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  1. 1. Venous Thromboembolism Prophylaxis for the Medical Patient CP1069179-1 John A. Heit, MD Professor of Medicine Director, Coagulation Laboratories & Coagulation Clinic Consultant, Cardiovascular Diseases and Hematology Research Mayo Clinic College of Medicine Rochester, MN
  2. 2. Annual Incidence of VTE in Olmsted County, MN: 1966-1995 By Age and Gender CP1198340-1 Annual incidence/100,000 Age group (yr) Men Women 
  3. 3. Risk Factors for DVT or PE Nested Case-Control Study (n=625 case-control pairs) Surgery Trauma Inpatient Malignancy with chemotherapy Malignancy without chemotherapy Central venous catheter or pacemaker Neurologic disease Superficial vein thrombosis Varicose veins/age 45 yr Varicose veins/age 60 yr Varicose veins/age 70 yr CHF, VTE incidental on autopsy CHF, antemortem VTE/causal for death Liver disease 0 5 10 15 20 25 50 Odds ratio
  4. 4. Overall and by Location in Community at Onset <ul><li>Overall* 117 9,605 71 </li></ul><ul><li>Men** 130 12,780 77 </li></ul><ul><li>Women** 110 6,586 65 </li></ul><ul><li>Deep vein thrombosis 48 4,593 36 </li></ul><ul><li>Pulmonary embolism 69 5,012 35 </li></ul>Overall/ 100,000 person-years * Adjusted to age and sex distribution of 1980 US whites. ** Adjusted to age distribution of 1980 US whites. In-hospital/ 100,000 bed-years Community/ 100,000 person-years Location at onset Population Incidence of VTE in Olmsted County, MN: 1966–1990
  5. 5. VTE Risk Factors: Medical Patients
  6. 6. VTE Risk Factors: Medical Patients
  7. 7. Independent Risk Factors for VTE after Hospitalization for Acute Medical Illness*: Olmsted County 1988-97 (n=198) *Controlled for Active Cancer and Event Year Heit, et al. J Thromb Haemost 2005 0.004 1.63, 4.05 2.30 Immobility Requiring Physical Therapy 0.019 0.17, 0.86 0.39 Anticoagulation Prophylaxis 0.016 1.19, 5.11 2.46 Prior Superficial Vein Thrombosis <0.001 1.63, 6.70 3.30 Central Venous Catheter 0.037 1.08, 12.67 3.70 Chronic Renal Disease 0.003 1.62, 10.14 4.06 Fracture <0.001 2.13, 12.07 5.07 Neurological Disease with Extremity Paresis <0.001 1.52, 4.92 2.73 BMI (kg/m 2 , per 2-fold increase) 0.001 1.08, 1.40 1.23 Age (per 10 years) P-value 95% CI OR Risk Factor
  8. 8. Relative Risk of VTE by Tumor Site
  9. 9. VTE Risk Factors: Nursing Home Residents
  10. 10. Parenteral Pharmacologic Prophylaxis <ul><li>Unfractionated (Standard) Heparin (UFH) </li></ul><ul><li>Low-Molecular-Weight Heparin (LMWH) </li></ul><ul><li>enoxaparin sodium (Lovenox ™) </li></ul><ul><li>dalteparin sodium (Fragmin ™) </li></ul><ul><li>(tinzaparin sodium [Innohep ™]) </li></ul>
  11. 11. Pharmacologic Prophylaxis <ul><li>Parenteral-Indirect Factor Xa Inhibitor </li></ul><ul><li>fondaparinux (Arixtra ™) </li></ul><ul><li>Parenteral-Direct Thrombin (IIa) Inhibitor </li></ul><ul><li>lepirudin (Refludan ™ ) </li></ul><ul><li>argatroban </li></ul><ul><li>bivalirudin (hirulog) </li></ul><ul><li>Oral-warfarin sodium </li></ul>
  12. 12. “Mechanical” Prophylaxis <ul><li>Intermittent Pneumatic Compression (IPC) </li></ul><ul><li>calf only, or calf & thigh IPC </li></ul><ul><li>venous foot pump </li></ul><ul><li>Graduated Compression Stockings (GCS) </li></ul><ul><li>(Inferior Vena Cava [IVC] Filter) </li></ul>
  13. 13. Prophylaxis Recommendations Acutely Sick Medical Inpatients <ul><li>UFH 5000 units subcutaneously three times daily, or </li></ul><ul><li>LMWH according to recommended dose and dose schedule. </li></ul><ul><li>GCS or IPC when anticoagulant prophylaxis is contraindicated. </li></ul><ul><li>7 th ACCP Consensus Conference. Chest 2004 </li></ul>

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