# Presentation: 461278

## Venous Thromboembolism Prophylaxis for the Medical Patient

**Venous Thromboembolism Prophylaxis for the Medical Patient**

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

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

**CP1198340-1**

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

**Annual incidence/100,000**

**Age group (yr)**

**Men**

**Women**

****

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

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

**Surgery**
**Trauma**
**Inpatient**
**Malignancy with chemotherapy**
**Malignancy without chemotherapy**
**Central venous catheter or pacemaker**
**Neurologic disease**
**Superficial vein thrombosis**
**Varicose veins/age 45 yr**
**Varicose veins/age 60 yr**
**Varicose veins/age 70 yr**
**CHF, VTE incidental on autopsy**
**CHF, antemortem VTE/causal for death**
**Liver disease**

- 0

- 5

- 10

- 15

- 20

- 25

- 50

**Odds ratio**

## Overall and by Location in Community at Onset

**Overall and by Location in Community at Onset**

- Overall*	117	9,605	71
- Men**	130	12,780	77
- Women**	110	6,586	65
- Deep vein thrombosis	48	4,593	36
- Pulmonary embolism	69	5,012	35

**Overall/****100,000 ****person-years**

- *	Adjusted to age and sex distribution of 1980 US whites.
- **	Adjusted to age distribution of 1980 US whites.

**In-hospital/****100,000****bed-years**

**Community/****100,000****person-years**

**Location at onset**

**Population**

**Incidence of VTE ****in Olmsted County, MN: 1966–1990**

## VTE Risk Factors:  Medical Patients

## VTE Risk Factors:  Medical Patients

## Independent Risk Factors for VTE after Hospitalization for Acute Medical Illness*:Olmsted County 1988-97 (n=198)

| Risk Factor | OR | 95% CI | P-value |
| --- | --- | --- | --- |
| Age (per 10 years) | 1.23 | 1.08, 1.40 | 0.001 |
| BMI (kg/m2, 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 | 1.63, 4.05 | 0.004 |
| Anticoagulation Prophylaxis | 0.39 | 0.17, 0.86 | 0.019 |

***Controlled for Active Cancer and Event Year**
**Heit, et al.  J Thromb Haemost 2005**

## Relative Risk of VTE by Tumor Site

## VTE Risk Factors:  Nursing Home Residents

## Parenteral Pharmacologic Prophylaxis 

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

## Pharmacologic Prophylaxis 

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

## “Mechanical” Prophylaxis 

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

## 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****th****	****ACCP Consensus Conference.  Chest 2004**