Extended Thromboprophylaxis in Medically Ill Patients - Episode 3

Length of Risk and Heparin or Mechanical Compression's Role

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Deepak Bhatt, MD, MPH: We’ve identified VTE [venous thromboembolism]. It’s a problem. Patients who are medically ill are at high risk of it. There are systems that should be in place to identify them. How long does that risk continue? You used the word enduring, Alex. How long does that risk continue, is it a couple of weeks, a month, 45 days, 3 months, 6 months, a year, lifelong?

Gregory Piazza, MD, MS: That’s something that we spent a lot of time thinking about. Having worked so hard to improve prophylaxis in the hospital, it was easy to kind of pat ourselves on the back after we had done work to handle that issue. What we learned is that most VTE that happens as a consequence of hospitalization is actually after the patient is discharged, is out in the outpatient realm. It appears that that risk actually continues highest after the first month from discharge, but it even persists into the second and third month. We see that clinically all the time.

Deepak Bhatt, MD, MPH: What is that risk from, is it a thrombus that’s formed somewhere prior to discharge, or is it that they are still recuperating on the couch at home and are forming de novo VTE at home?

Gregory Piazza, MD, MS: I think it’s a combination of the 2. Certainly, we had this expectation that these risk factors just miraculously go away at the time of discharge. But with the compression of length of stay to the fact where it’s only like 2, 3 days now, patients are going home to do some recuperating. They’re convalescing from their COPD [chronic obstructive pulmonary disease], their pneumonia at home. Sometimes their mobility is actually decreasing as they go home because a physical therapist isn’t walking them, and they’re finishing off their “Game of Thrones” season 6.

Deepak Bhatt, MD, MPH: Is binge TV-watching a risk factor for DVT [deep vein thrombosis], do you know?

Gregory Piazza, MD, MS: I don’t know if it’s been looked at specifically, but in the professional gaming world, there have been a number of reports of professional gamers who will go on 24-, 48-hour binges of gaming, and there have been DVT reports with that.

Alex C. Spyropoulos, MD, FACP, FCCP, FRCPC: Deepak, I think what Greg said is actually critical because what we’ve now done with our very compressed length of stay in the US systems where most of the data tell us absolutely that length of stay is in the 3-, 4-, 5-day range, that we’ve transferred the risk of VTE from the hospital setting to the post-discharge setting. The risk is still there. The immobility criteria are still there. They’re still recuperating from that acute disease process that brought them into the hospital. But now we’re not seeing the VTE events any longer in the hospital.

What’s crucial as well, and I think I have to say, this is one area where the current American Society of Hematology guidelines fell short, is that they use the word “inpatient” prophylaxis as opposed to standard duration prophylaxis. Because even the older inpatient-based trials were done with a duration of prophylaxis anywhere from 7 to 14 days. If you use the word inpatient, you’re condemning the vast majority of US hospitalized medical patients to an inappropriately short duration of prophylaxis. At the very least, these patients should get the minimum duration prophylaxis for 7 to 14 days. As we discussed, maybe we’ll talk about it a little bit later, there is a subset of these patients that probably would benefit from extended prophylaxis.

Deepak Bhatt, MD, MPH: For that inpatient therapy, should it be heparin, unfractionated heparin? Should it be low-molecular weight heparin [LMWH]? Should it be an oral agent? Should it be compression stockings? What should that inpatient therapy be in medically ill patients, someone admitted with a pneumonia or heart failure or something?

Gary Raskob, PhD: I think if the risk score is sufficient, and I think in present day practice, to get into the hospital in the United States nowadays you have to be pretty sick. I think for most it can really be simplified. If the risk says the patient is at high enough risk they should get prevention, I think what we’re doing in our system is simplifying this very significantly which is low molecular weight heparin or unfractionated heparin, unless it’s contraindicated. And use intermittent compression for people who have high risk of bleeding, mainly because it’s just easier, 1 shot a day, and you don’t have to worry about the issues about compliance with a device and patient acceptance of a compression device and all of those things. I think we’ll talk more about what’s coming, the oral option with the oral anticoagulant instead of parenteral low molecular weight heparin and unfractionated heparin.

Gregory Piazza, MD, MS: I will mention that the American College of Physicians took a position on this in 2011 and argued heavily against mechanical prophylaxis alone, especially compression stockings. I think there’s a tendency to think that you’re doing something with compression stockings, but it’s clearly not as good as pharmacological prophylaxis.

Deepak Bhatt, MD, MPH: I think there’s confusion on that point after those guidelines. What exactly is the role of mechanical compression? How useful is it?

Gregory Piazza, MD, MS: I think if you look at the data on pneumatic compression boots, there’s some validity to that as a prophylactic technique. The issue with that is they’re often not where they need to be, actually on the patient’s body. They don’t travel well with patients either. They don’t go home. They don’t go down to CT [computed tomography], and so it’s an issue. Compression stockings, which traditionally have been leaned upon heavily as prophylaxis, don’t seem to do the job, and there are a number of trials, CLOTS 1/2 trials, that show they don’t really make the difference that we hoped they did.

Transcript edited for clarity.