Panel 6: Venous Thromboembolism Prophylaxis for the Medical Patient

Surgeon General's Workshop on Deep Vein Thrombosis

1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13

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SLIDE 1: Venous Thromboembolism Prophylaxis for the Medical Patient

John Heit, MD
Professor of Medicine
Director, Coagulation Laboratories & Coagulation Clinic
Consultant, Cardiovascular Diseases and Hematology Research
Mayo Clinic College of Medicine Rochester, MN

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SLIDE 2: Annual Incidence of VTE in Olmsted County, MN: 1966-1995 By Age and Gender

Graph showing the annual incidence of VTE in Olmsted County, MN: 1966-1995 By Age and Gender

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SLIDE 3: Risk Factors for DVT or PE Nested Case-Control Study (n=625 case-control pairs)

Chart illustrating the risk factors for DVT or PE Nested Case-Control Study (n=625 case-control pairs)

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SLIDE 4: Incidence of VTE in Olmsted County, MN: 1966-1990

Location at onset
	Overall/ 100,000 person-years	In hospitals / 100,000 bed-years	Community/ 100,000 person-years
Overall *	117	9,605	71
Men **	130	12,780	77
Women **	110	6,586	65
Deep Vein Thrombosis	48	4,593	36
Pulmonary	69	5012	35
* Adjusted to age and sex distribution of 1980 US whites. ** Adjusted to age distribution of 1980 US whites.

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SLIDE 5: VTE Risk Factors: Medical Patients

Characteristic	OR*	AR † (%)
Hospitalization for Acute Medical Illness	10.5	21.5
Nursing Home Confinement	2.3	13.3
Active Malignant Neoplasm Without chemotherapy	5.2	6.4
Active Malignant Neoplasm With chemotherapy	9.7	11.6
Central Venous Catheter/Transvenous Pacemaker	5.9	9.1
Neurological Disease with Extremity Paresis	6.1	6.9
Prior Superficial Vein Thrombosis	3.8	5.4
*Odds Ratio †Population-Attributable Risk Heit, et al. Arch Intern Med 2000 Heit, et al. Arch Intern Med 2002

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SLIDE 6: VTE Risk Factors: Medical Patients

Characteristic	OR	95% CI*
Myeloproliferative Disorders	5.10	1.14, 18.53
Nephrotic Syndrome	2.74	1.09, 6.88
Inflammatory Bowel Disease	2.82	0.95, 8.37
Oral Contraceptives	2.65	0.98, 7.15
Pregnancy/Postpartum	4.24	1.15, 15.61
Estrogen Therapy	1.25	0.79, 1.97
Tamoxifen	4.12	1.10, 15.43
*95% Confidence Interval Heit, et al. Blood 2004

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SLIDE 7: Independent Risk Factors for Venous Thromboembolism Among Patients Hospitalized for Acute Medical Illness*(Olmsted County, MN)

Characteristic	OR	95% CI	P-value
Age (per 10 years increase in age)	1.23	1.08, 1.40	0.001
Body Mass Index (kg/m 2; per 2-fold increase)	2.73	1.52, 4.92	<0.001
Neurological Disease with Extremity Paresis	5.07	2.13, 12.07	<0.001
Fracture	4.06	1.62, 10.14	0.003
Chronic Renal Disease	3.70	1.08, 12.67	0.037
Central Venous Catheter	3.30	1.63, 6.70	<0.001
Prior Superficial Vein Thrombosis	2.46	1.19, 5.11	0.016
Immobility Requiring Physical Therapy	2.30	1.30, 4.05	0.004
*After controlling for event year and active cancer. Heit, et al. J Thromb Haemost 2005

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SLIDE 8: Relative Risk of VTE by Tumor Site

Tumor Site	Observed	Expected	RR	95%CI
Pancreas	13	0.35	37.0	19.7, 63.2
Lymphoma	15	0.47	31.8	17.8, 52.4
Brain	3	0.11	26.8	5.5, 77.9
Liver	2	0.08	24.0	2.9, 86.7
Leukemia	8	0.38	21.0	9.0, 41.3
Other digestive	4	0.24	17.0	4.6, 43.5
Other gynecologic	7	0.50	14.1	5.7, 19.1
Multiple myeloma	2	0.16	12.3	1.5, 44.4
Bladder	7	0.60	11.7	4.7, 24.2

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SLIDE 9: VTE Risk Factors: Nursing Home Residents

Characteristic	OR	95% CI	P-value
CHF	0.90	0.41, 1.99	0.79
COPD	1.14	0.48, 2.67	0.77
Diabetes	0.59	0.25, 1.41	0.23
Malignancy	1.77	0.83, 3.79	0.14
Neurological disease*	1.00	0.27, 3.72	1.00
Parkinson’s disease	0.27	0.06, 1.21	0.09
Fracture	0.28	0.08, 1.01	0.05
Infection	1.24	0.57, 2.73	0.59
Obesity	1.11	0.37, 3.32	0.85

*Neurological disease included hemiplegia, multiple sclerosis, and cauda equina syndrome

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SLIDE 10: Parenteral Pharmacologic Prophylaxis

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

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SLIDE 11: Pharmacologic Prophylaxis

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

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SLIDE 12: "Mechanical" Prophylaxis

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

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SLIDE 13: Prophylaxis Recommendations Acutely Sick Medical Inpatients

UFH 5000 units subcutaneously three times daily or
LMWH according to recommended dose and dose schedule
GCS or IPC when anticoagulant prophylaxis is contraindicated

7^thACCP Consensus Conference. Chest 2004

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