Can we Avoid DVT and PE? What is the Role of Prophylaxis? Steven Fein, M.D., MPH What I m Going to Tell You Identifying who is at risk for DVT/PE Preventing DVT/PE in post-op ortho patients Preventing DVT/PE in other hospital patients Weighing the risks and benefits of using anticoagulants for DVT/PE prevention Better to Be a Bleeder than a Clotter Bleeders Younger people Liver dysfunction Bleeding disorders Anticoagulants Wine with dinner? Clotters Older people CAD, CVD, PVD, cancer Chronic inflammatory states Prior stroke/tia or DVT/PE Known clotting disorders Causes longevity Causes mortality and disability 1
Arterial Thrombosis is Common Clot Missions Prevent post-op DVT/PE after ortho surgery Prevent post-op DVT/PE after other surgery Prevent first DVT/PE in non-surgical patients Prevent second DVT/PE in known clotters Prevent stroke in atrial fibrillation patients Prevent second stroke in atrial fibrillation pts Prevent second stroke in prior stroke/tia pts Clot Missions Prevent post-op DVT/PE after ortho surgery Prevent post-op DVT/PE after other surgery Prevent first DVT/PE in non-surgical patients Prevent second DVT/PE in known clotters Prevent stroke in atrial fibrillation patients Prevent second stroke in atrial fibrillation pts Prevent second stroke in prior stroke/tia pts 2
DVT/PE is a common problem Death Pulmonary hypertension 30,000 PE Post-thrombotic syndrome Symptomatic DVT Asymptomatic DVT 600,000 800,000 2 million DVT/PE Affects VIP Why does DVT matter? Associated with pulmonary embolism (50%) Post-thrombotic syndrome (30%) Recurrent DVT (30% long-term recurrence) Mortality 3
Who is at Risk for DVT/PE? Among age>75 1%/yr have DVT/PE DVT/PE Risk Assessment Who Needs Anticoagulation? 4
Noninvasive DVT Prevention History of Anticoagulation How Anticoagulants Work 5
VTE Prophylaxis Form Problems with Heparin Every preparation different Reports of contaminated heparin supply (2009) Dosing and pharmacokinetics unpredictable Common to develop Anti-heparin antibody and poses a risk for developing HIT syndrome Heparin Causes HIT 6
Fondaparinux for Post-Op DVT/PE Prevention NOAC for DVT Prevention After Knee Replacement Rivaroxaban efficacy story Apixaban safety story Anticoagulants for DVT Prevention in Non-Surgical Patients 7
Anticoagulants for Non-Surgical Patients Anticoagulants for Non-Surgical Patients Rivaroxaban for Non-Surgical DVT Prevention Efficacy comparable to LMWH More bleeding than LMWH 8
How a Hematologist Thinks About Anticoagulation Decisions Benefits Risks Back of VTE Prophylaxis Form Still Searching for the Holy Grail: No Bleeding 9
My Recommendations for DVT/PE Prevention Do risk assessment: age, cancer, prior clotting Weight benefits vs. risk for anticoagulants Use NOAC for post-op orthopedic prevention Inject anticoagulants in other hospital patients Fondaparinux 2.5mg daily if Age<75 and nl creat Enoxaparin 30mg daily if Age>75 or abnormal creat Heparin 5000U sc q12h if ESRD and no hep allergy Thrombophilia Testing: Are we Wasting Cash and Blood? Steven Fein, MD, MPH How to Explain Clots to Patients What caused the clot? What to do about the clot? How to prevent future clots? 10
How to Explain Clots to Patients What caused the clot? Don t usually know Doesn t matter very much because patient still a clotter even if cause unknown What to do about the clot? Injection anticoagulants relieve symptoms How to prevent future clots? Oral or injection anticoagulants prevent clots How to Explain Clots to Patients What caused the clot? Don t usually know Doesn t matter very much because patient still a clotter even if cause unknown What to do about the clot? Injection anticoagulants relieve symptoms How to prevent future clots? Oral or injection anticoagulants prevent clots What Caused My Clot? 11
DVT/PE Risk Factors Hypercoagulability Inherited hypercoagulable states Factor V Leiden mutation Prothrombin 20210 mutation Protein C deficiency Protein S deficiency Antithrombin deficiency Acquired hypercoagulable states APLA / lupus anticoagulant Malignancy Medications (OCP/HRT) Heparin-induced thrombosis Venous Stasis LE immobility Bed rest (ICU 33%) Surgery Pregnancy R-sided CHF/obesity Endothelial Injury Previous DVT Indwelling catheter Trauma or LE surgery Hospitalized Patients More Likely to Be Clotters Who s in the hospital? Older people Stroke, CAD patients Cancer patients What happens in the hospital? Surgery, lines, and bedrest Lots of heparin use may cause HIT Hematologist s Perspective on Describing Clotters Hypercoagulable state means having clot Thrombophilia means definable disorder People become more clotty with age Clotters may clot anywhere: arterial or venous Anticoagulants are usually beneficial but as always the benefit has to exceed the risk to justify prescribing a medication You do not need thrombophilia defined to justify using anticoagulants in clotters 12
What is a Hypercoagulable State? Factor V Leiden mutation Prothrombin mutation PC/PS/AT deficiency Sickle cell disease Lupus AC/APLA Homocysteine Myeloproliferatice d/o Lymphoproliferative d/o PNH Clinical features Recent heparin exposure (HIT) Recent surgery or injury Prior clotting h/o MI, CAD, stroke, DVT, PE h/o vascular disease Lack of easy bleeding Estrogen or pregnancy or OCP Cancer Platelet count irrelevant low plts maybe more clotty What is a Hypercoagulable State? Factor V Leiden mutation Prothrombin mutation PC/PS/AT deficiency Sickle cell disease Lupus AC/APLA Homocysteine Myeloproliferatice d/o Lymphoproliferative d/o PNH Clinical features Recent heparin exposure (HIT) Recent surgery or injury Prior clotting h/o MI, CAD, stroke, DVT, PE h/o vascular disease Lack of easy bleeding Estrogen or pregnancy or OCP Cancer Platelet count irrelevant low plts maybe more clotty 13
HIT Testing PROS Minimize use of heparin Avoiding heparin may prevent/resolve HIT Using alternative anticoagulants prevents/resolves HIT syndrome May avoid liability CONS Heparin use needed/wanted Avoiding heparin poses challenges to surgery Using alternative anticoagulants may pose new bleeding risk May promote liability HIT Testing PROS Minimize use of heparin Avoiding heparin may prevent/resolve HIT Using alternative anticoagulants prevents/resolves HIT syndrome May avoid liability Saves money? CONS Heparin use needed/wanted Avoiding heparin poses challenges to surgery Using alternative anticoagulants may pose new bleeding risk May promote liability Costs money Lupus Anticoagulant Autoimmune Clotting Tendency Arterial or Venous Risk of Stroke or recurrent DVT/PE Risk of Miscarriage Antibody tests (ELISA) Cardiolipin Antibody B2-GP1 Antibody Functional tests Lupus Anticoagulant Anti-phospholipid Ab 14
Why else do we want to know the cause of the clotting? Clotting Recurs in Clotters Being a clotter is what predicts future clotting Hereditary Thrombophilia and Recurrent DVT/PE Heterozygous FVL/PT mutation MAY increase risk, but evidence is weak (maybe 2x baseline) Homozygous FVL/PT mutation MAY increase risk but not necessarily life-threatening events PC/PS/AT deficiency found in some families, rarely found in new clotters with first event Can t be interpreted with clots or any anticoag ACCP: NONE of these proven to matter 15
Testing for Clotting Mutations FV Leiden and PT mutation PROS May identify one of the reasons for clotting Resolve anxiety about why Identify/counsel family members Maybe change management CONS Infrequent to find patient whose management changes Cause anxiety about future Maybe overaggressive mgmt for pt and family No evidence of benefit for family (primary prev) Testing for Clotting Mutations FV Leiden and PT mutation PROS May identify one of the reasons for clotting Resolve anxiety about why Identify/counsel family members Maybe change management Maybe NOAC era makes it more favorable to use maintenance anticoagulant CONS Infrequent to find patient whose management changes Cause anxiety about future Maybe overaggressive mgmt for pt and family No evidence of benefit for family (primary prev) Cost of testing and f/u and using more anticoagulants How to Decide Who to Test 16
How to Decide Who to Test TEST Clotter age<60 with FHx Cerebral sinus thrombosis Pregnancy loss 2-3 trimester Portal/mesenteric vein DO NOT TEST Clotter age>60 Cancer clotter Women starting OCP no FHx Asymptomatic no FHx MAYBE TEST: Clotter age<60 no FHx (even if cancer or post-op) Pregnant or OCP clotter What We Have Discussed All patients with clots can be considered clotters Anticoagulant decisions mostly based on clinical data r/o HIT in patients with new clot while in hosp Testing for thrombophilia is appropriate for some Use your judgment and patient preferences to decide Know the goals & pros/cons of mutation testing Patients want to know, may affect management/family Don t test PC/PS/AT in hospital patients 17