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Venous
Thromboembolism in
Rehabilitation Medicine:
“the Last Frontier”Dr. Bill GeertsSunnybrook & Women’s College HSC
University of Toronto
March 1, 2002
Medical College of Virginia
OBJECTIVES
1. Risks of venous thromboembolism in various
patient groups who undergo rehabilitation.
2. Current thromboprophylaxis recommendations
for each of these groups in acute care.
3. Published studies of VTE in rehabilitation settings.
4. Thromboprophylaxis strategies in rehabilitation.
5. Current treatment of acute VTE.
Risk of DVT in Hospitalized Patients
Patient group DVT prevalence
Medical patients 10-20 %
Major gyne/urol/gen surgery 15-40 %
Neurosurgery 15-40 %
Stroke 20-50 %
Critical care patients 15-80 %
Hip/knee surgery 40-60 %
Major trauma 40-80 %
Spinal cord injury 60-80 %
Rehabilitation low-high
6th American College of Chest Physicians Consensus Conference
on Antithrombotic Therapy
Prevention of Venous
ThromboembolismChest January 2001 Supplement
Mechanical Prophylaxis
• Graduated compression stockings
• Intermittent pneumatic compression
• Venous foot pump
Mechanical Prophylaxis
ADVANTAGES DISADVANTAGES
• no bleeding• efficacious in moderate risk patients
Mechanical Prophylaxis
ADVANTAGES DISADVANTAGES
• no bleeding• efficacious in moderate risk patients
• limited efficacy data• no data related to routine use• cumbersome• poor compliance• may mobilization • no long-term use data• no mortality data• cost
Pharmacologic Prophylaxis• Low dose heparin
• Adjusted-dose heparin
• Low molecular weight heparin
• Danaparoid
• Hirudin
• Pentasaccharide
• Oral thrombin inhibitors: ximelagatran
• Warfarin
Pharmacologic Prophylaxis
ADVANTAGES DISADVANTAGES• proven efficacy (RRR 60-80%)• broad spectrum of pts• N > 100,000• multiple agents• ease of use• high compliance• no monitoring (except OAC)• demonstrated cost-effectiveness• mortality reduction
Pharmacologic Prophylaxis
ADVANTAGES DISADVANTAGES• proven efficacy (RRR 60-80%)• broad spectrum of pts• N > 100,000• multiple agents• ease of use• high compliance• no monitoring (except OAC)• demonstrated cost-effectiveness• mortality reduction
• bleeding - GS 0.1% - ortho 1%• cost (low high)
Orthopedic
SurgeryHip arthroplasty
Knee arthroplasty
Hip fracture surgery
HIP ARTHROPLASTY - PROPHYLAXIS
No. of No. of Risk Regimen Trials Patients DVT Red’nControl/placeboGrad comp stockings AspirinLow dose heparinWarfarinInt pneum compressLMW heparinHirudin
ACCP CONSENSUS GUIDELINES - CHEST (2001)
• prospective trials with mandatory venography
1246
11 13
730
3
626290473
1016 1828
42362161172
54 %42 %40 %30 %22 %20 %16 %16 %
---23 %26 %45 %59 % 63 %70 %70 %
Elective hip replacementRecommended: LMWH started 12 hr before surgery, 1A 12-24 hr after surgery, or 4-6 hr after surgery at half the usual high dose or Warfarin (INR 2-3) 1A
Alternative: adjusted-dose heparin to aPTT > ULN 2A
Not recommended: aspirin, LDH, IPC alone
6th ACCP Consensus Conference on Antithrombotic Therapy
KNEE ARTHROPLASTY - PROPHYLAXIS
No. of No. of Risk Regimen Trials Patients DVT Red’n
Placebo
Aspirin
Warfarin
Low dose heparin
LMW heparin
Int pneum compress
6
6
9
2
13
4
199
443
1294
236
1740
110
64 %
56 %
47 %
43 %
31 %
28 %
---
13 %
27 %
33 %
52 %
56 %
ACCP CONSENSUS GUIDELINES - CHEST (2001)
• prospective trials with mandatory venography
Recommended: LMWH 1A or Warfarin (INR 2-3) 1A
Alternative: optimal use of IPC 1B
Not recommended: aspirin, LDH 1C+
6th ACCP Consensus Conference on Antithrombotic Therapy
Elective knee replacement
HIP FRACTURE - PROPHYLAXIS
No. of No. of Risk Regimen Studies Patients DVT Red’n
Control/placebo
Aspirin
Low dose heparin
LMW heparin
Warfarin
9
3
2
5
5
381
171
59
437
239
48 %
34 %
27 %
27 %
24 %
---
29 %
44 %
44 %
48 %
ACCP CONSENSUS GUIDELINES - CHEST (2001)
• prospective trials with mandatory venography
Recommended: LMWH 1B or Warfarin (INR 2-3) 1B
Alternative: Low dose heparin 2B
Not recommended: aspirin 2A
6th ACCP Consensus Conference on Antithrombotic Therapy
Hip fracture surgery
NEED FOR POST-DISCHARGE PROPHYLAXIS
THR RLMWH
placebo
LMWH
dischargeday 6-14
venogramday 30-35
(or warfarin)
In-hosp
In-hosp + 3-4 weeks post-discharge
In-hospital vs Post-discharge LMWH After THR
Author, yearBergqvist, 1996
Planes, 1996
Dahl, 1997
Spiro, 1997
Lassen, 1998
Hull, 2000*
COMBINED
Patients 223
173
218
435
215
533
1797
Placebo 37 %
19 %
32 %
23 %
12 %
37 %
27 %
LMWH 18 %
7 %
19 %
8 %
4 %
20 %
14 %
Placebo 24 %
8 %
13 %
13 %
5 %
9 %
12 %
LMWH 7 %
6 %
9 %
3 %
1 %
3 %
4 %
* In-hospital prophylaxis with warfarin.
DVT Proximal DVT
6th ACCP Consensus Conference on Antithrombotic Therapy
Eikelboom - Lancet (2001)
Extended Duration Prophylaxis: Symptomatic
VTE
Trauma
MAJOR TRAUMA PATIENTS ARE
THE HIGHEST RISK GROUP
FOR THROMBOSIS
Sunnybrook VTE in Trauma Study - 1
• ISS > 9; no prophylaxis given• Prospective; routine bilateral venography• N = 443; mean age 39; ISS 27
All patients 58 % 16 %
Major injuries: Face/ chest / abdomen 50 % 15 %
Head 54 % 20 %
Spine 62 % 27 %
L.E. Ortho 69 % 24 %Geerts - NEJM (1994)
DVT PROX DVT
Major TraumaRecommended: Prophylaxis should be used if possible LMWH as soon as considered safe 1AWith high bleeding risk: initial mechanical prophylaxis (IPC, 1C ES) until LMWH safeHigh TE risk + suboptimal prophylaxis: consider screen with DUS 1CIVC Filter: not for prophylaxis 1C
6th ACCP Consensus Conference on Antithrombotic Therapy
Spinal Cord Injury
ACUTE SPINAL CORD INJURY: LDH + EPC vs LMWH
• Randomized trial in 27 acute spinal cord units• C2-T12 SCI ASIA A, B, or C (motor nonfunctional)
Heparin + IPC Heparin 5000 U Q8H5000 U Q8H
Enoxaparin Enoxaparin 40 mg once daily30 mg Q12H
2 weeksbilateral venography
+ DUS
8 weeks DUS
VTER
No VTE
No VTE
Acute Phase Rehab Phase
SCI Multicenter Trial:Rehabilitation Phase (Weeks 2-8)
• Patients who completed Acute Phase without VTE
• Routine DUS at start of Rehab Phase + 6 weeks later
Heparin Enoxaparin5000 Q8H 40 mg QD
No. 60 59
New VTE 22% 8%
DVT 18% 7%
PE 3%* 2%
Major bleeding 1 0 * 1 fatal
6th ACCP Consensus Conference on Antithrombotic Therapy
Acute Spinal Cord InjuryRecommended: LMWH 1B
If anticoagulants C/I early after injury: IPC and ES LMWH 2B
Possible alternative: IPC/ES + LMWH/LDH 2B
Not recommended: LDH, ES, IPC alone 1C
Rehabilitation phase: continue LMWH or warfarin (INR2-3) 1C
Stroke
Ischemic Stroke
Recommended:
LDH, LWMH, danaparoid 1A
If anticoagulants contraindicated:
ES or IPC 1C+
6th ACCP Consensus Conference on Antithrombotic Therapy
Studies of VTE in
Rehabilitation
VTE IN REHABILITATION: PROBLEMS1. Scanty, poor quality data - ??? risk
2. Huge patient variability: underlying conditions, time
in acute care, pre-rehab prophylaxis, duration of rehab
3. Some patients have DVT on admission
4. Symptoms/signs: nonspecific, reduced communication
5. Risk often prolonged
6. Often no diagnostic testing on site
7. ? Higher threshold for Dx larger thrombi/emboli
8. Resource utilization: transportation, diagnostic tests,
two hosp beds, interrupts/prolongs rehab, drug costs
GENERAL REHABILITATION
Author, year
Prophylaxisprior to rehab
Method of Dx
When screened No. DVT
Prox DVT
Halvorsen, 1985a
Katz, 1995
NS
70 %(various)
FgLS veno
IPG DUS
NS
on adm(< 6 mos)
150
301
18%
---
NS
1%
STROKE REHABILITATION
Author, yr
Prophylaxisprior to rehab
Method of Dx
When screened No. DVT
Prox DVT
Cope, 73
Miyamoto, 80
Sioson, 88
Desmukh, 91
Oczkowski, 92
Pambianco, 95
Harvey, 96
NS
NS
21%
NS
35 %
NS
some
veno
FgLS
IPG
DUS
IPG
DUS
DUS
on adm
10-14 d
45 d
21 d
81 d
on adm
25 d
42
141
98
123
93
421
105
40 %
28 %
---
18 %
---
14 %
13 %
NS
NS
33 %
NS
12 %
NS
NS
TRAUMATIC BRAIN INJURY REHABILITATION
Author, year
Prophylaxisprior to rehab
Method of Dx
When screened No. DVT
Prox DVT
Cifu, 1996
Meythaler, 1996
All (LDH or
IPC)none
DUS
DUS
On adm(4-29 d)
On adm(< 4 mos)
82
116
18%
NS
14 %
8 %
SPINAL CORD INJURY REHAB
Author, year
Prophylaxisprior to rehab
Method of Dx
When screened No. DVT
Prox DVT
Jarrell, 1983Yelnik, 1991
Gunduz, 1993
LDH
91%
allnone
FgLS + IPGveno
venoveno
NS
on adm(45 d)80 d27 d
209
127
87 30
65 %
23 %
14 %53 %
NS
NS
NS28 %
VTE in Rehabilitation
The best strategy is
optimal prophylaxis
in the acute care setting
PROPHYLAXIS OPTIONS IN REHAB
1. Mobilization
2. Physiotherapy
3. Low dose heparin
4. Low molecular weight heparins
5. Warfarin
PREVENTING VTE in REHAB: PRINCIPLES
• Appropriate prophylaxis MUST start in acute care
• Written policy (care pathway)
• Simple, universal
• Routine prophylaxis for high risk patients (SCI,
hip and knee surgery, orthopedic trauma)
• No prophylaxis (or individual decision) for lower
risk patients (stroke, head injury, amputation, burn)
• No routine screening for DVT
Strategies to facilitate effective, safe, efficient, and cost-effective
thromboprophylaxis in rehab settings
• Written, “approved” and used protocols
• Pharmacy involvement
• Point of care INR testing
• Greater use of LMWH if LOS < 2 weeks
• “Education” of referring centers
REHAB PROPHYLAXIS SUMMARY
Patient Group
Spinal cord injury
LE orthop trauma
THR
TKR
Hip fracture
Others
Method
Warfarin (INR 2-3)
Warfarin (INR 2-3)• LMWH• Warfarin
(INR 2-3)
• None• Individualize
Duration
Until discharge
Until discharge
2-4 wks postop
(~ til discharge)
? Post-rehab Prophylaxis
Almost never
Treatment of VTE in
Rehabilitation
Treatment of Venous Thromboembolism:S/C Low Molecular Weight Heparin
is Preferred over IV Heparin
1. At least as efficacious
2. Safer: bleeding
HIT
3. Reduced all-cause mortality
4. Cheaper
5. No lab monitoring
6. Most can be treated as out-patients
Treatment of DVT/PE
LMWH S/C
Oral Anticoagulation (INR 2.0 - 3.0)
5-7 d 3 mos-indefinite
• Subcutaneous LMWH:
dalteparin (Fragmin) 100 U/kg BID or 200 U/kg QD
enoxaparin (Lovenox) 1 mg/kg BID or 1.5 mg/kg QD
nadroparin (Fraxiparine) 86 U/kg BID
tinzaparin (Innohep) 175 U/kg QD
• No lab monitoring or dosage adjustment
INDICATIONS FOR PROLONGED LMWH THERAPY
1. Pregnancy2. Uncontrolled malignancy3. High risk of bleeding4. Warfarin failure5. Major chemotherapy6. INR monitoring difficult
- poor venous access
- geographic inaccessibility- unstable values
7. Need for recurrent invasive procedures8. PATIENT PREFERENCE
Indications for an IVC Filter
Recent PROXIMAL DVT PLUS:
1. Absolute C/I to full anticoagulation
2. Untreatable, major bleeding on anticoag
NOT for: PE without proximal DVT
Minor bleeding
Minor/moderate surgery
Primary prophylaxis
“Recurrent” VTE/failure of Rx
Vitamin K: Routes & Doses
IM NEVER
SC RARELY (only if NPO)
IV 1 mg for MINOR bleeding 10 mg for MAJOR bleeding
PO ROUTE OF CHOICE INR < 9 1 mg
INR > 9 2.5-5 mg
FFP Only if major bleeding, surgery imminent
Duration of Anticoagulation
1. RISK FACTOR RESOLUTION
2. NUMBER OF EPISODES OF VTE
3. THROMBOEMBOLISM RESOLUTION
4. BLEEDING RISK
5. PATIENT PREFERENCE
INDIVIDUALIZE
Discussion
Questions
6th ACCP Consensus Conference on Antithrombotic TherapyChest Supplement January 2001
Prevention of Venous Thromboembolism
Bill Geerts, chair
John Heit
Patrick Clagett
Graham Pineo
Cliff Colwell
Fred Anderson
Brownell Wheeler
ACCP CONSENSUS CONFERENCES ON ANTITHROMBOTIC
THERAPY
Chest 1986, 1989, 1992,
1995, 1998, 2001, 2003
Pulmonary Embolism in UK Hospitals
• 0.9 % of pts admitted to hospital DIE from PE
• < 1/2 of high risk pts had any prophylaxis
• 400 deaths/yr could be saved by prophylaxis
• £ 33-82 million/yr COST SAVINGS with more
appropriate use of prophylaxis
Office of Health Economics (1996)
Making Health Care Safer: A Critical
Analysis of Patient Safety Practices
• UCSF-Stanford Evidence-Based Practice Center report for
Agency for Healthcare Research and Quality, US DOHHR• systematic review of practices to improve patient safety • rank practices according to strength of evidence supporting
more widespread implementation
No. 1 = “Appropriate use of prophylaxis to prevent venous thromboembolism in patients at risk”
Shojania (2001)
Rationale for Prophylaxis
• high incidence of VTE
• associated mortality and morbidity
• cost of diagnosis and treatment
• treatment-related complications
OPPORTUNITY TO: 1. Improve patient outcomes, AND 2. Reduce costs
VTE Prevalence after THR or TKR Surgery, or Surgery for Hip Fracture
* DVT rates among control/placebo groups in RCTs using routine venography
Procedure
THR
TKR
Hip fracture surgery
Deep Vein Thrombosis*
Total, % Proximal, %
45-57 23-36
40-84 9-20
36-60 17-36
Pulmonary Embolism Total, % Fatal, %
0.7-30 0.1-0.4
1.8-7 0.2-0.7
4.3-24 3.6-12.9
6th ACCP Consensus Conference on Antithrombotic Therapy
HIP ARTHROPLASTY
1000 patients undergoing THA
Without Prophylaxis:
500 develop DVT
166 have symptomatic DVT
100 develop symptomatic nonfatal PE
20 die due to PE
Paiement - Am J Surg (1991)
DVT after THR
• 289 patients prophylaxed with GCS + SCD• Ipsilateral duplex ultrasound 5 days postop
Proximal DVT
OverallAnesthetic - general - regionalAge > 75 < 75Age > 75 + GA
6 %11 % 4 %16 % 3 %26 %
Woolson - JBJS (1996)
Warfarin vs Dalteparin in THR
Francis - JBJS (1997)
• 580 patients; bilateral contrast venography
PatientsDVTProximal DVTMajor bleedingOp site bleedingTransfused - OR day - D 1 - 8
190 26 % 8 % 1 % 1 % 65 % 44 %
192 15 % 5 % 2 % 4 % 69 % 68 %
Warfarin Dalteparin P INR 2.5 5000 U daily
0.006 NS NS0.03 NS0.004
Prevention of DVT After THR Surgery*
Prophylaxis Regimen
Control/placebo
Elastic stockings
Aspirin
Low dose heparin
Adjusted-dose warfarin
IPC
LMWH
Recombinant hirudin
Adjusted-dose heparin
No. ofTrials
12
4
6
11
13
7
30
3
4
Combined
Enrollment
626
290
473
1016
1828
423
6216
1172
293
Total DVTPrevalence RRR
54 % ---
42 % 23 %
40 % 26 %
30 % 45 %
22 % 59 %
20 % 63 %
16 % 70 %
16 % 70 %
14 % 74 %
* Pooled DVT rates using routine contrast venography.
Proximal DVTPrevalence RRR
27 % --
26 % 4 %
11 % 57 %
19 % 27 %
5 % 80 %
14 % 48 % 6 % 78 %
4 % 85 %
10 % 62 %
6th ACCP Consensus Conference on Antithrombotic Therapy
Prevention of DVT After TKR Surgery*
Prophylaxis Regimen
Control/placebo
Elastic stockings
Aspirin
Warfarin
Low dose heparin
Venous foot pump
LMWH
Int. Pneum. Compr.
No. ofTrials
6
2
6
9
2
4
13
4
Combined Enrollment
199
145
443
1294
236
172
1740
110
Total DVTPrevalence RRR
64 % ---
61 % 6 %
56 % 13 %
47 % 27 %
43 % 33 %
41 % 37 %
31 % 52 %
28 % 56 %
* Pooled DVT rates using routine contrast venography.
Proximal DVTPrevalence RRR
15 % --
17 % --
9 % 42 %
10 % 35 %
11 % 25 %
2 % 85 % 6 % 63 %
7 % 52 %
6th ACCP Consensus Conference on Antithrombotic Therapy
Prevention of DVT After Surgery for Hip Fracture*
Prophylaxis Regimen
Control/placebo
Aspirin
Low dose heparin
LMWH/heparinoid
Warfarin
No. ofTrials
9
3
2
5
5
Combined
Enrollment
381
171
59
437
239
DVT
48 %
34 %
27 %
27 %
24 %
(95 % CI)
(43-53)
(27-42)
(16-40)
(23-31)
(19-30)
Relative RiskReduction
- -
29 %
44 %
44 %
48 %
* Pooled total DVT rates in RCTs using routine contrast venography.
6th ACCP Consensus Conference on Antithrombotic Therapy
This concept has been challenged by 4 prospective studies based on symptomatic
VTE after in-hospital prophylaxis for THR or TKR
02.0%7.3LMTHRHeit 2000
0.1%3.7%7.0WTHR 1999
0.1%3.6%7.5LMTHRColwell
0.4%3.9%9.0LMTKR 1998
04.3%9.0LMTHRLeclerc
00.6%9.8WTKR 1997
9.8 W
588
1494
1516
842
1142
257
249THRRobinson
SymptDVT Fatal
PE
nDuration,
dProcedure Therapy
W, warfarin; LM, low molecular weight heparin ACCP - Chest (2001)
1.2% 0
Eikelboom - Lancet (2001)
Extended Duration Prophylaxis:Venography
Expt Ctrl Peto OR Weight Peto OR Study n/N n/N (95% CI Fixed) % (95% CI Fixed)
Bergqvist 2/191 10/131 19.7 0.26 (0.08, 0.79)
Dahl 4/117 6/110 16.6 0.62 (0.17, 2.18)
Helt 7/607 10/588 26.6 0.66 (0.26, 1.78)
Hull 4/291 9/133 10.2 0.58 (0.12, 2.91)
Lassen 2/140 9/141 8.5 0.57 (0.11,6.92)
Planes 3/90 7/88 16.9 0.49 (0.12, 1.52)
Total (95% CI) 22/1370 39/1192 100.0 0.50 (0.30, 0.83)
Risk reduction of clinical VTE
1051.2.1
Favours treatment Favours control
Cohen - Thromb Haemost (2001)
6th ACCP Consensus Conference on Antithrombotic Therapy
Orthopedic Surgery - Other Issues
Duration of Prophylaxis:
Uncertain, but at least 7-10 days
Extended, out-of-hospital LMWH may reduce
clinically-important VTE and is recommended
at least for high-risk patients
Pre-discharge Screening:
Routine DUS not recommended
1A
1A
1A
Symptomatic VTE After In-hospital Prophylaxis
Author, yearRobinson, 1997
Leclerc, 1998
Colwell, 1999
Heit, 2000
OperationTHR
TKR
THR
TKR
THR
THR
THR/TKR
No. 506
518
1,142
842
1,516
1,495
588
Prophylaxis warfarin
warfarin
LMWH
LMWH
LMWH
warfarin
LMWH
Duration ofProphylaxis 9.8 d
9.8 d
9.0 d
9.0 d
7.5 d
7.0 d
7.3 d
Sympt.VTE, (%) 6 (1.2)
3 (0.6)
49 (4.3)
33 (3.9)
55 (3.6)
56 (3.7)
11 (1.9)
Fatal PE, (%) 0
1 (0.2)
0
3 (0.4)
2 (0.1)
2 (0.1)
3 (0.5)
6th Consensus Conference on Antithrombotic Therapy
Clinical Outcomes After THA
• Patients: elective, unilateral, primary THA• Design: 156 centers, unblinded RCT• Interventions: enoxaparin 30 mg BID postop warfarin INR 2-3 pre- or postop
in hospital(x = 7.3 d)}
No.Symptomatic VTE (OR ---> 3 mos)
In-hospitalDischarge ---> 3 mos
Fatal PEBleeding - all - major
Warfarin* Enoxaparin1495 1516 3.7 % 3.6 % 1.1 % 0.3 % p=0.008 2.6 % 3.4 % 2 2 7.4 % 10.0 % p=0.01 0.5 % 1.2 % p=0.06
* only 35 % had INR >2 by day 7 Colwell - JBJS (1999)
• Extended duration of prophylaxis for 30 – 42 days reduced symptomatic VTE:
1.3 % vs 3.3 %, OR: 0.38, 95% CI: 0.24 – 0.61, NNT = 50
• Asymptomatic venographic DVT also significantly reduced:9.6 % vs 19.6 %, OR: 0.49,
95% CI: 0.36 – 0.63, NNT = 10
• Major bleeding: similar in extended prophylaxis as in placebo and untreated groups
• Routine use of extended-duration prophylaxis will prevent 20 sympt.
VTE/1000 elective THR or TKR
• Assuming 5% case-fatality rate, this is equivalent to preventing 1 additional death for every 1000 patients
• Outpatient costs is US $24 – 28
Eikelboom - Lancet (2001)
• There is good evidence that prolonged prophylaxis reduces asymptomatic DVT
• Also good evidence that prolonged prophylaxis reduces symptomatic VTE
• Unable to identify the patients at risk for late VTE
• A 2 % rate for (preventable) symptomatic VTE is excessive in view of the high frequency of major orthopedic surgery
Conclusions
Duration of Prophylaxis after Major Orthopedic Surgery
Optimal duration after THR/TKR uncertain
Recommendations: at least 7-10 days 1A extended out-of-hospital prophylaxis 2A may reduce clinically important VTE and is recommended at least for high- risk patients6th ACCP Consensus Conference on Antithrombotic Therapy
Incidence of DVT in Trauma Patients (No Prophylaxis)
Freeark, 1967
Hjelmstedt, 1968
Nylander, 1972
Kudsk, 1989
Geerts, 1994
Abelseth, 1996
LE Prox Author, yr Patients No . Fracture DVT DVT
Injuries bedrest > 3 weeks
Tibial fractures
Tibial fractures
Multisystem trauma, bedrest > 10 d
Major trauma, ISS > 9
Isolated LE # Rx’d surgically
42
76
14
38
349
102
33 %
100 %
100 %
55 %
52 %
100 %
29 %
45 %
57 %
63 %
58 %
28 %
NS
8 %
NS
32 %
18 %
4 %
6th ACCP Consensus Conference on Antithrombotic Therapy
Randomized Studies of DVT Prevention after Acute SCI
Regimen Author, yr Endpoints DVT, No. (%)
Low-dose heparin Green, 1988 Green, 1990 Geerts, 1996
IPC Green, 1982
Adjusted-dose heparin Green, 1988
LMWH Green, 1990 Geerts, 1996
Combinations Green, 1982(IPC, ASA, dipyridamole)
IPGIPG, DUSVenography
FgLS/IPG
IPG
IPG, DUSVenography
FgLS/IPG
9/29 (31) 5/19 (26)10/15 (67)
6/15 (40)
2/29 ( 7)
0/16 ( 0) 4/8 (50)
3/12 (25)
6th ACCP Consensus Conference on Antithrombotic Therapy
DVT in Patients with Acute SCI - No Prophylaxis
Author, year
Brach, 1977
Rossi, 1980
Myllynen, 1985
Merli, 1988
Petaja, 1989
Geerts, 1994
Endpoint
FgLS/IPG
FgLS
FgLS
FgLS/IPG
FgLS
Venography
DVT
90 %
72 %
100 %
48 %
67 %
81 %
Proximal DVT
NS
17 %
NS
NS
NS
35 %
No. of
Patients
10
18
9
8
9
26
6th ACCP Consensus Conference on Antithrombotic Therapy
SCI Multicenter Trial:Acute Treatment Phase (Weeks 0-2)
• Routine venography and DUS day 14 + 3; blinded interpretation
Heparin 5000 Q8H Enoxaparin + IPC 30 mg BID
No. rand/completed 246/48 230/58
VTE 63% 66%
DVT 46% 60%
Proximal DVT 7% 9%
PE 10% 3%
Major VTE (pDVT+PE) 16% 12%
Major bleeding 5% 3%
1 2 3 4 5 6 weeks
1 2 years
RISK
B
CA
RISK OF SYMPTOMATIC VTE AFTER SCI
A. age-matched controlsB. no prophylaxisC. prophylaxis
Cost-effectiveness of Prophylaxis
• 1000 patients undergoing THA
Paiement - Am J Surg (1991)
Strategy
Observation only
Warfarin
Warfarin + duplex scan
Warfarin X 12 wks
Fatal PE
20.0
4.0
0.3
0.15
Charges (US $)
$ 774,000
394,000
616,000
595,000
VTE in Stroke• Prospective studies• No prophylaxis• Routine screening for DVT (17/18 used FgLS)
Studies 18
Patients 749
DVT 49 %
Prox DVT 11 % (17/152)
PE 6 % (10/174)
Fatal PE 4 % (12/270)
Prevention of DVT in Ischemic Stroke
Trials Patients DVT RRR
Control
Low dose heparin
LMWH
Danaparoid
8
5
3
4
346
364
158
203
55 %
24 %
23 %
10 %
---
56 %
58 %
82 %
Geerts (6th ACCP) - Chest (2001)
Risk Factors for VTE in Stroke
UNKNOWN
NO
YES Degree of paralysisAge
Level of consciousness
Improvement in weaknessPrevious VTEVaricose veinsObesity
DVT Treatment: UFH or LMWH?
• meta-analysis of RCTs• adjusted UFH vs fixed-dose S/C LMWH• 11 studies, 3674 patients
Recurrent VTE
All cause mortality
Major bleeding
UFH
5.4 %
6.8 %
1.9 %
LMWH
4.6 %
5.0 %
1.1 %
RRR
15 %
27 %
42 %
P
> 0.2
0.02
0.47
NNT
114
61
164
Gould - AIM (1999)