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Thromboembolic Disorders
VTE Toolk i t
• Acute coronary syndrome, ischemic or cardioembolic stroke, venous thromboembolic disease, acute limb ischemia
• Acute vascular diseases are the commonest cause of death
• VTE (DVT, PE) 3rd commonest vascular disease
• More deaths from PE than AIDS, breast cancer and motor vehicle crashes combined
• Risk of VTE increases with age
Thromboembolic Disorders
VTE Toolk i t
• Affects approximately 1/1,000 people annually
• DVT alone accounts for 300,000–600,000 hospitalizations each year in the USA
• PE causes nearly 200,000 deaths per year in the USA
• Major costs of diagnosis, treatment
Dan Blocker (Hoss Cartright)
VTE Toolk i t
• Of the hit TV show, Bonanza• Died of pulmonary embolism after gall bladder
surgery• Age 43
General George S. Patton
VTE Toolk i t
• One of the greatest generals of all time – “Old Blood and Guts”
• WWII commander of the US 3rd army in Europe and North Africa
• December 1945 – car accident near Heidelberg
• Died of pulmonary embolism 12 days later
• Age 60“May God have mercy on my enemies, because I won’t.”
All of them had a blood clot!
VTE Toolk i t
Dick CheneyVice President2001-2009
Jesse VenturaGov. of Minnesota1999-2003
Richard NixonPresident1969-1974
Dan QuayleVice President
1989-1993
Hillary ClintonSecretary of
State2009-present
Risk Factors• Surgery• Trauma (major trauma
or leg injury)• Immobilization
(bedrest, stroke, paralysis)• Cancer and its
treatment (CTX, RTX, hormonal)• Acute medical illness
(heart or respiratory
failure, infection, inflammation)• Previous DVT or PE• Increased age• Estrogen use (BCP,
HRT), pregnancy, postpartum• Central venous lines • Blood clotting disorders
(thrombophilia)
VTE Toolk i t
VTE Risk Increases with Age
VTE Toolk i t
Residents of Worcester, MA
Anderson - Arch Intern Med 1991;151:933
Population Attributable Risk for VTE
VTE Toolk i t
(case-control study/adjusted for age, sex, year)
Risk factor Adjusted AR
Hospitalization with surgery 24%
Hospitalization without surgery 22%
Active cancer 18%
Nursing home 13%
Trauma 12%
Prior CVC or pacemaker 9%
Neurologic disease with leg paresis 7%
Heit - Arch Intern Med 2002;162:1245
• California Patient Discharge Database (N = 1,653,275)• VTE during surgical admission or within 3 months
• Thromboprophylaxis data was not available
Symptomatic VTE after Surgery
VTE Toolk i t
Benign disease Hip replacement
2.4% Craniotomy
2.3% Knee replacement
1.7% Coronary bypass
1.1% Colectomy
1.1% Hysterectomy
0.3% TUR prostate
0.3% Lap. Cholecystectomy
0.2%
Malignant disease Craniotomy3.6% Colectomy1.7% Pneumonectomy1.6% Rad. Prostatectomy1.5% Hysterectomy1.2% Mastectomy0.4%
White - Thromb Haemost 2003;90:446
Postoperative VTE is AssociatedWith Increased Mortality
VTE Toolk i t
• 118,258 surgical patients in 120 VA hospitals
• Symptomatic VTE is associated with significantly increased 30-day mortality
Gangireddy - J Vasc Surg 2007;45:335
30-dayVTE MortalityNo 4.4%Yes 16.9%
p<0.0001
VTE is often a chronic diseaseRecurrent VTE is Common
VTE Toolk i t
CumulativeFrequency of Recurrent VTE
30 %
25 %
20 %
15 %
10 %
5 %
0 1 2 3 4 5 6 7 8 Years Since Index DVT
Prandoni - Ann Intern Med 1996;125:1
Post-Thrombotic Syndrome is Common
VTE Toolk i t
Prospective study of 355 patients with DVT All patients advised to wear 40 mmHg stockings
0%5%
10%15%20%25%30%35%
1 2 3 4 5 6 7 8Years Since DVT
Cumulative Frequency of PTS
Pradoni – Ann Intern Med 1996; 125:1