Panel 7: Translation and Application Issues in Relation to Deep Vein Thrombosis

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SLIDE 1: Translation of Evidence Based Data Into Clinical Practice

Joseph A Caprini, M.D.

SLIDE 2: The Many Faces Of Venous Thromboembolism

Prevent Fatal pulmonary emboli.
- 1-5% incidence in patients with >4 risk factors.
- 16.7% mortality at 3 months.
- 25% of those with Pulmonary emboli present as sudden death.
Prevent chronic pulmonary hypertension
- 4% of patients suffering PE
Prevent clinical venous thromboembolism.
- Morbidity, drugs, tests, hose, changes in life style.
Prevent silent venous thromboembolism.
- Risk of subsequent event double that of control population.
Prevent embolic stroke (20-30% PFO rate).
- 50% disabled; 20% die; 30% recover.
Prevent the post thrombotic syndrome.
- 25% incidence following DVT and 7% severe.
May not be evident for 2-5 YEARS>

SLIDE 3: A Clinical Manifestation Of Venous Thromboembolism

SLIDE 4: Post Thrombotic Syndrome

Image of a woman with post thrombotic syndrome

SLIDE 5: ACCP Chest guidelines

Total Risk Factor Score	Incidence of DVT	Risk Level	Prophylaxis Regimen	Legend
0-1	<10%	Low Risk	No specific measures; early and aggressive ambulation	GCS: Graduated compression stockings IPC: Intermittent pneumatic compression LDUH: Low-dose unfractionated heparin LMWH: Low molecular weight heparin Factor Xa - Factor X Inhibitor
2	10-20%	Moderate Risk	LDUH (q12h), LMWH (≤3400 U daily), GCS, or IPC
3-4	20-40%	High Risk	LDUH (q8h), LMWH (>3400 U daily),* or IPC
5 or more	40-80% 1-5% mortality	Highest Risk	LMWH (>3400 U daily),* warfarin (INR, 2-3),* or Factor Xa* ortho, or IPC/GCS + LDUH/LMWH

patients with severe renal impairment (creatinine clearance <30 mL/min), please refer to the
manufacturer’s product information for dose adjustment.

SLIDE 6: Patient Intake Form

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SLIDE 7:Translation of Evidence Based Data Into Clinical Practice

Prospective validation of the entire risk assessment tool is one avenue to translate data from the literature into routine clinical practice.
A number of individual correlations between risk or in the incidence of venous thromboembolism have been observed but until the instrument is prospectively validated some clinicians are unwilling to spend the time in effort to record and track these data elements.
We have developed a protocol to validate this instrument which is widely used as part of the AVF venous screening program, hospitals participating in DVT awareness month, and several hundred university and community settings in the US and as far away as the middle east.

SLIDE 8: Topics/Issues Not Covered In National Guidelines

Incidence of VTE in those with very high risk scores
- Is there a level of risk where elective quality-of-life surgical procedures should not be done.
Guidelines for outpatient prophylaxis in those not admitted to hospital Data to show that shortening the length of standard prophylaxis is justified just because the patient is discharged before 5-7 days.*
Detailed guidelines regarding the prevention and treatment of the post-thrombotic syndrome.
- For most clinicians compression therapy equals antiembolism stockings.

SLIDE 9: Topics/Issues Not Covered In National Guidelines

Treatment of calf vein thrombosis
- Observation and serial scanning has resulted in some deaths
- Treatment has not been associated with mortality
The anticancer effects of LMWH
- What drug? what dose?, how long?
Doesn't the level of risk rather than the type of procedure dictate the use of prophylaxis
Integrating the choice of drug, onset of prophylaxis, duration of prophylaxis, and intensity of prophylaxis according to available evidence.
Separate editorial statements from the evidence based data.
- "we place a relatively low value on the prevention of venographic thrombosis, and a relatively high value on minimizing bleeding complications".
- Some of us feel that the identification of those patients likely to develop venous thrombosis may prevent not only some sudden deaths, but also some cases of disabling stroke and most importantly help prevent the post thrombotic syndrome.
- bleeding rarely results in death and in the prospective randomized trials almost never leads to a serious disabling result due to joint removal for infection secondary to bleeding.

SLIDE 10: This slide has a big X -- should we omit this?

SLIDE 11: What Works to Improve Care? Role of Systems-based Improvement

SLIDE 12: Suggestions For Discussion

Public awareness of DVT
- National implementation of the American Venous Forum screening program in as many communities in the US as possible.
- Increase physician awareness by having the patients present selected educational materials along with their report card to their local physician.
- Encourage the patients to get a DVT expert on the AVF website in order to interpret their report card. Partner with the coalition for DVT, National Alliance for Thrombosis and Thrombophilia, and other interested organizations.
- Representatives help with screening and distribute brochures explaining those organizations at the screening sites.
Media blitz
- Each month run a feature story on a thrombosis victim in a national news venueóparade magazine, people magazine, usa today, wall street journal, etc.
- Inundate the press with human interest stories regarding VTE.

SLIDE 13: Suggestions For Discussion