging that most patients received appropriate prophylaxis in compliance with the protocol.

Reference:

J Am Coll Surg 2016 Jun;222(6):1074-80. doi: 10.1016/j.jamcollsurg.2015.12.022.Epub 2015 Dec 24.

during the same hospitalization count for 2 points each if the anesthesia time exceeds 45 minutes.

 

MAJOR LOWER EXTREMITY ARTHROPLASTY
These procedures are high-risk however if additional risk factors are present that further increases the risk. It has been shown that once the score reaches

10 and above

Implementation and Validation of the 2013 Caprini Score for Risk Stratification of Arthroplasty Patients in the Prevention of Venous Thrombosis

Eugene S Krauss 1, Ayal Segal 1, MaryAnne Cronin 2, Nancy Dengler 1, Martin L Lesser 3, Seungjun Ahn 3, Joseph A Caprini 2 4

 

PMID: 30939898. PMCID: PMC6714918. DOI: 10.1177/1076029619838066

Erratum in Corrigendum.

[No authors listed]Clin Appl Thromb Hemost. 2019 Jan-Dec;25:1076029619851962. doi: 10.1177/1076029619851962.PMID: 31099256 Free PMC article. No abstract available.

Abstract

Appropriate chemoprophylaxis choice following arthroplasty requires accurate patient risk assessment. We compared the results of our prospective department protocol to the Caprini risk assessment model (RAM) retrospectively in this study group. Our goal was to determine whether the department protocol or the Caprini score would identify venous thromboembolism (VTE) events after total joint replacement. A secondary purpose was to validate the 2013 Caprini RAM in joint arthroplasty and determine whether patients with VTE would be accurately identified using the Caprini score. A total of 1078 patients met inclusion criteria. A Caprini score of 10 or greater is considered high risk and a score of 9 or less is considered low risk. The 2013 version of the Caprini RAM retrospectively stratified 7 of the 8 VTE events correctly, while only 1 VTE was identified with the prospective department protocol. This tool provided a consistent, accurate, and efficacious method for risk stratification and selection of chemoprophylaxis.

Reference:

Clin Appl Thromb Hemost. Jan-Dec 2019;25:1076029619838066.doi: 10.1177/1076029619838066.

the VTE risk is significantly
greater

Frequency and Risk Factor of Lower-limb Deep Vein Thrombosis after Major Orthopedic Surgery in Vietnamese Patients

My Hanh Bui 1, Duong Duc Hung 2, Pham Quang Vinh 3, Nguyen Hoang Hiep 4, Le Lan Anh 3, Toi Chu Dinh 3

PMID: 32215072. PMCID: PMC7084020. DOI: 10.3889/oamjms.2019.369

Abstract

Background: Deep venous thrombosis (DVT) is a prevalent complication of orthopedic surgery. According in many studies. The incidence of DVT may be up to 50% if thromboprophylaxis is not available.

Aim: The objective of this study was to check the degree of disease, clinical characteristics and analyzed factors in vulnerabilities with lower-limp DVT after orthopedic surgery in a Vietnam teaching hospital.

Methods: Orthopedic patients who met criteria were recruited at our hospital between August 2017 and June 2018. Ultrasound was used to discovering lower-limp DVT in pre-surgery and 7 days after surgery in all patients.

Results: The incidence of DVT after orthopedic surgery was 7.2%. Patients with older age (> 60) have a risk of 2 times higher of DVT after surgery than normal people (p < 0.05). The incidence of postoperative DVT was higher in immobile individuals > 72 hours (p < 0.05). Patients with prolonged surgical time (>120 minutes) had a higher risk of postoperative DVT than non-surgical patients’ surgery (p < 0.05).

Conclusions: DVT remains a common complication following orthopedic surgery. Older age, immobility status, and surgical time have been found to be risky factors for the development of postoperative lower-limp DVT in orthopedic patients.

Reference:

Maced J Med Sci. 2019 Dec 20;7(24):4250-4254. doi: 10.3889/oamjms.2019.369.eCollection 2019 Dec 30.

. If the procedure is being done as a result of a hip
fracture

Usefulness of clinical predictors for preoperative screening of deep vein thrombosis in hip fractures

Kitchai Luksameearunothai 1 2Paphon Sa-Ngasoongsong 3Noratep Kulachote 1Sorawut Thamyongkit 1 4Praman Fuangfa 5Pongsthorn Chanplakorn 1Patarawan Woratanarat 1Chanyut Suphachatwong 1

 

PMID: 28532441. PMCID: PMC5440897. DOI: 10.1186/s12891-017-1582-5

Abstract

Background: Recent studies showed that preoperative deep vein thrombosis (DVT) was common after hip fracture (HF), and preoperative DVT screening has been recommended for preventing the fatal DVT-related complications, especially in elderly HF patients with high surgical risk. However, to our knowledge, no previous studies have demonstrated the correlation between the clinical risk predictors and preoperative DVT. Therefore, this study aimed to correlate those clinical predictors related to DVT risk assessment with the incidence of preoperative DVT.

Methods: A prospective study was conducted, between July 2015 and June 2016, in 92 HF patients. All patients were evaluated for the DVT-related risk, as patients’ characteristics, clinical signs, D-dimer, DVT risk assessment score (Wells score and Caprini score), and then underwent doppler ultrasonography preoperatively. The incidence of preoperative DVT was correlated with each clinical risk predictor, and then significant factors were calculated for diagnostic accuracy.

Results: The average patients’ age was 78 ± 10 years. Sixty-eight patients (74%) were female. The incidence of preoperative DVT was 16.3% (n = 15). The median time from injury to doppler ultrasonography was 2 days (range 0-150 days). DVT group showed a significantly higher in Wells score and Caprini score compared to the non-DVT group (p < 0.05 all). Sensitivity and specificity of Wells score ≥ 2 and Caprini score ≥12 were 47 and 81, and 93 and 35%, respectively.

Conclusion: DVT risk assessment may be helpful for stratifying the risk of preoperative DVT in elderly HFs. Those with Caprini score ≥ 12 should be screened with doppler ultrasonography preoperatively. Those with Wells score 0-1 had low risk for preoperative DVT, so the surgery could perform without delay.

Reference:

BMC Musculoskelet Disord. 2017 May 22;18(1):208.doi: 10.1186/s12891-017-1582-5.

 preoperative screening may be beneficial.

Past major surgery (more than 45 minutes) within the last month

Major surgery done during the preceding month includes past staged procedures.

Visible varicose veins *

These include visible bulging veins and not spider veins or telangiectasia. Varicose veins represent a risk factor for

Thrombosis

Association of Varicose Veins With Incident Venous Thromboembolism and Peripheral Artery Disease

Shyue-Luen Chang 1 2 3Yau-Li Huang 1 2 3Mei-Ching Lee 1 2 3Sindy Hu 1 2 3 4Yen-Chang Hsiao 5Su-Wei Chang 6 7Chee Jen Chang 8 9Pei-Chun Chen 6 10

PMID: 29486040 PMCID: PMC5838574 DOI: 10.1001/jama.2018.0246

Free PMC article

Abstract

Importance: Varicose veins are common but rarely associated with serious health risks. Deep venous thrombosis (DVT), pulmonary embolism (PE), and peripheral artery disease (PAD) are also vascular diseases but associated with serious systemic effects. Little is known about the association between varicose veins and the incidence of other vascular diseases including DVT, PE, and PAD.

Objective: To investigate whether varicose veins are associated with an increased risk of DVT, PE, or PAD.

Design, setting, and participants: A retrospective cohort study using claims data from Taiwan’s National Health Insurance program. Patients aged 20 years and older with varicose veins were enrolled from January 1, 2001-December 31, 2013, and a control group of patients without varicose veins were matched by propensity score. Patients previously diagnosed with DVT, PE, or PAD were excluded. Follow-up ended December 31, 2014.

Exposures: Presence of varicose veins.

Main outcomes and measures: Incidence rates of DVT, PE, and PAD were assessed in people with and without varicose veins. Cox proportional hazards models were used to estimate relative hazards, with the control group as reference.

Results: There were 212 984 patients in the varicose veins group (mean [SD] age, 54.5 [16.0] years; 69.3% women) and 212 984 in the control group (mean [SD] age, 54.3 [15.6] years; 70.3% women). The median follow-up duration was 7.5 years for DVT, 7.8 years for PE, and 7.3 years for PAD for patients with varicose veins, and for the control group, follow-up duration was 7.6 years for DVT, 7.7 years for PE, and 7.4 years for PAD. The varicose veins group had higher incidence rates than the control group for DVT (6.55 vs 1.23 per 1000 person-years [10 360 vs 1980 cases]; absolute risk difference [ARD], 5.32 [95% CI, 5.18-5.46]), for PE (0.48 for the varicose veins group vs 0.28 for the control group per 1000 person-years [793 vs 451 cases]; ARD, 0.20 [95% CI, 0.16-0.24]), and for PAD (10.73 for the varicose veins group vs 6.22 for the control group per 1000 person-years [16 615 vs 9709 cases]; ARD, 4.51 [95% CI, 4.31-4.71]). The hazard ratios for the varicose veins group compared with the control group were 5.30 (95% CI, 5.05-5.56) for DVT, 1.73 (95% CI, 1.54-1.94) for PE, and 1.72 (95% CI, 1.68-1.77) for PAD.

Conclusions and relevance: Among adults diagnosed with varicose veins, there was a significantly increased risk of incident DVT; the findings for PE and PAD are less clear due to the potential for confounding. Whether the association between varicose veins and DVT is causal or represents a common set of risk factors requires further research.

Reference

JAMA. 2018 Feb 27;319(8):807-817. doi: 10.1001/jama.2018.0246.

. This risk is especially true in cancer
Patients

Presence of varicose veins in cancer patients increases the risk for occurrence of venous thromboembolism

O Königsbrügge 1F LötschE-M ReitterT BrodowiczC ZielinskiI PabingerC Ay

Affiliations expand

PMID: 24112869.  DOI: 10.1111/jth.12408

Free article

Abstract

Background: Cancer patients are at increased risk of venous thromboembolism (VTE).

Objective: We investigated the association of a history of VTE, superficial thrombophlebitis, or the presence of varicose veins with the occurrence of VTE during the course of cancer.

Methods: Cancer patients were recruited in a prospective cohort study, the Vienna Cancer and Thrombosis Study. Patients who had VTE within 3 months before study inclusion were excluded. At study inclusion, history of VTE, history of superficial thrombophlebitis, and presence of varicose veins were recorded. Primary end point was the occurrence of symptomatic VTE. Hazard ratios were obtained using the competing risk analysis according to Fine and Gray.

Results: The cohort consisted of 1270 patients followed over a median of 590 days. A history of VTE was found in 66 patients (5.2%), superficial thrombophlebitis in 79 patients (6.2%), and varicose veins in 160 patients (12.6%). Ninety-eight patients (7.7%) developed VTE during follow-up. The hazard ratios for the risk of VTE in patients with a history of VTE or superficial thrombophlebitis were 1.44 (95% confidence interval: 0.67-3.07) and 1.94 (1.04-3.61), respectively, and 2.01 (1.26-3.21) in those with varicose veins. In multivariable analysis including history of VTE, history of superficial thrombophlebitis, presence of varicose veins, and other patient-related factors, the presence of varicose veins (2.10 [1.29-3.41]) remained significantly associated with an increased risk of VTE.

Conclusion: The presence of varicose veins is associated with an elevated risk of VTE in cancer patients. This clinical parameter could be useful for individual risk assessment of VTE in these patients.

Reference:

J Thromb Haemost. 2013 Nov;11(11):1993-2000. doi: 10.1111/jth.12408.

. The notion that varicose veins are a harmless benign disorder is not well
Founded

Varicose veins are a risk factor for deep venous thrombosis in general practice patients

Uwe Müller-Bühl 1Rüdiger LeutgebPeter EngeserEdwane N AchankengJoachim SzecsenyiGunter Laux

Affiliations expand

PMID: 22915533. DOI: 10.1024/0301-1526/a000222

Abstract

Background: The role of varicose veins (VV) as a risk factor for development of deep venous thrombosis (DVT) is still controversial. The aim of this study in primary care was to determine the impact of varicosity as a potential risk factor for developing DVT.

Patients and methods: During the observation period between 01-Jan-2008 and 01-Jan-2011, all cases with VV (ICD code I83.9) and DVT (ICD codes I80.1 – I80.9) were identified out of the CONTENT primary care register (Heidelberg, Germany). The exposure of VV and DVT was based solely on ICD coding without regarding the accuracy of the diagnosis. The covariates age, gender, surgery, hospitalization, congestive heart failure, malignancy, pregnancy, hormonal therapy, and respiratory infection were extracted for each patient. Multivariate binary logistic regression was performed in order to assess potential risk factors for DVT. The SAS procedure “PROC GENMOD” (SAS version 9.2, 64-bit) was parameterised accordingly. A potential cluster effect (patients within practices) was regarded in the regression model.

Results: There were 132 out of 2,357 (5.6 %) DVT episodes among patients with VV compared to 728 out of 80,588 (0.9 %) in the patient cohort without VV (p < 0.0001). An increased risk of DVT was associated with previous DVT (adjusted odds ratio (OR): 9.07, 95 % confidence interval (CI): 7.78 – 10.91), VV (OR 7.33 [CI 6.14 – 8.74]), hospitalization during the last 6 months (OR 1.69 [CI 1.29 – 2.22]), malignancy (OR 1.55 [CI 1.19 – 2.02]), and age (OR 1.02 [CI 1.01 – 1.03]).

Conclusions: There are strong associations between VV and DVT in a general practice population with documented VV. Special medical attention is required for patients with VV, a history of previous venous thromboembolism, comorbid malignancy, and recent hospital discharge, particularly those with a combination of these factors.

Reference:

Vasa. 2012 Sep;41(5):360-5. doi: 10.1024/0301-1526/a000222.

.

 

A history of Inflammatory Bowel Disease (IBD) (for example, Crohn’s disease or ulcerative colitis) *

This risk factor includes regional ileitis, ulcerative colitis, and not irritable bowel syndrome. Patients with inactive as well as active

Disease

Elevated Venous Thromboembolism Risk Following Colectomy for IBD Is Equal to Those for Colorectal Cancer for Ninety Days After Surgery

Fadwa Ali 1Sadeer G Al-Kindi 2Jacqueline J Blank 1Carrie Y Peterson 3Kirk A Ludwig 3Timothy J Ridolfi 3

PMID: 29420429. DOI: 10.1097/DCR.0000000000001036

Abstract

Background: The risk of postoperative venous thromboembolism is high in patients with colon cancer and IBD. Although The American Society of Colon and Rectal Surgeons suggests posthospital prophylaxis after surgery in patients with colon cancer, there are no such recommendations for patients with IBD.

Objective: This study aims to analyze the incidence and risk factors for postoperative venous thromboembolism.

Design: This was a retrospective review using the Explorys platform.

Settings: Aggregated electronic medical records from 26 major health care systems across the United States from 1999 to 2017 were used for this study.

Patients: Patients who underwent colon surgery were included.

Main outcome measures: Patients were followed up to 90 days postoperatively for deep vein thrombosis and pulmonary embolism.

Results: A total of 75,620 patients underwent colon resections, including 32,020 patients with colon cancer, 9850 patients with IBD, and 33,750 patients with diverticulitis. The 30-day incidence of venous thromboembolism was higher in patients with cancer and IBD than in patients with diverticulitis (2.9%, 3.1%, and 2.4%, p < 0.001 for both comparisons). The 30-day incidence of venous thromboembolism in patients with ulcerative colitis is greater than in patients with Crohn’s disease (4.1% vs 2.1%, p < 0.001). The cumulative incidence of venous thromboembolism increased from 1.2% at 7 days after surgery to 4.3% at 90 days after surgery in patients with cancer, and from 1.3% to 4.3% in patients with IBD. In multivariable analysis, increase in the risk of venous thromboembolism was associated with cancer diagnosis, IBD diagnosis, age ≥60, smoking, and obesity.

Limitations: This study was limited by its retrospective nature and by the use of the aggregated electronic database, which is based on charted codes and contains only limited collateral clinical data.

Conclusions: Because of the elevated and sustained risk of postoperative thromboembolism, patients with IBD, especially ulcerative colitis, might benefit from extended thromboembolism prophylaxis similar to that of patients with colon cancer. See Video Abstract at http://links.lww.com/DCR/A544.

Reference:

Dis Colon Rectum. 2018 Mar;61(3):375-381. doi: 10.1097/DCR.0000000000001036.

should be
Included

The risk of venous thromboembolism during and after hospitalisation in patients with inflammatory bowel disease activity

Thomas P C Chu 1Matthew J Grainge 1Timothy R Card 1 2

PMID: 30294897. DOI: 10.1111/apt.15010

Abstract

Background: Inflammatory bowel disease (IBD) increases the risk of venous thromboembolism.

Aims: To determine when patients are at high risk of thromboembolic events, including after major surgery, and to guide timing of thromboprophylaxis.

Methods: Each IBD patient from Clinical Practice Research Datalink, linked with Hospital Episode Statistics, was matched to up to five non-IBD patients in this cohort study. We examined their risk of thromboembolism in hospital and within 6 weeks after leaving hospital, with or without undergoing major surgery, and while ambulant. Hazard ratios were estimated using Cox regression, with adjustment for age, sex, body mass index, smoking and history of malignancy or thromboembolism.

Results: Overall 23 046 IBD patients had a thromboembolic risk 1.74-times (95% CI = 1.55-1.96) higher than 106 795 non-IBD patients. Among ambulant patients, the thromboembolic risk was raised during acute (hazard ratio = 3.94, 2.79-5.57) or chronic disease activity (3.97, 2.90-5.45) but their absolute risk remained below 5/1000 person-years. The hazard ratio for thromboembolism among in-patients not undergoing major surgery was 1.13 (0.63-2.02), compared to 2.43 (1.20-4.92) among surgical patients, with a near doubling of absolute risk associated with surgery (59.5/1000 person-years, compared with 31.1 without surgery). The absolute risk remained elevated within 6 weeks after leaving hospital (18.6/1000 person-years in IBD patients after surgery).

Conclusions: IBD patients are at an increased risk of venous thromboembolism. Absolute risks are raised during active disease, when in hospital, and after leaving hospital following major surgery.

Reference:

Aliment Pharmacol Ther. 2018 Nov;48(10):1099-1108. doi: 10.1111/apt.15010. Epub 2018 Oct 8

. The thrombotic risk is increased during active disease. Extended prophylaxis post operatively may be of benefit in the presence of acute disease.

Swollen legs (current) *

Swollen legs

See full article for a thorough discussion on leg swelling.

https://journals.sagepub.com/doi/full/10.1177/1358863X16672576

Reference:
Vasc Med 2016 Dec;21(6):562-564. doi: 10.1177/1358863X16672576. Epub 2016 Oct 12.

 

include pitting edema of any level, loss of definition of the Bony prominences, obscured surface foot veins, or indentation of the leg when a stocking is removed. This factor refers to either one or two legs affected. The physical exam should include pretibial pressure to see if an indentation is present indicating leg
swelling

The outpatient with unilateral leg swelling

G J Merli 1J Spandorfer

PMID: 7877400. DOI: 10.1016/s0025-7125(16)30077-3

Abstract

Approaching the patient with unilateral leg swelling presents a challenge to the physician in ambulatory practice. Contributing to the difficulty is the lack of studies that have assessed a population of patients presenting with unilateral leg swelling. The purpose of this article is to discuss unilateral leg swelling with respect to the chronicity of the presentation and the most common differential diagnoses based on a review of the current literature and personal clinical experience.

Reference:

Med Clin North Am. 1995 Mar;79(2):435-47. doi: 10.1016/s0025-7125(16)30077-3.

.

Overweight or obese (Body Mass Index of 25 or higher) *

This factor was derived from several sources documenting the incidence of thrombosis in patients readmitted with DVT following total joint replacement, and DVT occurring in patients taking birth control pills who had a BMI >25.

Total

Joint replacement

Predictors of rehospitalization for symptomatic venous thromboembolism after total hip arthroplasty

R H White 1S GettnerJ M NewmanK B TraunerP S Romano

PMID: 11114314. DOI: 10.1056/NEJM200012143432403

Abstract

Background: Recent studies have shown that symptomatic venous thromboembolism after total hip arthroplasty most commonly develops after the patient is discharged from the hospital. Risk factors associated with these symptomatic thromboembolic events are not well defined.

Methods: Using administrative data from the California Medicare records for 1993 through 1996, we identified 297 patients 65 years of age or older who were rehospitalized for thromboembolism within three months after total hip arthroplasty. We compared demographic, surgical, and medical variables potentially associated with the development of thromboembolism in these patients and 592 unmatched controls.

Results: A total of 89.6 percent of patients with thromboembolism and 93.8 percent of control patients were treated with pneumatic compression, warfarin, enoxaparin, or unfractionated heparin, alone or in combination. In addition, 22.2 percent and 29.7 percent, respectively, received warfarin after discharge. A body-mass index (the weight in kilograms divided by the square of the height in meters) of 25 or greater was associated with rehospitalization for thromboembolism, with an odds ratio of 2.5 (95 percent confidence interval, 1.8 to 3.4). In a multivariate model, the only prophylactic regimens associated with a reduced risk of thromboembolism were pneumatic compression in patients with body-mass indexes of less than 25 (odds ratio, 0.3; 95 percent confidence interval, 0.2 to 0.6) and warfarin treatment after discharge (odds ratio, 0.6; 95 percent confidence interval, 0.4 to 1.0).

Conclusions: In patients who underwent total hip arthroplasty, a body-mass index of 25 or greater was associated with subsequent hospitalization for thromboembolism. Pneumatic compression in patients with a body-mass index of less than 25 and prophylaxis with warfarin after discharge were independently protective against thromboembolism.

Reference:

N Engl J Med. 2000 Dec 14;343(24):1758-64. doi: 10.1056/NEJM200012143432403.

 


Birth control
pills

Obesity: risk of venous thrombosis and the interaction with coagulation factor levels and oral contraceptive use

Morteza Abdollahi 1Mary CushmanFrits R Rosendaal

PMID: 12624633

Abstract

Deep vein thrombosis (DVT) is a common disease with an annual incidence of about 1 in 1000. Many risk factors have already been studied, both genetic and acquired. It is unclear whether obesity affects thrombotic risk in unselected patients. Obesity is common, with a prevalence of 20-25% and may therefore have a considerable impact on the overall incidence of thrombosis. We evaluated the risk of thrombosis due to overweight and obesity using data from a large population based case-control study. Four hundred and fifty-four consecutive patients with a first episode of objectively diagnosed thrombosis from three Anticoagulation Clinics in the Netherlands were enrolled in a case-control study. Controls were matched on age and sex to patients and were introduced by the patients. All patients completed a standard questionnaire and interview, with weight and height measured under standard conditions. The associations of obesity with clotting factor levels were studied to investigate possible mechanisms. Obesity (BMI >/=30 kg/m(2)) increased the risk of thrombosis twofold (CI95: 1.5 to 3.4), adjusted for age and sex. Obese individuals had higher levels of factor VIII and factor IX, but not of fibrinogen. The effect on risk of obesity was not changed after adjustment for coagulation factors levels (fibrinogen, F VIII, F IX, D-dimer). The relative risk estimates were similar in different age groups and in both sexes, indicating a larger absolute effect in older age groups. Evaluation of the combined effect of obesity and oral contraceptive pills among women aged 15-45 revealed that oral contraceptives further increased the effect of obesity on the risk of thrombosis, leading to 10-fold increased risk amongst women with a BMI greater than 25 kg/m(2) who used oral contraceptives. Obesity is a risk factor for deep vein thrombosis. Among women with a BMI greater than 25 kg/m(2) the synergistic effect with oral contraceptives should be considered when prescribing these.

Reference:

Thromb Haemost. 2003 Mar;89(3):493-8. PMID: 12624633.

 

Heart attack within the past month *

This risk factor is associated with a transient increased VTE risk for the first six months independent of traditional atherosclerotic

Risk factors

Impact of incident myocardial infarction on the risk of venous thromboembolism: the Tromsø Study

L B Rinde 1C Lind 1B Småbrekke 1I Njølstad 1 2E B Mathiesen 1 3T Wilsgaard 2M-L Løchen 2E M Hald 1 4A Vik 1 4S K Braekkan 1 4J-B Hansen 1 4

PMID: 27061154. DOI: 10.1111/jth.13329

Abstract

Essentials Registry-based studies indicate a link between arterial- and venous thromboembolism (VTE). We studied this association in a cohort with confounder information and validated outcomes. Myocardial infarction (MI) was associated with a 4.8-fold increased short-term risk of VTE. MI was associated with a transient increased risk of VTE, and pulmonary embolism in particular.

Summary: Background Recent studies have demonstrated an association between venous thromboembolism (VTE) and arterial thrombotic diseases. Objectives To study the association between incident myocardial infarction (MI) and VTE in a prospective population-based cohort. Methods Study participants (n = 29 506) were recruited from three surveys of the Tromsø Study (conducted in 1994-1995, 2001-2002, and 2007-2008) and followed up to 2010. All incident MI and VTE events during follow-up were recorded. Cox regression models with age as the time scale and MI as a time-dependent variable were used to calculate hazard ratios (HRs) of VTE adjusted for sex, body mass index, blood pressure, diabetes mellitus, HDL cholesterol, smoking, physical activity, and education level. Results During a median follow-up of 15.7 years, 1853 participants experienced an MI and 699 experienced a VTE. MI was associated with a 51% increased risk of VTE (HR 1.51; 95% confidence interval [CI] 1.08-2.10) and a 72% increased risk of pulmonary embolism (PE) (HR 1.72; 95% CI 1.07-2.75), but not significantly associated with the risk of deep vein thrombosis (DVT) (HR 1.36; 95% CI 0.86-2.15). The highest risk estimates for PE were observed during the first 6 months after the MI (HR 8.49; 95% CI 4.00-18.77). MI explained 6.2% of the PEs in the population (population attributable risk) and 78.5% of the PE risk in MI patients (attributable risk). Conclusions Our findings indicate that MI is associated with a transient increased VTE risk, independently of traditional atherosclerotic risk factors. The risk estimates were particularly high for PE.

Reference:

Thromb Haemost. 2016 Jun;14(6):1183-91. doi: 10.1111/jth.13329. Epub 2016 May 10.

. The strength of this risk factor decreases after three
months

Heart disease may be a risk factor for pulmonary embolism without peripheral deep venous thrombosis

Henrik T Sørensen 1Erzsebet Horvath-PuhoTimothy L LashChristian F ChristiansenRaffaele PesaventoLars PedersenJohn A BaronPaolo Prandoni

 

PMID: 21900083. DOI: 10.1161/CIRCULATIONAHA.111.025627

Abstract

Background: Heart diseases increase the risk of arterial embolism; whether they increase the risk of pulmonary embolism without peripheral venous thrombosis is less certain.

Methods and results: We conducted a nationwide, population-based case-control study in Denmark using patients diagnosed with pulmonary embolism and/or deep venous thrombosis between 1980 and 2007. We computed odds ratios to estimate relative risks associating preceding heart disease with pulmonary embolism, pulmonary embolism and deep venous thrombosis, or deep venous thrombosis alone. In this study, 45,282 patients had pulmonary embolism alone, 4680 had pulmonary embolism and deep venous thrombosis, and 59,790 had deep venous thrombosis alone; 541,561 were population controls. Myocardial infarction and heart failure in the preceding 3 months conferred high risks of apparently isolated pulmonary embolism (odds ratio, 43.5 [95% confidence interval (CI), 39.6-47.8] and 32.4 [95% CI, 29.8-35.2], respectively), whereas the risks of combined pulmonary embolism and deep venous thrombosis (19.7 [95% CI, 16.0-24.2] and 22.1 [95% CI, 18.7-26.0], respectively) and deep venous thrombosis alone (9.6 [95% CI, 8.6-10.7] and 12.7 [95% CI, 11.6-13.9], respectively) were lower. Left-sided valvular disease was associated with an odds ratio of 13.5 (95% CI, 11.3-16.1), whereas the odds ratio was 74.6 (95% CI, 28.4-195.8) for right-sided valvular disease. Restricting the analysis to cases diagnosed after 2000 led to lower risk estimates but the same overall pattern.

Conclusion: Heart diseases increase the near-term risk for pulmonary embolism not associated with diagnosed peripheral vein thrombosis.

Circulation. 2011 Sep 27;124(13):1435-41. doi: 10.1161/CIRCULATIONAHA.111.025627.Epub 2011 Sep 6.

.

Congestive heart failure within the past month *

The Venous Thromboembolism risk is similar for those with preserved or reduced ejection

fraction

Incident Heart Failure and Long-Term Risk for Venous Thromboembolism

Christina L Fanola 1Faye L Norby 2Amil M Shah 3Patricia P Chang 4Pamela L Lutsey 2Wayne D Rosamond 4Mary Cushman 5Aaron R Folsom 2

PMID: 31948643. PMCID: PMC7262575. DOI: 10.1016/j.jacc.2019.10.058

Abstract

Background: Heart failure (HF) hospitalization places patients at increased short-term risk for venous thromboembolism (VTE). Long-term risk for VTE associated with incident HF, HF subtypes, or structural heart disease is unknown.

Objectives: In the ARIC (Atherosclerosis Risk In Communities) cohort, VTE risk associated with incident HF, HF subtypes, and abnormal echocardiographic measures in the absence of clinical HF was assessed.

Methods: During follow-up, ARIC identified incident HF and subcategorized HF with preserved ejection fraction or reduced ejection fraction. At the fifth clinical examination, echocardiography was performed. Physicians adjudicated incident VTE using hospital records. Adjusted Cox proportional hazards models were used to evaluate the association between HF or echocardiographic exposures and VTE.

Results: Over a mean of 22 years in 13,728 subjects, of whom 2,696 (20%) developed incident HF, 729 subsequent VTE events were identified. HF was associated with increased long-term risk for VTE (adjusted hazard ratio: 3.13; 95% confidence interval: 2.58 to 3.80). In 7,588 subjects followed for a mean of 10 years, the risk for VTE was similar for HF with preserved ejection fraction (adjusted hazard ratio: 4.71; 95% CI: 2.94 to 7.52) and HF with reduced ejection fraction (adjusted hazard ratio: 5.53; 95% confidence interval: 3.42 to 8.94). In 5,438 subjects without HF followed for a mean of 3.5 years, left ventricular relative wall thickness and mean left ventricular wall thickness were independent predictors of VTE.

Conclusions: In this prospective population-based study, incident hospitalized HF (including both heart failure with preserved ejection fraction and reduced ejection fraction), as well as echocardiographic indicators of left ventricular remodeling, were associated with greatly increased risk for VTE, which persisted through long-term follow-up. Evidence-based strategies to prevent long-term VTE in patients with HF, beyond time of hospitalization, are needed.

Reference:

J Am Coll Cardiol. 2020 Jan 21;75(2):148-158. doi: 10.1016/j.jacc.2019.10.058

. A variety of criteria fit the definition of this risk
factor

Classification of heart failure in the atherosclerosis risk in communities (ARIC) study: a comparison of diagnostic criteria

Wayne D Rosamond 1Patricia P ChangChris BaggettAnna JohnsonAlain G BertoniEyal ShaharAnita DeswalGerardo HeissLloyd E Chambless

PMID: 22271752. PMCID: PMC3326579. DOI: 10.1161/CIRCHEARTFAILURE.111.963199

Abstract

Background: Population-based research on heart failure (HF) is hindered by lack of consensus on diagnostic criteria. Framingham (FRM), National Health and Nutrition Examination Survey (NHANES), Modified Boston (MBS), Gothenburg (GTH), and International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) code criteria, do not differentiate acute decompensated heart failure (ADHF) from chronic stable HF. We developed a new classification protocol for identifying ADHF in the Atherosclerosis Risk in Communities (ARIC) Study and compared it with these other schemes.

Methods and results: A sample of 1180 hospitalizations with a patient address in 4 study communities and eligible discharge codes were selected. After assessing whether the chart contained evidence of possible HF signs, 705 were fully abstracted. Two independent reviewers classified each case as ADHF, chronic stable HF, or no HF, using ARIC classification guidelines. Fifty-nine percent of cases met ARIC criteria for ADHF and 13.9% and 27.1% were classified as chronic stable HF or no HF, respectively. Among events classified as HF by FRM criteria, 68.4% were validated as ADHF, 9.6% as chronic stable HF, and 21.9% as no HF. However, 92.5% of hospitalizations with a primary ICD-9-CM 428 “heart failure” code were validated as ADHF. Sensitivities of comparison criteria to classify ADHF ranged from 38-95%, positive predictive values from 62-92%, and specificities from 19-96%.

Conclusions: Although comparison criteria for classifying HF were moderately sensitive in identifying ADHF, specificity varied when applied to a randomly selected set of suspected HF hospitalizations in the community.

Reference:

Circ Heart Fail. 2012 Mar 1;5(2):152-9. doi: 10.1161/CIRCHEARTFAILURE.111.963199. Epub 2012 Jan 23.

.

Serious infection (for example, pneumonia) within the past month. *

Preoperative pneumonia is a significant risk

factor

Risk factors and clinical impact of postoperative symptomatic venous thromboembolism

Chethan Gangireddy 1John R RectenwaldGilbert R UpchurchThomas W WakefieldShukri KhuriWilliam G HendersonPeter K Henke

PMID: 17264013. DOI: 10.1016/j.jvs.2006.10.034

Abstract

Background: Although common risk factors for venous thromboembolism (VTE) are well known, little data exist concerning the clinical impact of VTE in postoperative patients outside of controlled studies. This study evaluated prospective perioperative demographic and clinical variables associated with occurrence of postoperative symptomatic VTE.

Methods: Demographic and clinical data were collected on surgical patients undergoing nine common general, vascular, and orthopedic operations presenting to the Veterans Health Administration Hospitals between 1996 and 2001 as part of the National Surgical Quality Improvement Program (NSQIP). The association between covariates and the incidence of postoperative symptomatic VTE (includes deep venous thrombosis and pulmonary embolism) was assessed using bivariable and multivariable regression.

Results: Complete demographic and clinical information for analysis were available for 75,771 patients. The mean patient age was 65 years, and 96.6% were men. Major comorbidities included diabetes mellitus (DM), 25%; chronic obstructive pulmonary disease (COPD), 18.3%; and congestive heart failure (CHF), 3.9%. Symptomatic VTE was diagnosed in 805 patients (0.68%), varied significantly with procedure (0.14% for carotid endarterectomy vs 1.34% for total hip arthroplasty), and was associated with increased 30-day mortality (16.9% vs 4.4%, P < .0001). The incidence of VTE did not decline substantially between 1996 and 2001 (0.72% vs 0.68%). Preoperative factors associated with symptomatic VTE were older age, male gender, corticosteroid use, COPD, recent weight loss, disseminated cancer, low albumin, and low hematocrit (all P < .01) but not DM. Postoperative factors associated with VTE were myocardial infarction (MI), blood transfusion (>4 units), coma, pneumonia, and urinary tract infection (UTI), whereas those with hemodialysis-dependent renal failure were less likely to experience VTE (all P < .01). In multivariable analysis, adjusting for age and the variables significant by bivariable analysis, the strongest positive predictors of symptomatic VTE included UTI (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.3 to 2.5), acute renal insufficiency (OR, 1.9; 95% CI, 1.1 to 3.2), postoperative transfusion (OR, 2.3; 95% CI, 1.4 to 3.7), perioperative MI (OR, 2.4; 95% CI, 1.5 to 3.9), and pneumonia (OR, 2.7; 95% CI, 2.1 to 3.5). In contrast, hemodialysis (OR, 0.3; 95% CI, 0.07 to 0.71), DM (OR, 0.75; 95% CI, 0.61 to 0.93), and higher preoperative albumin levels (OR, 0.8; 95% CI, 0.74 to 0.96, per mg/dL change) were protective from symptomatic VTE.

Conclusions: Although the overall incidence of symptomatic VTE is low in surgical patients, it is associated with significantly increased 30-day mortality. In addition to previously recognized risk factors, patients who have postoperative complications of an infectious nature, bleeding, or MI are at particular risk.

Reference:

J Vasc Surg. 2007 Feb;45(2):335-341; discussion 341-2. doi: 10.1016/j.jvs.2006.10.034.

for
VTE

Preoperative Pneumonia and Postoperative Venous Thrombosis: A Cohort Study of 427,656 Patients Undergoing Major General Surgery

Karim Z Masrouha 1Khaled M Musallam 2 3Frits R Rosendaal 4Jamal J Hoballah 5Faek R Jamali 6

PMID: 26817651. DOI: 10.1007/s00268-016-3409-1

Abstract

Background: The literature is sparse regarding the association between pneumonia and venous thrombosis in surgical patients. The aim of this study was to investigate the risk of postoperative venous thrombosis in patients who fit the criteria for preoperative pneumonia using data from the ongoing American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database while adjusting for potential confounders.

Methods: This is a cohort study using data from the ACS NSQIP database participating sites from 2008 (211 sites) and 2009 (237 sites). 427,656 patients undergoing major general surgery were included. The 30-day risk of postoperative venous thrombosis including deep vein thrombosis (DVT) and pulmonary embolism (PE) was evaluated in patients with preoperative pneumonia diagnosed before undergoing major general surgery.

Results: Patients with preoperative pneumonia had a higher incidence of both 30-day DVT and PE than patients without preoperative pneumonia. After adjusting for all potential confounders, the effect estimates for the association between preoperative pneumonia and venous thrombosis were DVT, OR: 1.67 (95% CI 1.32-2.11) and PE, OR: 2.18 (95% CI 1.48-3.22).

Conclusions: A large, multicenter database of surgical patients showed that preoperative pneumonia may increase risk for developing venous thrombosis. This adds to our understanding of risk factors for venous thrombosis and suggests a potential benefit of diagnosing preoperative pneumonia in patients undergoing major general surgery.

Reference:

World J Surg. 2016 Jun;40(6):1288-94. doi: 10.1007/s00268-016-3409-1.

. Postoperative pneumonia is also a significant VTE risk factor. Do not count an additional point for infection unless another source of infection is identified.

Existing lung disease including emphysema or COPD *

COPD Is a leading cause of morbidity and mortality worldwide characterized by systemic inflammation and venous thromboembolism in up to 30% of these patients. The presence of idiopathic pulmonary fibrosis in Association with COPD poses a higher risk for VTE.

Suffered a stroke within the past month *

Stroke is the 3rd leading cause of death and frequently leads to

Reference:

Benjamin EJ, Muntner P, Alonso A, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Das SR, Delling FN, Djousse L, Elkind MSV, Ferguson JF, Fornage M, Jordan LC, Khan SS, Kissela BM, Knutson KL, Kwan TW, Lackland DT, Lewis TT, Lichtman JH, Longenecker CT, Loop MS, Lutsey PL, Martin SS, Matsushita K, Moran AE, Mussolino ME, O’Flaherty M, Pandey A, Perak AM, Rosamond WD, Roth GA, Sampson UKA, Satou GM, Schroeder EB, Shah SH, Spartano NL, Stokes A, Tirschwell DL, Tsao CW, Turakhia MP, VanWagner LB, Wilkins JT, Wong SS, Virani SS; American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart Disease and Stroke Statistics-2019 Update: A Report From the American Heart Association. Circulation. 2019 Mar 5;139(10):e56-e528. doi: 10.1161/CIR.0000000000000659. Erratum in: Circulation. 2020 Jan 14;141(2):e33. PMID: 30700139.

. A
paradoxical embolus

Paradoxical embolism

Stephan Windecker 1Stefan Stortecky 2Bernhard Meier 2

PMID: 25060377. DOI: 10.1016/j.jacc.2014.04.063

Abstract

Paradoxical embolism is an important clinical entity among patients with venous thromboembolism in the presence of intracardiac or pulmonary shunts. The clinical presentation is diverse and potentially life-threatening. Although the serious nature and complications of paradoxical embolism are recognized, the disease entity is still rarely considered and remains under-reported. This paper provides an overview on the different clinical manifestations of paradoxical embolism, describes the diagnostic tools for the detection of intracardiac and pulmonary shunts, reviews therapeutic options, and summarizes guideline recommendations for the secondary prevention of paradoxical embolism.

Reference:
J Am Coll Cardiol. 2014 Jul 29;64(4):403-15. doi: 10.1016/j.jacc.2014.04.063.

can occur in a patient from a DVT that travels to the heart and through a patent foramen ovale (PFO) entering the systemic circulation leading to a thrombotic stroke. Another common cause of an embolic stroke occurs in patients with
atrial fibrillation

Antithrombotic Therapy for Atrial Fibrillation: CHEST Guideline and Expert Panel Report

Gregory Y H Lip 1Amitava Banerjee 2Giuseppe Boriani 3Chern En Chiang 4Ramiz Fargo 5Ben Freedman 6Deirdre A Lane 7Christian T Ruff 8Mintu Turakhia 9David Werring 10Sheena Patel 11Lisa Moores 12

PMID: 30144419. DOI: 10.1016/j.chest.2018.07.040

Abstract

Background: The risk of stroke is heterogeneous across different groups of patients with atrial fibrillation (AF), being dependent on the presence of various stroke risk factors. We provide recommendations for antithrombotic treatment based on net clinical benefit for patients with AF at varying levels of stroke risk and in a number of common clinical scenarios.

Methods: Systematic literature reviews were conducted to identify relevant articles published from the last formal search perfomed for the Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (9th Edition). The overall quality of the evidence was assessed using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach. Graded recommendations and ungraded consensus-based statements were drafted, voted on, and revised until consensus was reached.

Results: For patients with AF without valvular heart disease, including those with paroxysmal AF, who are at low risk of stroke (eg, CHA2DS2-VASc [congestive heart failure, hypertension, age ≥ 75 (doubled), diabetes, stroke (doubled)-vascular disease, age 65-74 and sex category (female)] score of 0 in males or 1 in females), we suggest no antithrombotic therapy. The next step is to consider stroke prevention (ie, oral anticoagulation therapy) for patients with 1 or more non-sex CHA2DS2-VASc stroke risk factors. For patients with a single non-sex CHA2DS2-VASc stroke risk factor, we suggest oral anticoagulation rather than no therapy, aspirin, or combination therapy with aspirin and clopidogrel; and for those at high risk of stroke (eg, CHA2DS2-VASc ≥ 2 in males or ≥ 3 in females), we recommend oral anticoagulation rather than no therapy, aspirin, or combination therapy with aspirin and clopidogrel. Where we recommend or suggest in favor of oral anticoagulation, we suggest using a non-vitamin K antagonist oral anticoagulant drug rather than adjusted-dose vitamin K antagonist therapy. With the latter, it is important to aim for good quality anticoagulation control with a time in therapeutic range > 70%. Attention to modifiable bleeding risk factors (eg, uncontrolled BP, labile international normalized ratios, concomitant use of aspirin or nonsteroidal antiinflammatory drugs in an anticoagulated patient, alcohol excess) should be made at each patient contact, and HAS-BLED (hypertension, abnormal renal/liver function [1 point each], stroke, bleeding history or predisposition, labile international normalized ratio, elderly (0.65), drugs/alcohol concomitantly [1 point each]) score used to assess the risk of bleeding where high risk patients (≥ 3) should be reviewed and followed up more frequently.

Conclusions: Oral anticoagulation is the optimal choice of antithrombotic therapy for patients with AF with ≥1 non-sex CHA2DS2-VASc stroke risk factor(s).

Reference:

Chest. 2018 Nov;154(5):1121-1201. doi: 10.1016/j.chest.2018.07.040.Epub 2018 Aug 22.

. Thrombotic strokes in the past should be counted as a previous thrombosis and scored as 3
points

Insights from thrombi retrieved in stroke due to large vessel occlusion

Marco Bacigaluppi 1Aurora Semerano 1Giorgia Serena Gullotta 1Davide Strambo 1 2

PMID: 31213164. PMCID: PMC6681524. DOI: 10.1177/0271678X19856131

Abstract

The recent advances of endovascular procedures to treat stroke due to large cerebral vessel occlusion have made it possible to analyze the retrieved thrombus material. Analysis of cerebral thrombi is emerging as a relevant opportunity to complement the diagnostic workup of etiology, to develop new lytic approaches and to optimize the acute treatment of stroke due to large vessel occlusion. Nonetheless, retrieved thrombi are frequently discarded since their informative potential is often neglected and standards are missing. This review provides an overview of the current knowledge and expanding research relating to thrombus composition analysis in large vessel occlusions. We first discuss the heterogeneity of thrombogenic factors that underlie the thrombotic formation in stroke and its implications to identify stroke etiology and thrombus age. Further, we show that understanding structural characteristics of thrombus is pivotal for the development of new-targeted lytic therapies as well as to improve, through thrombus modeling, the development of thrombectomy devices. Finally, we discuss the on-going attempts to identify a signature of thrombus composition indirectly through imaging and peripheral blood biomarkers, which might in future assist treatment decision-making as well as secondary prevention. Thrombus analysis might contribute to the advancement and optimization of personalized stroke treatments.

Reference:

J Cereb Blood Flow Metab. 2019 Aug;39(8):1433-1451.doi: 10.1177/0271678X19856131. Epub 2019 Jun 18.

.

Bed rest or restricted mobility during the past month *

Defined -- not being able to walk 30 feet (10 meters) at one time. Bathroom privileges or walking in the room are not considered ambulation. Walking this distance reduces the VTE risk by

50%

Does ambulation modify venous thromboembolism risk in acutely ill medical patients?

Alpesh N Amin 1Frederick GirardMeyer M Samama

PMID: 20838741. DOI: 10.1160/TH10-04-0236

Abstract

In the US, ambulatory status is often a criterion for stopping prophylaxis for venous thromboembolism (VTE). In an analysis of the prophylaxis in MEDical patients with ENOXaparin (MEDENOX) trial, ambulatory status was assessed as outcome and patients grouped accordingly for further analysis. Rates of VTE and bleeding were evaluated. Using multivariate logistic regression, the relationships between thromboprophylaxis, VTE risk, and ambulatory status were assessed. Ambulatory status was reached in 607/1,084 patients, in a mean time of 4.4 days. Thromboprophylaxis was provided for 7.3 and 7.7 days in the ambulatory and non-ambulatory groups. Although VTE rates were lower in ambulatory patients, enoxaparin 40 mg once daily significantly reduced the risk of VTE vs. placebo in ambulatory (3.3% vs. 10.6%; relative risk [RR] = 0.31; 95% confidence interval [CI], 0.13-0.78; p=0.008) and non-ambulatory patients (9.0% vs. 19.7%; RR = 0.46; 95% CI, 0.23-0.91; p=0.02). Major bleeding was not significantly different between enoxaparin and placebo in either group. By multivariate regression analysis, VTE risk in ambulatory patients was lower with enoxaparin vs. placebo (odds ratio [OR] = 0.28; 95% CI, 0.11-0.74; p=0.01), but higher in patients with a history of VTE (OR = 3.74; 95% CI, 1.59-8.84; p=0.003) or cancer (OR = 2.12; 95% CI, 1.00-4.48; p=0.049). Despite timely mobilisation, patients who become ambulatory are at VTE risk and experience a significant risk reduction with enoxaparin 40 mg. Therefore, it is essential that ambulatory patients receive recommended thromboprophylaxis.

Reference:

Thromb Haemost. 2010 Nov;104(5):955-61. doi: 10.1160/TH10-04-0236. Epub 2010 Sep 13.

. Click here for
video

.


MOBILITY - BEDREST > 3 Days.
Defined -- Same mobility distance as above. PE mortality increased for those immobile for >

4 days

Influence of recent immobilization and recent surgery on mortality in patients with pulmonary embolism

D Nauffal 1M BallesterR Lopez ReyesD JiménezR OteroR QuintavallaM MonrealRIETE Investigators

Collaborators,

PMID: 22726525. DOI: 10.1111/j.1538-7836.2012.04829.x

Abstract

Background: The influence of recent immobilization or surgery on mortality in patients with pulmonary embolism (PE) is not well known.

Methods: We used the Registro Informatizado de Enfermedad TromboEmbólica (RIETE) data to compare the 3-month mortality rate in patients with PE, with patients categorized according to the presence of recent immobilization, recent surgery, or neither.

Results: Of 18,028 patients with PE, 4169 (23%) had recent immobilization, 2212 (12%) had recent surgery, and 11,647 (65%) had neither. The all-cause mortality was 10.0% (95% confidence interval [CI] 9.5-10.4), and the PE-related mortality was 2.6% (95% CI 2.4-2.9). One in every two patients who died from PE had recent immobilization (43%) or recent surgery (6.7%). Only 25% of patients with immobilization had received prophylaxis, as compared with 65% of the surgical patients. Fatal PE was more common in patients with recent immobilization (4.9%; 95% CI 4.3-5.6) than in those with surgery (1.4%; 95% CI 1.0-2.0) or those with neither (2.1%; 95% CI 1.8-2.3). On multivariate analysis, patients with immobilization were at increased risk for fatal PE (odds ratio 2.2; 95% CI 1.8-2.7), with no differences being seen between patients immobilized in hospital or in the community.

Conclusions: Forty-three per cent of patients dying from PE had recent immobilization for ≥4 days. Many of these deaths could have been prevented.

Reference:

J Thromb Haemost. 2012 Sep;10(9):1752-60. doi: 10.1111/j.1538-7836.2012.04829.x.

.

Non-removable plaster cast, removable leg brace or mold that has kept you from moving your leg within the last month *

This includes any 

device

The impact of risk assessment on the implementation of venous thromboembolism prophylaxis in foot and ankle surgery

Nikiforos Pandelis Saragas 1Paulo Norberto Faria Ferrao 2Evanthia Saragas 3Barry F Jacobson 4

PMID: 24796824. DOI: 10.1016/j.fas.2013.11.002

Abstract

Background: The purpose of this prospective study was to determine whether the more frequently quoted procedure and patient specific risk factors have any impact in the implementation of venous thromboembolism (VTE) prophylaxis following foot and ankle surgery.

Methods: Two hundred and sixteen patients were included in the study. A variety of operative procedures was carried out with the common denominator being a below knee cast for at least 4 weeks and nonweightbearing for an average of 6 weeks in 130 patients. The remainder of the patients (88) had hallux surgery not requiring a cast and were allowed to weightbear. No patient received any form of thromboprophylaxis postoperatively. All patients were subjected to compression ultrasonography for deep vein thrombosis (DVT) between 2 and 6 weeks postoperatively.

Results: There was a 5.09% incidence of VTE (0.9% pulmonary embolism) overall. As no VTE (neither DVT nor pulmonary embolus) developed in the hallux subgroup, i.e. patients not requiring immobilization and were allowed to weightbear, the incidence of VTE in the cast/nonweightbearing group was 8.46%. The results are descriptive and only statistically analyzed where possible, as the sample size of the VTE group was small. There was no significant difference in number of risk factors and no association between gender in the VTE and non VTE groups. 90.9% of patients in the VTE group had a total risk factor score of 5 or more and 73.7% of patients in the non VTE group had a total risk factor score of 5 or more. The average timing to the diagnosis of VTE in this current study was 33.1 days.

Conclusions: In view of the unacceptable incidence of VTE and the average total risk factor score of 5 or more (for which thromboprophylaxis is recommended) in the majority of the patients, the authors feel that the routine use of thromboprophylaxis in foot and ankle surgery requiring nonweightbearing in combination with short leg cast immobilization, is warranted. This prophylaxis should continue until the patient regains adequate mobility either by weightbearing (in or out of the cast) or removal of cast immobilization (weightbearing or nonweightbearing), usually between 28 and 42 days.

Reference:

Foot Ankle Surg. 2014 Jun;20(2):85-9. doi: 10.1016/j.fas.2013.11.002. Epub 2013 Nov 14.

that interferes with calf muscle pumping action by limiting ankle
motion

Pharmacological thromboprophylaxis to prevent venous thromboembolism in patients with temporary lower limb immobilization after injury: systematic review and network meta-analysis

Daniel Horner 1 2John W Stevens 2Abdullah Pandor 2Tim Nokes 3Jonathan Keenan 3Kerstin de Wit 4Steve Goodacre 2

PMID: 31654551. PMCID: PMC7028118. DOI: 10.1111/jth.14666

Abstract

Background: Thromboprophylaxis has the potential to reduce venous thromboembolism (VTE) following lower limb immobilization resulting from injury.

Objectives: We aimed to estimate the effectiveness of thromboprophylaxis, compare different agents, and identify any factors associated with effectiveness.

Methods: We undertook a systematic review and network meta-analysis (NMA) of randomized trials reporting VTE or bleeding outcomes that compared thromboprophylactic agents with each other or to no pharmacological prophylaxis, for this indication. An NMA was undertaken for each outcome or agent used, and a series of study-level network meta-regressions examined whether population characteristics, type of injury, treatment of injury, or duration of thromboprophylaxis were associated with treatment effect.

Results: Data from 6857 participants across 13 randomized trials showed that, compared with no treatment, low molecular weight heparin (LMWH) reduced the risk of any VTE (odds ratio [OR]: 0.52; 95% credible interval [CrI]: 0.37-0.71), clinically detected deep vein thrombosis (DVT) (OR: 0.39; 95% CrI: 0.12-0.94) and pulmonary embolism (PE) (OR: 0.16; 95% CrI: 0.01-0.74), whereas fondaparinux reduced the risk of any VTE (OR: 0.13; 95% CrI: 0.05-0.30) and clinically detected DVT (OR: 0.10; 95% CrI: 0.01-0.86), with inconclusive results for PE (OR: 0.40; 95% CrI: 0.01-7.53).

Conclusions: Thromboprophylaxis with either fondaparinux or LMWH appears to reduce the odds of both asymptomatic and clinically detected VTE in people with temporary lower limb immobilization following an injury. Treatment effects vary by outcome and are not always conclusive. We were unable to identify any treatment effect modifiers other than thromboprophylactic agent used.

J Thromb Haemost. 2020 Feb;18(2):422-438. doi: 10.1111/jth.14666.Epub 2019 Dec 1.

 

. Patients who are not weight bearing are also at-risk since no improvement in baseline blood flow
occurs

The effect of ankle joint immobilization on lower limb venous flow

Johnathan D Craik 1Amanda Clark 2James Hendry 2Andrea H Sott 2Paul D Hamilton 2

PMID: 25249319. DOI: 10.1177/1071100714552823

Abstract

Background: Below-knee cast immobilization is associated with an increased risk of developing deep vein thrombosis secondary to venous stasis. We investigated the effect of weight-bearing in a below-knee cast or pneumatic walking boot on lower limb venous blood flow.

Methods: Duplex ultrasonography was used to measure venous blood flow in the popliteal vein of 10 healthy volunteers. Venous blood flow was measured while at rest, ambulating non-weight-bearing, partial weight-bearing, and full weight-bearing. Measurements were performed without ankle joint immobilization, with the ankle immobilized in a neutral cast, and with the ankle immobilized in a pneumatic walking boot in both neutral and equinus.

Results: There was no significant reduction in venous blood flow measurements between full weight-bearing without ankle joint immobilization and full weight-bearing in a neutral cast or neutral pneumatic walking boot. However, venous blood flow was reduced when partial weight-bearing (50%) and when full weight-bearing in a pneumatic walking boot in equinus.

Conclusion: These results demonstrate that venous blood flow returned to normal levels when the subjects were permitted to fully bear weight in below-knee casts or walking boots, provided that the ankle joint was not in equinus.

Clinical relevance: Weight-bearing status and ankle joint position should be appreciated during decisions for the provision of chemical thromboprophylaxis.

Reference:

Foot Ankle Int.  2015 Jan;36(1):18-23.

 doi: 10.1177/1071100714552823. Epub 2014 Sep 23.

.

Age – Please check one box *

Venous thromboembolism is

rare

Incidence and mortality of venous thrombosis: a population-based study

I A Naess 1S C ChristiansenP RomundstadS C CannegieterF R RosendaalJ Hammerstrøm

PMID: 17367492 DOI: 10.1111/j.1538-7836.2007.02450.x

Abstract

Background: Estimates of the incidence of venous thrombosis (VT) vary, and data on mortality are limited.

Objectives: We estimated the incidence and mortality of a first VT event in a general population.

Methods: From the residents of Nord-Trøndelag county in Norway aged 20 years and older (n = 94 194), we identified all cases with an objectively verified diagnosis of VT that occurred between 1995 and 2001. Patients and diagnosis characteristics were retrieved from medical records.

Results: Seven hundred and forty patients were identified with a first diagnosis of VT during 516,405 person-years of follow-up. The incidence rate for all first VT events was 1.43 per 1000 person-years [95% confidence interval (CI): 1.33-1.54], that for deep-vein thrombosis (DVT) was 0.93 per 1000 person-years (95% CI: 0.85-1.02), and that for pulmonary embolism (PE) was 0.50 per 1000 person-years (95% CI: 0.44-0.56). The incidence rates increased exponentially with age, and were slightly higher in women than in men. The 30-day case-fatality rate was higher in patients with PE than in those with DVT [9.7% vs. 4.6%, risk ratio 2.1 (95% CI: 1.2-3.7)]; it was also higher in patients with cancer than in patients without cancer [19.1% vs. 3.6%, risk ratio 3.8 (95% CI 1.6-9.2)]. The risk of dying was highest in the first months subsequent to the VT, after which it gradually approached the mortality rate in the general population.

Conclusions: This study provides estimates of incidence and mortality of a first VT event in the general population.

Reference:

Thromb Haemost. 2007 Apr;5(4):692-9. doi: 10.1111/j.1538-7836.2007.02450.x.

in children and young adults unless they have strong predisposing risk factors. These may include cancer, trauma, indwelling lines , systemic infection, or family history of thrombosis. Patients who are greater than
40 years

Prevention of postoperative deep venous thrombosis and pulmonary emboli with combined modalities

M BorowH J Goldson

PMID: 6195948

Abstract

Worldwide statistics reveal that 25 to 40 per cent of patients who are over the age of 40 years and operated on for 1 or more hours will develop a deep venous thrombosis (DVT). The studies reviewed in this paper were performed to evaluate several modalities and compare their effectiveness in preventing DVT in postoperative patients. In the first study, five modalities plus a control group were evaluated in 562 patients from five surgical specialties. The incidence of DVT in the control group was 35 per cent. Though most of the pharmacologic agents were effective in reducing the incidence of DVT, the antistasis devices (gradient elastic stockings and intermittent pneumatic compression) were most effective. The purpose of the second study was to evaluate the effectiveness of combining a pharmacologic drug with an antistasis modality. Deep venous thrombosis was virtually eliminated in this group of 328 patients. There was only a 1.5 per cent incidence of DVT in the treated population as compared to a 26.8 per cent incidence in the control group. Thus, it seems that combining one antistasis and one pharmacologic agent greatly reduces the incidence of lower extremity thrombi. I-125 fibrinogen scanning was the most sensitive test in detecting DVT and had an accuracy of 97 per cent.

Reference:

Am Surg. 1983 Nov;49(11):599-605.

of age remain at significantly increased risk compared to younger patients and the risk approximately doubles with each subsequent
decade

Risk factors for venous thromboembolism

Frederick A Anderson Jr 1Frederick A Spencer

PMID: 12814980 DOI: 10.1161/01.CIR.0000078469.07362.E6

Abstract

Until the 1990s, venous thromboembolism (VTE) was viewed primarily as a complication of hospitalization for major surgery (or associated with the late stage of terminal illness). However, recent trials in patients hospitalized with a wide variety of acute medical illnesses have demonstrated a risk of VTE in medical patients comparable with that seen after major general surgery. In addition, epidemiologic studies have shown that between one quarter and one half of all clinically recognized symptomatic VTEs occur in individuals who are neither hospitalized nor recovering from a major illness. This expanding understanding of the population at risk challenges physicians to carefully examine risk factors for VTE to identify high-risk patients who could benefit from prophylaxis. Factors sufficient by themselves to prompt physicians to consider VTE prophylaxis include major surgery, multiple trauma, hip fracture, or lower extremity paralysis because of spinal cord injury. Additional risk factors, such as previous VTE, increasing age, cardiac or respiratory failure, prolonged immobility, presence of central venous lines, estrogens, and a wide variety of inherited and acquired hematological conditions contribute to an increased risk for VTE. These predisposing factors are seldom sufficient by themselves to justify the use of prophylaxis. Nevertheless, individual risk factors, or combinations thereof, can have important implications for the type and duration of appropriate prophylaxis and should be carefully reviewed to assess the overall risk of VTE in each patient.

Reference:

Circulation. 2003 Jun 17;107(23 Suppl 1):I9-16. doi: 10.1161/01.CIR.0000078469.07362.E6.

.

 

Please indicate your gender *
Current use of birth control or Hormone Replacement Therapy (HRT)
Birth control replacement

Combined oral contraceptives, thrombophilia and the risk of venous thromboembolism: a systematic review and meta-analysis

E F W van Vlijmen 1S Wiewel-Verschueren 1 2T B M Monster 3K Meijer 1

PMID: 27121914. DOI: 10.1111/jth.13349

Abstract

Essentials We performed a meta-analysis on thrombosis risk in thrombophilic oral contraceptive (COC)-users. The results support discouraging COC-use in women with a natural anticoagulant deficiency. Contrary, additive risk of factor V Leiden (FVL) or prothrombin-G20210A (PT) mutation is modest. Women with a FVL/PT-mutation as single risk factor can use COCs if alternatives are not tolerated.

Summary: Background Combined oral contraceptives (COCs) are associated with an increased risk of venous thromboembolism (VTE), which is shown to be more pronounced in women with hereditary thrombophilia. Currently, WHO recommendations state that COC-use in women with hereditary thrombophilias (antithrombin deficiency, protein C deficiency, protein S deficiency, factor V Leiden and prothrombin-G20210A mutation) is associated with an unacceptable health risk. Objective To perform a meta-analysis evaluating the additional risk of VTE in COC-users with thrombophilia. Methods The MEDLINE and EMBASE databases were searched on 10 February 2015 for potential eligible studies. A distinction was made between ‘mild’ (factor V Leiden and prothrombin-G20210A mutation) and ‘severe’ thrombophilia (antithrombin deficiency, protein C deficiency, protein S deficiency, double heterozygosity or homozygosity of factor V Leiden and prothrombin-G20210A mutation). Results We identified 12 case-control and three cohort studies. In COC-users, mild and severe thrombophilia increased the risk of VTE almost 6-fold (rate ratio [RR], 5.89; 95% confidence interval [CI], 4.21-8.23) and 7-fold (RR, 7.15; 95% CI, 2.93-17.45), respectively. The cohort studies showed that absolute VTE risk was far higher in COC-users with severe thrombophilia than in those with mild thrombophilia (4.3 to 4.6 vs. 0.49 to 2.0 per 100 pill-years, respectively), and these differences in absolute risks were also noted in non-affected women (0.48 to 0.7 vs. 0.19 to 0.0), but with the caveat that absolute risks were estimated in relatives of thrombophilic patients with VTE (i.e. with a positive family history). Conclusion These results support discouraging COC-use in women with severe hereditary thrombophilia. By contrast, additive VTE risk of mild thrombophilia is modest. When no other risk factors are present, (e.g. family history) COCs can be offered to these women when reliable alternative contraceptives are not tolerated.

Reference:

J Thromb Haemost. 2016 Jul;14(7):1393-403. doi: 10.1111/jth.13349.Epub 2016 Jun 16.

is a risk factor for thrombosis which has
many variables

Different combined oral contraceptives and the risk of venous thrombosis: systematic review and network meta-analysis

Bernardine H Stegeman 1Marcos de BastosFrits R RosendaalA van Hylckama VliegFrans M HelmerhorstTheo StijnenOlaf M Dekkers

PMID: 24030561. PMCID: PMC3771677. DOI: 10.1136/bmj.f5298

Abstract

Objective: To provide a comprehensive overview of the risk of venous thrombosis in women using different combined oral contraceptives.

Design: Systematic review and network meta-analysis.

Data sources: PubMed, Embase, Web of Science, Cochrane, Cumulative Index to Nursing and Allied Health Literature, Academic Search Premier, and ScienceDirect up to 22 April 2013.

Review methods: Observational studies that assessed the effect of combined oral contraceptives on venous thrombosis in healthy women. The primary outcome of interest was a fatal or non-fatal first event of venous thrombosis with the main focus on deep venous thrombosis or pulmonary embolism. Publications with at least 10 events in total were eligible. The network meta-analysis was performed using an extension of frequentist random effects models for mixed multiple treatment comparisons. Unadjusted relative risks with 95% confidence intervals were reported. The requirement for crude numbers did not allow adjustment for potential confounding variables.

Results: 3110 publications were retrieved through a search strategy; 25 publications reporting on 26 studies were included. Incidence of venous thrombosis in non-users from two included cohorts was 1.9 and 3.7 per 10,000 woman years, in line with previously reported incidences of 1-6 per 10,000 woman years. Use of combined oral contraceptives increased the risk of venous thrombosis compared with non-use (relative risk 3.5, 95% confidence interval 2.9 to 4.3). The relative risk of venous thrombosis for combined oral contraceptives with 30-35 µg ethinylestradiol and gestodene, desogestrel, cyproterone acetate, or drospirenone were similar and about 50-80% higher than for combined oral contraceptives with levonorgestrel. A dose related effect of ethinylestradiol was observed for gestodene, desogestrel, and levonorgestrel, with higher doses being associated with higher thrombosis risk.

Conclusion: All combined oral contraceptives investigated in this analysis were associated with an increased risk of venous thrombosis. The effect size depended both on the progestogen used and the dose of ethinylestradiol.

Reference:

BMJ. 2013 Sep 12;347:f5298. doi: 10.1136/bmj.f5298.

depending on the drug and dose combinations, the risk of thrombosis
drug and dose combinations

Mechanisms of estrogen-induced venous thromboembolism

Svetlana N Tchaikovski 1Jan Rosing

PMID: 20163835. DOI: 10.1016/j.thromres.2010.01.045

Abstract

The use of oral contraceptives (OC) is a well established risk factor for venous thrombosis. It has been known for many years that almost all haemostatic parameters i.e. plasma levels of coagulation factors, anticoagulant proteins and proteins involved in the fibrinolytic pathway change during OC use. The discovery of several risk factors of venous thrombosis in the 1990s shed new light on the association between the effects of OC on the haemostatic system and the increased risk of venous thrombosis. In this review, we summarize the current knowledge on the effects of different kinds of hormonal contraceptives (OC, transdermal contraceptives, vaginal ring and levonorgestrel-releasing intrauterine device) on haemostatic variables and the relationship between the changes of these variables and the risk of venous thrombosis.

Reference:

Thromb Res. 2010 Jul;126(1):5-11. doi: 10.1016/j.thromres.2010.01.045.Epub 2010 Feb 16.

.
Hormone replacement

Use of hormone replacement therapy and risk of venous thromboembolism: nested case-control studies using the QResearch and CPRD databases

Yana Vinogradova 1Carol Coupland 2Julia Hippisley-Cox 2

PMID: 30626577. PMCID: PMC6326068. DOI: 10.1136/bmj.k4810

Erratum in

[No authors listed]BMJ. 2019 Jan 15;364:l162. doi: 10.1136/bmj.l162.PMID: 30647094 Free PMC article. No abstract available.

Abstract

Objective: To assess the association between risk of venous thromboembolism and use of different types of hormone replacement therapy.

Design: Two nested case-control studies.

Setting: UK general practices contributing to the QResearch or Clinical Practice Research Datalink (CPRD) databases, and linked to hospital, mortality, and social deprivation data.

Participants: 80 396 women aged 40-79 with a primary diagnosis of venous thromboembolism between 1998 and 2017, matched by age, general practice, and index date to 391 494 female controls.

Main outcome measures: Venous thromboembolism recorded on general practice, mortality, or hospital records. Odds ratios were adjusted for demographics, smoking status, alcohol consumption, comorbidities, recent medical events, and other prescribed drugs.

Results: Overall, 5795 (7.2%) women who had venous thromboembolism and 21 670 (5.5%) controls had been exposed to hormone replacement therapy within 90 days before the index date. Of these two groups, 4915 (85%)and 16 938 (78%) women used oral therapy, respectively, which was associated with a significantly increased risk of venous thromboembolism compared with no exposure (adjusted odds ratio 1.58, 95% confidence interval 1.52 to 1.64), for both oestrogen only preparations (1.40, 1.32 to 1.48) and combined preparations (1.73, 1.65 to 1.81). Estradiol had a lower risk than conjugated equine oestrogen for oestrogen only preparations (0.85, 0.76 to 0.95) and combined preparations (0.83, 0.76 to 0.91). Compared with no exposure, conjugated equine oestrogen with medroxyprogesterone acetate had the highest risk (2.10, 1.92 to 2.31), and estradiol with dydrogesterone had the lowest risk (1.18, 0.98 to 1.42). Transdermal preparations were not associated with risk of venous thromboembolism, which was consistent for different regimens (overall adjusted odds ratio 0.93, 95% confidence interval 0.87 to 1.01).

Conclusions: In the present study, transdermal treatment was the safest type of hormone replacement therapy when risk of venous thromboembolism was assessed. Transdermal treatment appears to be underused, with the overwhelming preference still for oral preparations

 

later in life is also a significant risk factor for thrombosis.
Pregnant or had a baby within the last month?

Pregnancy Represents a risk factor for thrombosis which escalates during 

pregnancy

Thromboprophylaxis in Pregnancy

Diana Kolettis 1Sabrina Craigo 2

PMID: 29747737. DOI: 10.1016/j.ogc.2018.01.007

Abstract

Venous thromboembolism is a leading cause of maternal morbidity and mortality worldwide. Identifying women who are at greatest risk for venous thromboembolism, and managing their pregnancies with appropriate thromboprophylaxis is essential to decreasing this life-threatening condition. Those at greatest risk are patients with thrombophilias, a personal or family history of venous thromboembolism, and those undergoing cesarean delivery. Current international guidelines on thromboprophylaxis vary in details, but all strategies rely on risk factor identification and thromboprophylaxis for the highest risk patients. All guidelines require clinicians to think critically about individual patient’s risk factors throughout pregnancy and the postpartum period.

Keywords: Pregnancy; Prophylaxis; Thromboembolism; Thromboprophylaxis.

Reference:

Obstet Gynecol Clin North Am. 2018 Jun;45(2):389-402. doi: 10.1016/j.ogc.2018.01.007.

 

and may reach the highest risk level in the postpartum period.

History of unexplained stillborn infant, recurrent spontaneous abortion (more than 3), premature birth with toxemia or growth restricted infant?

Patients who have experience these

obstetrical complications

(slide)may harvest the antiphospholipid antibody syndrome. This is an acquired thrombophilia marker that maybe present in the patients blood
long after the obstetrical event

Persistent antiphospholipid antibody (aPL) in asymptomatic carriers as a risk factor for future thrombotic events: a nationwide prospective study

P Mustonen 1K V Lehtonen 2K Javela 3M Puurunen 4

PMID: 25164304. DOI: 10.1177/0961203314545410

Abstract

Objectives: The long-term prognosis of individuals fulfilling the laboratory criteria, but not clinical criteria, of antiphospholipid syndrome (APS) has not been widely investigated. The primary aim of this study was to evaluate the incidence of first thrombotic event (deep venous thrombosis (DVT), pulmonary embolism (PE), myocardial infarction (MI), stroke or transient ischaemic attack (TIA) in a nationwide antiphospholipid antibody (aPL) carrier cohort.

Design: We conducted a prospective nationwide cohort study.

Setting: The aPL profile of participants was recorded from the laboratory database. Information was collected about thrombotic and pregnancy complications, subsequent medical history, other risk factors for thrombosis, use of prophylactic antithrombotic medication and general health.

Participants: Participants included adult asymptomatic aPL carriers recognized in Finland during 1971-2009.

Main outcome measure: The main outcome measure was incidence of first thrombotic event.

Results: A total of 119 (89% female) aPL carriers were followed for mean (SD) of 9.1 (7.5) years (range 3-41 years). Sixty-one per cent of the study participants had autoimmune disease, most often systemic lupus erythematosus (SLE). Thirty-six of 119 (30%) were either double or triple positive, 56% single lupus anticoagulant (LA) positive, and 8% and 5% single anticardiolipin antibodies (aCL) and anti-β2glycoprotein I antibodies (aβ2GPI) positive, respectively. Nine (7.6%) study patients experienced a first thrombotic event (five DVT, one PE, two MI, one TIA) mean (SD) 7.2 (8.3) years (range 1-26 years) after aPL detection (annual incidence rate 0.8%). All individuals who developed thrombotic complications had autoimmune disease. Annual rate of first thrombotic event in carriers of single positivity (0.65%) was equal to the known risk of thrombosis in the healthy Caucasian population, whereas the rate was two times higher in carriers of double or triple positivity (1.27%). Sixteen of 79 (20%) women experienced pregnancy complications.

Conclusions: Double or triple positivity for aPL is a risk factor for future thrombotic events, especially in individuals with an underlying autoimmune disease, whereas single positivity does not seem to carry an elevated risk of thrombosis.

Keywords: Antiphospholipid antibodies; anticardiolipin antibodies; lupus anticoagulant; thrombosis; β2-glycoprotein I antibodies.

Reference:

2014 Dec;23(14):1468-76. doi: 10.1177/0961203314545410. Epub 2014 Aug 27.

.

Current or past malignancy, excluding basal cell skin cancer

This factor excludes basal cell skin cancer except for melanoma. Cancer is a major factor for developing

VTE

Incidence of venous thromboembolism in patients undergoing surgical treatment for malignancy by type of neoplasm: An analysis of ACS-NSQIP data from 2005 to 2010

Caroline E Reinke 1Giorgos C KarakousisRachel A HadlerJeffrey A DrebinDouglas L FrakerRachel R Kelz

PMID: 22828139. DOI: 10.1016/j.surg.2012.05.003

Abstract

Introduction: This study investigates the incidence, relative risk, and adjusted odds ratio of venous thromboembolism (VTE) among patients with malignant neoplasms compared with those with benign neoplasms, as well as the incidence of outpatient VTE diagnosis.

Methods: We performed a retrospective cohort study of patients in the ACS-NSQIP database from 2005 to 2010 with a postoperative diagnosis of neoplasm. The incidence of 30-day VTE, post-VTE death, the incidence of postdischarge VTE diagnosis, and the relative risk of postoperative VTE was calculated by cancer site. Logistic regression was used to calculate an independent odds ratio for each neoplasm site, adjusting for age, gender, body mass index, and operative time.

Results: Of 208,200 patients, 159,752 had a malignant diagnosis of the sites of interest and 48,448 had benign/carcinoma in situ neoplasms. The incidence, relative risk, and odds ratio of 30-day VTE varied substantially by site of malignancy. The absolute incidence of outpatient VTE diagnosis varied by site and percent of VTE diagnosed as an outpatient was found to increase over time.

Conclusion: Recommendations for VTE prophylaxis and duration of VTE prophylaxis for patients undergoing operations may benefit from tailoring to the specific type of malignancy. The increasing percentage of VTE events diagnosed as an outpatient may impact hospitals substantially as financial penalties for readmission are enacted.

Reference:

Surgery. 2012 Aug;152(2):186-92. doi: 10.1016/j.surg.2012.05.003.

. VTE in the cancer patient is one of the leading causes of death and is associated with a decrease in quality of
life

Incidence of venous thromboembolism and its effect on survival among patients with common cancers

Helen K Chew 1Theodore WunDanielle HarveyHong ZhouRichard H White

PMID: 16505267. DOI: 10.1001/archinte.166.4.458

Abstract

Background: The incidence of venous thromboembolism after diagnosis of specific cancers and the effect of thromboembolism on survival are not well defined.

Methods: The California Cancer Registry was linked to the California Patient Discharge Data Set to determine the incidence of venous thromboembolism among cancer cases diagnosed between 1993 and 1995. The incidence and timing of thromboembolism within 1 and 2 years of cancer diagnosis and the risk factors associated with thromboembolism and death were determined.

Results: Among 235 149 cancer cases, 3775 (1.6%) were diagnosed with venous thromboembolism within 2 years, 463 (12%) at the time cancer was diagnosed and 3312 (88%) subsequently. In risk-adjusted models, metastatic disease at the time of diagnosis was the strongest predictor of thromboembolism. Expressed as events per 100 patient-years, the highest incidence of thromboembolism occurred during the first year of follow-up among cases with metastatic-stage pancreatic (20.0), stomach (10.7), bladder (7.9), uterine (6.4), renal (6.0), and lung (5.0) cancer. Adjusting for age, race, and stage, diagnosis of thromboembolism was a significant predictor of decreased survival during the first year for all cancer types (hazard ratios, 1.6-4.2; P<.01).

Conclusions: The incidence of venous thromboembolism varied with cancer type and was highest among patients initially diagnosed with metastatic-stage disease. The incidence rate of thromboembolism decreased over time. Diagnosis of thromboembolism during the first year of follow-up was a significant predictor of death for most cancer types and stages analyzed. For some types of cancer, the incidence of thromboembolism was sufficiently high to warrant prospective clinical trials of primary thromboprophylaxis.

Reference:

Arch Intern Med. 2006 Feb 27;166(4):458-64. doi: 10.1001/archinte.166.4.458.

.

Tube in blood vessel or neck or chest that delivers blood or medicine directly to heart within the past month (also called central venous access, PICC line, or port)

Catheter

Central venous catheters and upper extremity deep vein thrombosis in medical inpatients: the Medical Inpatients and Thrombosis (MITH) Study

J P Winters 1P W Callas 1M Cushman 1A B Repp 1N A Zakai 1

PMID: 26340226. DOI: 10.1111/jth.13131

Abstract

Background: Upper extremity deep vein thrombosis (UEDVT) is an increasingly recognized complication in medical inpatients, with few data available regarding the incidence, risk factors and association with central venous catheter (CVC) use.

Methods: Between 2002 and 2009 all cases of hospital-acquired venous thromboembolism (VTE) at a university hospital were frequency matched 1 : 2 to non-cases without VTE by admission year and medical service. Records were abstracted to identify, characterize and assess risk factors for UEDVT. Weighted logistic regression was used to calculate odds ratios (ORs) for UEDVT associated with use of a CVC, adjusting for known VTE risk factors.

Results: Two hundred and ninety-nine cases of VTE complicated 64 034 admissions to medical services (4.6 per 1000 admissions). UEDVT constituted 51% (91/180) of all deep vein thrombosis (DVT), for an incidence of 1.4 per 1000 admissions (95% confidence interval [CI], 0.8-1.7). There were 247 CVCs placed per 1000 admissions (95% CI, 203-292). The use of a CVC was associated with a 14.0-fold increased risk of UEDVT (95% CI, 5.9-33.2), but was not associated with a significantly increased risk of PE (OR, 1.3; 95% CI, 0.8-2.1). Peripherally inserted central catheters had a higher OR for UEDVT (OR, 13.0; 95% CI, 6.1-27.6) than centrally inserted central venous catheters (CICC) (OR, 3.4; 95% CI, 1.7-6.8).

Conclusion: UEDVT is a relevant complication affecting medical inpatients, accounting for half of hospital-acquired DVTs. Use of CVCs was strongly associated with risk of UEDVT.

Reference:

J Thromb Haemost. 2015 Dec;13(12):2155-60. doi: 10.1111/jth.13131. Epub 2015 Oct 27.

in a blood vessel in the arm, neck, or chest that delivers blood or medicine directly to the heart within the last month(
central venous access

Risk of venous thromboembolism associated with totally implantable venous access ports in cancer patients: A systematic review and meta-analysis

Meng Jiang 1Chang-Li Li 2Chun-Qiu Pan 3Xin-Wu Cui 1Christoph F Dietrich 4

PMID: 32479699. DOI: 10.1111/jth.14930

Abstract

Background: Totally implantable venous access ports (TIVAPs) for chemotherapy are associated with venous thromboembolism (VTE). We aimed to quantify the incidence of TIVAP-associated VTE and compare it with external central venous catheters (CVCs) in cancer patients through a meta-analysis.

Methods: Studies reporting on VTE risk associated with TIVAP were retrieved from medical literature databases. In publications without a comparison group, the pooled incidence of TIVAP-related VTE was calculated. For studies comparing TIVAPs with external CVCs, odds ratios (ORs) were calculated to assess the risk of VTE.

Results: In total, 80 studies (11 with a comparison group and 69 without) including 39 148 patients were retrieved. In the noncomparison studies, the overall symptomatic VTE incidence was 2.76% (95% confidence interval [CI]: 2.24-3.28), and 0.08 (95 CI: 0.06-0.10) per 1000 catheter-days. This risk was highest when TIVAPs were inserted via the upper-extremity vein (3.54%, 95% CI: 2.94-4.76). Our meta-analysis of the case-control studies showed that TIVAPs were associated with a decreased risk of VTE compared with peripherally inserted central catheters (OR = 0.20, 95% CI: 0.09-0.43), and a trend for lower VTE risk compared with Hickman catheters (OR = 0.75, 95% CI: 0.37-1.50). Meta-regression models suggested that regional difference may significantly impact on the incidence of VTE associated with TIVAPs.

Conclusions: Current evidence suggests that the cancer patients with TIVAP are less likely to develop VTE compared with external CVCs. This should be considered when choosing the indwelling intravenous device for chemotherapy. However, more attention should be paid when choosing upper-extremity veins as the insertion site.

Reference:

J Thromb Haemost. 2020 Sep;18(9):2253-2273. doi: 10.1111/jth.14930.Epub 2020 Jul 15.

, port, PICC line)

Past personal history or current Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE)

Each episode of venous thrombosis in any location as well as pulmonary emboli are included. The combination of a DVT and PE remains three points. Subsequent surgical procedures in a patient with a thrombotic history are associated with a very high incidence of

thrombosis

Postoperative venous thrombosis. Evaluation of five methods of treatment

M BorowH Goldson

PMID: 6161550. DOI: 10.1016/0002-9610(81)90168-9

Abstract

Five methods for preventing deep venous thrombosis in postoperative patients were evaluated and compared with a control group. Five hundred patients from five surgical specialties were studied. The incidence of deep venous thrombosis was 37.3 percent in the control group but significantly less within all treatment groups. The minidose heparin group had the highest incidence (26.9 percent) because there were a large number of bilateral thromboses. The antistasis modalities did slightly better than the drugs; the intermittent pneumatic compression group had the fewest thromboses (11.9 percent). The significant risk factors for postoperative deep venous thrombosis are (1) obesity, (2) malignancy, (3) a history of venous disease, major surgery or major fracture, (4) length of surgery greater than 1 hour, and (5) increasing age. Four nonfatal pulmonary emboli occurred in 500 patients. Two were in women with hysterectomies in whom thrombosis had never been detected in an extremity; it is presumed that these clots arose from pelvic veins. It is thus recommended that patients in these high risk groups be treated prophylactically with one of the aforementioned modalities to decrease the risk of postoperative deep venous thrombosis. Of the different methods used to detect deep venous thrombosis, iodine-125 fibrinogen scanning was superior to both impedance plethysmography and venous Doppler ultrasound. One hundred percent of the thrombi were identified with scanning, whereas far fewer were detected with the latter methods. It is recommended that fibrinogen scanning be used clinically in patients in high risk categories who are undergoing major operative procedures.

Reference:

Am J Surg. 1981 Feb;141(2):245-51. doi: 10.1016/0002-9610(81)90168-9.

. Extended prophylaxis for up to one month may be
indicated

Efficacy of extended thrombo-prophylaxis in major abdominal surgery: what does the evidence show? A meta-analysis

Federico Jorge Bottaro 1Maria Cristina ElizondoCarlos DotiJulio Enrique BruetmanPablo Diego Perez MorenoEduardo Oscar BullorskyJose Manuel Ceresetto

Affiliations expand

PMID: 18521515. DOI: 10.1160/TH07-12-0759

Abstract

Venous thromboembolism (VTE) is a frequent complication following major abdominal surgery. The use of low-molecular-weight heparins (LMWH) to prevent thrombotic events in these patients is a common and well documented practice. However, there is some controversy surrounding the duration of the prophylaxis, as it has been suggested that the risk persists for several weeks after surgery. The objective of this meta-analysis is to systematically review the clinical studies that compared safety and efficacy of extended use of LMWH (for three to four weeks after surgery) versus conventional in-hospital prophylaxis. An electronic data base search was performed. Only randomized, controlled studies were eligible. Data on the incidence of deep vein thrombosis (DVT), VTE and bleeding were extracted. Only three studies fulfilled the inclusion criteria. The indication for surgery was neoplastic disease in 70.6% (780/1104) of patients. The administration of extended LMWH prophylaxis significantly reduced the incidence of VTE, 5.93% (23/388) versus 13.6% (55/405), RR 0.44 (CI 95% 0.28 – 0.7); DVT 5.93% (23/388) versus 12.9% (52/402), RR 0.46 (CI 95% 0.29 – 0.74); proximal DVT 1% (4/388) versus 4.72% (19/402), RR 0.24 (CI 95% 0.09 – 0.67). We found no significant difference in major or minor bleeding between the two groups: 3.85% (21/545) in the extended thrombo-prophylaxis (ETP) group versus 3.48% (19/559) in the conventional prophylaxis group; RR 1.12 (CI 95% 0.61 – 2.06). There was no heterogeneity between the studies. We conclude that ETP with LMWH should be considered as a safe and useful strategy to prevent VTE in high-risk major abdominal surgery.

Reference:

Thromb Haemost. 2008 Jun;99(6):1104-11. doi: 10.1160/TH07-12-0759.

.

Family history of Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE)

One of the most 

powerful

The value of family history as a risk indicator for venous thrombosis

Irene D Bezemer 1Felix J M van der MeerJeroen C J EikenboomFrits R RosendaalCarine J M Doggen

PMID: 19307525. DOI: 10.1001/archinternmed.2008.589

Abstract

Background: A positive family history of venous thrombosis may reflect the presence of genetic risk factors. Once a risk factor has been identified, it is not known whether family history is of additional value in predicting an individual’s risk. We studied the contribution of family history to the risk of venous thrombosis in relation to known risk factors.

Methods: In the Multiple Environmental and Genetic Assessment of risk factors for venous thrombosis, a population-based case-control study, we collected blood samples and information about family history and environmental triggers from 1605 patients with a first venous thrombosis and 2159 control subjects.

Results: A total of 505 patients (31.5%) and 373 controls (17.3%) reported having 1 or more first-degree relatives with a history of venous thrombosis. A positive family history increased the risk of venous thrombosis more than 2-fold (odds ratio [95% confidence interval], 2.2 [1.9-2.6]) and up to 4-fold (3.9 [2.7-5.7]) when more than 1 relative was affected. Family history corresponded poorly with known genetic risk factors. Both in those with and without genetic or environmental risk factors, family history remained associated with venous thrombosis. The risk increased with the number of factors identified; for those with a genetic and environmental risk factor and a positive family history, the risk was about 64-fold higher than for those with no known risk factor and a negative family history.

Conclusions: Family history is a risk indicator for a first venous thrombosis, regardless of the other risk factors identified. In clinical practice, family history may be more useful for risk assessment than thrombophilia testing.

Reference:

Arch Intern Med. 2009 Mar 23;169(6):610-5. doi: 10.1001/archinternmed.2008.589.

risk factors for thrombosis and also frequently not asked or included in some risk models, and frequently not included in
clinical trial

Familial risk of venous thromboembolism in first-, second- and third-degree relatives: a nationwide family study in Sweden

Bengt Zöller 1Henrik OhlssonJan SundquistKristina Sundquist

PMID: 23348971. DOI: 10.1160/TH12-10-0743

Erratum in

Thromb Haemost. 2013 Jul 1;110(1):204

Abstract

Venous thromboembolism (VTE) clusters in families, but the familial risk of VTE has only been determined in first-degree relatives. This nationwide study aimed to determine the familial risk of VTE in first-, second- and third-degree relatives of affected individuals. The Swedish Multi-Generation Register was linked to Hospital Discharge Register data for the period 1987-2009. This was a case-cohort study. Odds ratios (ORs) for VTE were calculated for individuals whose relatives were hospitalised for VTE, as determined by the International Classification of Diseases (ICD), and those whose relatives were unaffected by VTE. The familial OR for VTE was 2.49 in siblings (95% confidence interval [CI] 2.40-2.58), 2.65 in children (2.50-2.80), 2.09 in parents (2.03-2.15), 1.52 in maternal half-siblings (1.26-1.85), 2.34 in paternal half-siblings (2.00-2.73), 1.69 in nieces/nephews (1.57-1.82), 1.47 in cousins (1.33-1.64), and 1.14 in spouses of individuals diagnosed with VTE (1.09-1.18). Familial clustering was stronger at young ages. The familial transmission was slightly stronger for males compared with females but was only significant for siblings 1.13 (1.05-1.22) and parents 1.11 (1.05-1.78) of probands. The present data showing an increased VTE risk among not only first-degree relatives but also second- and third-degree relatives indicate that the genetic component of the familial clustering of VTE is strong. Family history is a potentially useful genetic surrogate marker for clinical VTE risk assessment, even in second- and third degree-relatives.

Reference:

Thromb Haemost. 2013 Mar;109(3):458-63. doi: 10.1160/TH12-10-0743. Epub 2013 Jan 24.

. Increased risk has been documented in first, second, and 
third-degree

relatives. This includes any DVT, PE, or thrombotic 
stroke

Hypercoagulability Is a Stronger Risk Factor for Ischaemic Stroke than for Myocardial Infarction: A Systematic Review

Alberto Maino 1Frits R Rosendaal 2Ale Algra 3Flora Peyvandi 4Bob Siegerink 5

PMID: 26252207. PMCID: PMC4529149. DOI: 10.1371/journal.pone.0133523

Abstract

Background and purpose: Hypercoagulability increases the risk of arterial thrombosis; however, this effect may differ between various manifestations of arterial disease.

Methods: In this study, we compared the effect of coagulation factors as measures of hypercoagulability on the risk of ischaemic stroke (IS) and myocardial infarction (MI) by performing a systematic review of the literature. The effect of a risk factor on IS (relative risk for IS, RRIS) was compared with the effect on MI (RRMI) by calculating their ratio (RRR = RRIS/RRMI). A relevant differential effect was considered when RRR was >1+ its own standard error (SE) or <1-SE.

Results: We identified 70 publications, describing results from 31 study populations, accounting for 351 markers of hypercoagulability. The majority (203/351, 58%) had an RRR greater than 1. A larger effect on IS risk than MI risk (RRE>1+1SE) was found in 49/343 (14%) markers. Of these, 18/49 (37%) had an RRR greater than 1+2SE. On the opposite side, a larger effect on MI risk (RRR<1-1SE) was found in only 17/343 (5%) markers.

Conclusions: These results suggest that hypercoagulability has a more pronounced effect on the risk of IS than that of MI.

Reference:

PLoS One. 2015 Aug 7;10(8):e0133523. doi: 10.1371/journal.pone.0133523.eCollection 2015.

Personal or family history of positive blood test indicating an increased risk of blood clotting

This includes

hereditary and acquired thrombophilia

Venous Thromboembolism: Genetics and Thrombophilias

Manila Gaddh 1Rachel P Rosovsky 2

PMID: 33694139. DOI: 10.1055/s-0041-1723937

Abstract

Venous thromboembolism (VTE) is a major cause of morbidity and mortality throughout the world. Up to one half of patients who present with VTE will have an underlying thrombophilic defect. This knowledge has led to a widespread practice of testing for such defects in patients who develop VTE. However, identifying a hereditary thrombophilia by itself does not necessarily change outcomes or dictate therapy. Furthermore, family history of VTE by itself can increase an asymptomatic person’s VTE risk several-fold, independent of detecting a known inherited thrombophilia. In this article, we will describe the current validated hereditary thrombophilias including their history, prevalence, and association with VTE. With a focus on evaluating both risks and benefits of testing, we will also explore the controversies of why, who, and when to test as well as discuss contemporary societal guidelines. Lastly, we will share how these tests have been integrated into clinical practice and how to best utilize them in the future.

Reference:

Semin Respir Crit Care Med. 2021 Apr;42(2):271-283. doi: 10.1055/s-0041-1723937.Epub 2021 Mar 10.

for example
Factor V Leiden

Hereditary thrombophilia

Astrit Dautaj 1Geraldo KrasiVilma BushatiVincenza PreconeMiriam GhezaFrancesco FiorettiMarianna SartoriAlisia CostantiniSabrina BenedettiMatteo Bertelli

PMID: 31577252. PMCID: PMC7233636. DOI: 10.23750/abm.v90i10-S.8758

Abstract

Thrombophilia is a group of disorders in which blood has an increased tendency to clot. It may be caused by inherited or acquired conditions. Thrombophilia is associated with risk of deep venous thrombosis and/or venous thromboembolism. Factor V Leiden thrombophilia is the most common inherited form of thrombophilia and prothrombin-related thrombophilia is the second most common genetic form of thrombophilia, occurring in about 1.7-3% of the European and US general populations (3). Thrombophilia may have autosomal dominant, autosomal recessive or X-linked inheritance. Genetic testing is useful for confirming diagnosis and for differential diagnosis, recurrence risk evaluation and asymptomatic diagnosis in families with a known mutation.

Reference:

Acta Biomed. 2019 Sep 30;90(10-S):44-46. doi: 10.23750/abm.v90i10-S.8758.

, Prothrombin gene mutation, Protein C & S deficiency, lupus anticoagulant, antiphospholipid antibody, Beta2 glycoprotein, antithrombin III, dysfibrinogenemia, and heparin induced thrombocytopenia (HIT).

Fracture of the hip, pelvis, or leg

These fractures are associated with an increased risk of VTE, and the degree of risk varies with location of the 

fracture

Venous thromboembolism rates remained unchanged in operative lower extremity orthopaedic trauma patients from 2008 to 2016

Jared A Warren 1Kavin Sundaram 2Robert Hampton 3Damien Billow 4Brendan Patterson 5Nicolas S Piuzzi 6

PMID: 31519436. DOI: 10.1016/j.injury.2019.09.003

Abstract

Background: Venous thromboembolism (VTE) is a serious complication that contributes to morbidity, mortality, and healthcare costs during the surgical care of patient with lower extremity fractures. Despite this, few recommendations on the topic exist and the literature on VTE incidence is incomplete. Therefore, this study will attempt to estimate annual incidence and trends in 30-day thrombotic events and mortality for the following fractures: (1) hip, (2) femur, (3) patella, (4) tibia and/or fibula, and (5) ankle.

Methods: We identified 120,521 operative lower extremity orthopaedic trauma patients from 2008 to 2016 using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. To evaluate the relationship between the year in which surgery was performed and comorbidities and demographic information bivariate analysis was performed. Bivariate analysis was also performed for the outcomes of interest and year in which the surgery was performed to assess for change. Additionally, bimodal multivariate logistic regression models for hip, femur, and ankle fractures were built, comparing the years 2009 to 2016 using 2008 as a baseline.

Results: Overall incidence for VTE over the study period was 1.7% for hip fractures, 2.4% for femur fractures, 0.9% for patella fractures, 1.1% in tibia and/or fibula fractures, and 0.6% in ankle fractures. Over the study period VTE incidence saw a significant decrease (p < 0.05) in hip and femur fractures, but not for patella, tibia and/or fibula, and ankle fractures. After adjusting for confounding factors with multivariate analysis, the change in hip and femur fractures was no longer significant, while no significant decrease was again found for ankle fractures (p > 0.05).

Conclusion: Our study demonstrates that VTE rates have remained unchanged in operative lower extremity orthopaedic trauma from 2008 to 2016. This highlights the need for higher quality evidence on this important topic in orthopaedic trauma, including a reevaluation on the necessity of thromboprophylaxis guidelines.

Reference:

Injury. 2019 Oct;50(10):1620-1626. doi: 10.1016/j.injury.2019.09.003. Epub 2019 Sep 4.

. although no clear guidelines are available, the presence of additional risk factors increases the degree of thrombotic risk. The incidence of pulmonary emboli may occur with equal frequency for above vs. below knee thrombosis.

Multiple traumatic injuries (for example multiple broken bones due to a fall or car accident)

This includes patients with multiple injuries involving fractures, severe chest and abdominal contusions, and internal injuries. The presence of venous thromboembolism increases mortality and prophylaxis is paramount in these

patients

Venous thromboembolism after severe trauma: incidence, risk factors and outcome

Thomas Paffrath 1Arasch WafaisadeRolf LeferingChristian SimanskiBertil BouillonTimo SpanholtzSebastian WutzlerMarc MaegeleTrauma Registry of DGU

PMID: 19608183. DOI: 10.1016/j.injury.2009.06.010

Abstract

Background: Venous thromboembolic events (VTEs) are common life-threatening complications after trauma, but epidemiology and reported risk factors still vary. The purpose of this investigation was to determine the incidence of VTEs among hospitalised trauma patients, to identify potential risk factors and to assess whether their presence was associated with: (a) the magnitude and pattern of injury, (b) therapeutic interventions and (c) outcome, all by using a large population-based registry.

Patients and methods: Patient data from the Trauma Registry of the German Society for Trauma Surgery (TR-DGU) including datasets from more than 35,000 trauma patients were screened for all clinically relevant VTEs, i.e. deep vein thrombosis (DVT) and pulmonary embolism (PE). A total of 7937 patients were identified for further investigation and multivariate logistic regression analyses were performed to assess potential risk factors for VTEs and to evaluate the effect of VTEs on outcome.

Results: One hundred forty-six of 7937 patients developed clinically relevant VTEs during post-traumatic hospitalisation corresponding to an overall incidence rate of 1.8%. Two-thirds (97/146) of all VTEs occurred during the first 3 weeks after admission. At the time point of the event 118/146 (80.8%) patients were under either mechanical or chemical prophylaxis. Multivariate analysis with VTE as dependent variable identified injury severity score, the number of operative procedures, pelvic injury (abbreviated injury scale > or = 2) and concomitant diseases (i.e. diabetes, renal failure, malignancies and congenital or acquired coagulation disorders) as independent risk factors. The presence of VTEs was associated with higher frequencies of sepsis (25% vs. 9.1%), single (63.6% vs. 41.3%) and multiple organ failure (49% vs. 25%) and prolonged in-hospital length of stay (52+/-34 days vs. 29+/-30 days; all p<0.001). The mortality in the VTE group totaled 13.7% vs. 7.4% in the non-VTE group (p=0.004). The presence of PE was associated with a mortality rate of 25.7%. The adjusted odds ratio of post-traumatic VTEs for hospital mortality was 2.08 (CI95 1.15-3.78; p=0.016).

Conclusion: The occurrence of clinically apparent VTEs during post-traumatic hospitalisation is low but associated with increased morbidity and mortality. Conclusions about the effectiveness of different thromboprophylactic measures could not be drawn, since detailed information was not recorded. However, 80.8% of VTE patients had received thromboprophylaxis at the time point of the event.

Reference:

Injury. 2010 Jan;41(1):97-101. doi: 10.1016/j.injury.2009.06.010.

. Bleeding issues in these patients preventing proper anticoagulation can be addressed with a program of surveillance and/or judicious use of temporary venacava
filters

An economic evaluation of venous thromboembolism prophylaxis strategies in critically ill trauma patients at risk of bleeding

T Carter Chiasson 1Braden J MannsHenry Thomas Stelfox

PMID: 19554085. PMCID: PMC2695771. DOI: 10.1371/journal.pmed.1000098

Abstract

Background: Critically ill trauma patients with severe injuries are at high risk for venous thromboembolism (VTE) and bleeding simultaneously. Currently, the optimal VTE prophylaxis strategy is unknown for trauma patients with a contraindication to pharmacological prophylaxis because of a risk of bleeding.

Methods and findings: Using decision analysis, we estimated the cost effectiveness of three VTE prophylaxis strategies-pneumatic compression devices (PCDs) and expectant management alone, serial Doppler ultrasound (SDU) screening, and prophylactic insertion of a vena cava filter (VCF) — in trauma patients admitted to an intensive care unit (ICU) with severe injuries who were believed to have a contraindication to pharmacological prophylaxis for up to two weeks because of a risk of major bleeding. Data on the probability of deep vein thrombosis (DVT) and pulmonary embolism (PE), and on the effectiveness of the prophylactic strategies, were taken from observational and randomized controlled studies. The probabilities of in-hospital death, ICU and hospital discharge rates, and resource use were taken from a population-based cohort of trauma patients with severe injuries (injury severity scores >12) admitted to the ICU of a regional trauma centre. The incidence of DVT at 12 weeks was similar for the PCD (14.9%) and SDU (15.0%) strategies, but higher for the VCF (25.7%) strategy. Conversely, the incidence of PE at 12 weeks was highest in the PCD strategy (2.9%), followed by the SDU (1.5%) and VCF (0.3%) strategies. Expected mortality and quality-adjusted life years were nearly identical for all three management strategies. Expected health care costs at 12 weeks were Can$55,831 for the PCD strategy, Can$55,334 for the SDU screening strategy, and Can$57,377 for the VCF strategy, with similar trends noted over a lifetime analysis.

Conclusions: The attributable mortality due to PE in trauma patients with severe injuries is low relative to other causes of mortality. Prophylactic placement of VCF in patients at high risk of VTE who cannot receive pharmacological prophylaxis is expensive and associated with an increased risk of DVT. Compared to the other strategies, SDU screening was associated with better clinical outcomes and lower costs.

Ref:

PLoS Med. 2009 Jun 23;6(6):e1000098. doi: 10.1371/journal.pmed.1000098. Epub 2009 Jun 23.

.

Spinal cord injury resulting in paralysis

Patients often do not report symptoms due to the nature of their nerve damage. Initial VTE presentation may include extensive 

thrombosis

Venous thromboembolism after spinal cord injury

Robert W Teasell 1Jane T HsiehJo-Anne L AubutJanice J EngAndrei KrassioukovLinh TuSpinal Cord Injury Rehabilitation Evidence Review Research Team

PMID: 19236977. PMCID: PMC3104991. DOI: 10.1016/j.apmr.2008.09.557

Abstract

Objective: To review systematically the published literature on the treatment of deep venous thromboembolism after spinal cord injury (SCI).

Data sources: MEDLINE/PubMed, CINAHL, EMBASE, and PsycINFO databases were searched for articles addressing the treatment of deep venous thromboembolism post-SCI. Randomized controlled trials (RCTs) were assessed for methodologic quality using the Physiotherapy Evidence Database Scale, while non-RCTs were assessed using the Downs and Black evaluation tool.

Study selection: Studies included RCTs, non-RCTS, cohort, case-control, case series, pre-post, and postinterventional studies. Case studies were included only when no other studies were available.

Data extraction: Data extracted included demographics, the nature of the study intervention, and study results.

Data synthesis: Levels of evidence were assigned to the interventions using a modified Sackett scale.

Conclusions: Twenty-three studies met inclusion criteria. Thirteen studies examined various pharmacologic interventions for the treatment or prevention of deep venous thrombosis in patients with SCI. There was strong evidence to support the use of low-molecular-weight heparin in reducing venous thrombosis events, and a higher adjusted dose of unfractionated heparin was found to be more effective than 5000 units administered every 12 hours, although bleeding complications were more common. Nonpharmacologic treatments were also reviewed, but again limited evidence was found to support these treatments.

Reference:

Arch Phys Med Rehabil. 2009 Feb;90(2):232-45. doi: 10.1016/j.apmr.2008.09.557.

and/or death. Management requires a multidisciplinary
approach

Prevention of Venous Thromboembolism in Individuals with Spinal Cord Injury: Clinical Practice Guidelines for Health Care Providers, 3rd ed.: Consortium for Spinal Cord Medicine

No authors listed

PMID: 29339863. PMCID: PMC4981016. DOI: 10.1310/sci2203-209

See full article for guidelines.

Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4981016/

Reference:

Top Spinal Cord Inj Rehabil. Summer 2016;22(3):209-240. doi: 10.1310/sci2203-209.

.

Skip to content