Combined assessment of thrombotic and haemorrhagic risk in acute medical patients

Summary

Acute medical patients have a high risk of venous thromboembolic events (VTE). Unfortunately, the fear of bleeding complications limits the use of antithrombotic prophylaxis in this setting. To stratify the VTE and haemorrhagic risk, two clinical scores (PADUA, IMPROVE) have recently been developed. However, it is not clear how many patients have a concomitant high VTE and haemorrhagic risk and what is the use of prophylaxis in this situation. To clarify these issues we performed a prospective cohort study enrolling consecutive patients admitted to internal medicine. Patients admitted to internal medicine (January to December 2013) were included. VTE and haemorrhagic risk were evaluated in all the included patients. Use and type of anti-thrombotic prophylaxis was recorded. A total of 1761 patients (mean age 77.6 years) were enrolled; 76.8 % (95 % CI 74.7–78.7) were at high VTE risk and 11.9 % (95 % CI 10.4–13.5) were at high haemorrhagic risk. Anti-thrombotic prophylaxis was used in 80.5 % of patients at high VTE risk and in 6.5 % at low VTE risk (p< 0.001), and in 16.6 % at high haemorrhagic risk and in 72.5 % at low haemorrhagic risk (p< 0.001). Prophylaxis was used in 20.4 % at both high VTE and haemorrhagic risk and in 88.9 % at high VTE risk but low haemor-rhagic risk. At multivariate-analysis, use of prophylaxis appeared highly influenced by the VTE risk (OR 68.2, 95 % CI 43.1 - 108.0). In conclusion, many patients admitted to internal medicine were at high risk of VTE. Since almost 90 % of them were at low haemorrhagic risk, pharmacological prophylaxis may be safely prescribed in most of these patients.

Supplementary Material to this article is available online at www.thrombosis-online.com.

Keywords

Anticoagulants - internal medicine - haemorrhage - prophylaxis - venous thromboembolism

• References

• 1 Tapson VF. et al. NABOR Steering Committee. Antithrombotic Therapy practices in US hospitals in an era of practice guidelines. Arch Intern Med 2005; 165: 1458-1464.
• 2 Sandler DA, Martin JF. Autopsy proven pulmonary embolism in hospital patients: are we detecting enough deep vein thrombosis?. J R Soc Med 1989; 82: 203-205.
• 3 Anderson Jr FA. et al. A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism. The Worcester DVT Study. Arch Intern Med 1991; 151: 933-938.
• 4 Baglin TP. et al. Fatal pulmonary embolism in hospitalised medical patients . J Clin Pathol 1997; 50: 609-610.
• 5 Samama MM. et al. A comparison of enoxaparin with placebo for the prevention of venous thromboembolism in acutely ill medical patients: prophylaxis in medical patients with enoxaparin study group. N Engl J Med 1999; 341: 793-800.
• 6 Leizorovicz A. et al. PREVENT Medical Thromboprophylaxis Study Group. Randomized placebo-controlled trial of dalteparin for the prevention of venous thromboembolism in acutely ill medical patients. Circulation 2004; 110: 874-879.
• 7 Cohen AT. et al. ARTEMIS Investigators. Efficacy and safety of fondaparinux for the prevention of venous thromboembolism in older acute medical patients: randomized placebo-controlled trial. Br Med J 2006; 332: 325-329.
• 8 Dentali F. et al. Meta-analysis: anticoagulant prophylaxis to prevent symptomatic venous thromboembolism in hospitalized medical patients. Ann Intern Med 2007; 146: 278-288.
• 9 Barbar S. et al. A risk assessment model for the identification of hospitalized medical patients at risk for venous thromboembolism: the Padua Prediction Score. J Thromb Haemost 2010; 08: 2450-2457.
• 10 Decousus H. et al. IMPROVE Investigators.IMPROVE Investigators. Factors at admission associated with bleeding risk in medical patients: findings from the IMPROVE investigators. Chest 2011; 139: 69-79.
• 11 CG92 Venous thromboembolism - reducing the risk: NICE guideline. February 16, 2010. Available at: https://http://www.nic.org.uk/guidance/cg92
• 12 Kahn SR. et al. Prevention of VTE in Nonsurgical Patients. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141 (Suppl) e195S-e226S.
• 13 Cohen AT. et al. ENDORSE Investigators. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study (published erratum appears in Lancet 2008; 371: 1914). Lancet 2008; 371: 387-394.
• 14 Tapson VF. et al. IMPROVE Investigators. Venous thromboembolism prophylaxis in acutely ill hospitalized medical patients: findings from the International Medical Prevention Registry on Venous Thromboembolism. Chest 2007; 132: 936-945.
• 15 Marcucci M. et al. REPOSI (REgistro POliterapie Societá Italiana di Medicina Interna) Investigators. Prophylaxis of venous thromboembolism in elderly patients with multimorbidity. Intern Emerg Med 2013; 08: 509-520.
• 16 Nieto JA. et al. ROCamacho Igators. Venous thromboembolism prophylaxis in acutely ill hospitalized medical patients. A retrospective multicentre study. Eur J Intern Med 2014; 25: 717-723.
• 17 Nendaz M. et al. Multicentre validation of the Geneva Risk Score for hospitalised medical patients at risk of venous thromboembolism. Explicit ASsessment of Thromboembolic RIsk and Prophylaxis for Medical PATients in SwitzErland (ESTIMATE). Thromb Haemost 2014; 111: 531-538.