DISCLOSURES - Philippine College of Physicians Sessions... · To define the problem of VTE in the...
Transcript of DISCLOSURES - Philippine College of Physicians Sessions... · To define the problem of VTE in the...
DISCLOSURES
SPEAKERS BUREAU: ASTRA ZENECA Phil SPEAKERS BUREAU: SANOFI ADVENTIS SPEAKERS BUREAU: PFIZER Phil SPEAKERS BUREAU: SERVIER Phil SPEAKER: BOEHRINGER Phil
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Celine Teves Aquino MD FPCP FPCC Ass Professor CIM
OBJECTIVES
To define the problem of VTE in the critical care setting
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1) To enumerate the factors that promote VTE 2) To identify the reasons why VTE diagnosis in ICU is difficult 3) To review the guidelines for VTE prophylaxis in the critically ill
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Background
VENOUS THROMBO- EMBOLISM
DEEP VENOUS THROMBOSIS
PULMONARY EMBOLISM
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Acquired risk factors Age > 40 Varicose Veins Direct Trauma to Vein Immobilization Pregnancy and
Hormones Malignancy
ANY “ACTIVATION” OF VIRCHOW’S TRIAD (endothelial injury, hypercoagulability, stasis)
Hereditary factors Coagulation Disorders Female Gender
VENOUS THROMBOSIS
WHO ARE AT RISK?
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STASIS / VESSEL INJURY
•POST-OPERATIVE especially ORTHOPEDIC
SEVERE MEDICAL ILLNESS particularly SEPSIS
* OBESITY CTA
HYPERCOAGULABILITY
* MALIGNANCIES * PREGNANCY
WHO ARE AT RISK?
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HIV infection
•Younger HIV patients •CD4+ COUNT <200 /mm3
•Development of AIDS •APAS
•Protein C & S deficiency •Exposure to protease inhibitors •Opportunistic infections
WHO ARE AT RISK?
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“STASIS” MOST COMMON RISK FACTOR IMPLICATED IN “SILENT” VTE
In medically ill patients (excluding those admitted for trauma, mental disorder or for VTE alone), risk for VTE include: 1) history of VTE (w/in 6 months) or surgery (w/in 30 days) 2) ICU admission 3) admission for heart failure 4) active cancer Am J Health Sys Pharm 2006
In medically ill patients (excluding those admitted for trauma, mental disorder or for VTE alone), risk for VTE include: 1) history of VTE (w/in 6 months) or surgery (w/in 30 days) 2) ICU admission 3) admission for heart failure 4) active cancer Am J Health Sys Pharm 2006
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So … what IS the problem?
MOST hospitalized patients have at least one risk factor for VTE
VTE risk increases 260 fold (!) in hospitalized patients Mayo Clin Proc 2001; 76:1102-10
VTE is “silent” in the majority of cases
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THROMBOSIS
BLOOD MOVES SLOWEST AT THE PERIPHERY OF THE VEIN
…COLLECTS IN ONE OR BOTH VENOUS VALVE CUSPS
…BECOMES STICKY, GATHERING AT VEIN WALL
…BECOMES A CLOT THAT CAN GROW BIG ENOUGH TO
CLOSE OFF A VEIN
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VENOUS THROMBOEMBOLISM
Reduced LV inflow
Reduced CO
Cardio- Vascular
compromise
Abrupt Occlusion Pulmonary
vessel
Pulm HPN & RV strain
Reduced pulmonary perfusion
Pulmonary infarct
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Is this problem prevalent ?
VTE risk even higher in the non- surgical critically ill
DVT estimated to occur within the first week of ICU stay in 30% of
patients who do NOT receive
prophylaxis
Arch Intern Med. 2001; 161:1268-79
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What is the impact of VTE in critical care?
Incidence ~ 1.59 % for admissions excluding trauma, labor, surgery, mental disorder
Edelsberg J, Hagiwara M
Am J Health Sys Pharm2006
26% of undiagnosed VTE develop fatal embolic event; another 26% have recurrent embolic events!
Edelsberg J, Hagiwara M
Am J Health Sys Pharm2006
What is the implication for the clinician?
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30 % of PE die within the first few hours of onset; even w/ anticoagulation, PE mortality at 14 and 90 days is 10% & 20%
www.nhlbi.nih/health-topics/pe www.vascularweb.org Task force on PE, Eur J Cardiol 2000
~ 5-10% of in-hospital deaths are due to PE
Lindblad B, Sternby NH etal. BMJ 1991
Sandler DA, Martin JF. R Soc Med 1989
Alikhan R, Peters F etal. J Clin Path 2004
post-mortem meta-analysis indicates: in the last 30 years, clinicians miss 70% of PE!
Pineda LA, Hathwar VS etal. Chest 2001
Rizkallah J, man SF etal. Chest 2009
Ageno W, Agnelli G etal. MASTER registry. Thromb Res 2008
Why is it overlooked so often?
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Shortness of breath is the most frequent presentation of VTE
not all things that seem alike are
alike
Concurrence of cardiovascular co- morbidities tends to delay the diagnosis of VTE because of similarity of presentation
Smith SB, Geske JB etal. J Emerg Med 2012
How should we approach the problem of VTE prophylaxis?
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Estimate VTE risk Estimate bleeding risk
VTE risk > bleeding risk?
Initiate pharmacologic prophylactic therapy
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major surgery most
important risk factor
Most important independent predictors
in medically ill: ICU admission, CHF,
neoplasms, neurologic disease w/ paresis, thrombophlebitis
Arch Int Med 2001;160: 809-15
Am J Health-Sys Pharm 2006; 63(20): S16-22
Estimate VTE risk
Active cancer (treatment or palliation w/in 6 months 1 Paralysis, paresis or recent (4 weeks) plaster immobilization 1 Recently bedridden > 3days &/or major surgery w/in 4 weeks 1 Localized tenderness along distribution of deep vein 1 Thigh and calf swollen 1 Calf swelling 3 cm greater than unaffected side (measured 10 cm below tibial tuberosity
1
Pitting edema on symptomatic leg only 1 Dilated superficial vein (non-varicose) in symptomatic leg only 1
* Score minus 2 if an alternative diagnosis is available High probability > 3 pts Moderate probability 1-2 pts Low < 0 Wells PS, Hirsch J etal.
J Intern Med 1998; 243:15-23
Clinical Scoring System for DVT
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Le Gal G, Righini M etal
(revised Geneva Score)Ann Intern Med 2006
“Combined” Wells & Geneva scoring for prediction of PE:
1) Hemoptysis 2) Tachycardia 3) Malignancy 4) Age > 65 years 5) History of VTE 6) Recent immobilization 7) Current symptoms of DVT
Wells PS, Anderson DR etal
Thromb Haemost 2000
> 4: PE likely < 4: PE unlikely
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PERC (Pulmonary Embolism Rule-out Criteria)
Carpenter CR, Keim SM etal
J Emerg Med 2009
Sinh B, Chnadra S etal
Ann IEmerg Med 2011
(+) all 8 criteria low enough probability to defer D-dimer determination
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1) Age < 50 years 2) Pulse < 100/min 3) Pulse oximetry > 94% 4) Absence of unilateral leg swelling 5) No history of VTE 6) No hemoptysis 7) No recent surgery 8) No oral hormones
Why shouldn’t we give prophylaxis for every patient admitted to the ICU?
BLEEDING !
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VTE risk > bleeding risk?
H - Hypertension 1
A - Abnormal liver function - Abnormal renal function
1 1
S - Stroke 1
B - Bleeding (anemia or predisposition to bleed) 1
L - Labile INRs 1
E - Elderly (age > 65 years) 1
D - Drug use (concomitant NSAID, anti-platelet) - Alcohol use (> 8 alcoholic drinks/week)
1 1
0 1.13 bleed/100 1 1.02 bleed/100 2 1.88 bleed/100 3 3.74 bleed/100 4 8.70 bleed/100 5 12.50 bleed/100
Pisters R, Lane DA etal. The Euro Heart Survey
Chest 2010; 138: 1093-100
HAS-BLED scoring for estimation of Bleeding Risk
Increasing score correlates With increasing bleeding risk
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VTE
prophylaxis
ANTI-PLATELET AGENTS
ANTI- COAGULANTS
Initiate pharmacologic prophylactic therapy
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L LDL
L LDL
L LDL
ARTERIAL THROMBOSIS
VENOUS THROMBOSIS
FORMED UNDER HIGH SHEAR FORCES
FORMED UNDER LOWER SHEAR FORCES
THROMBI are PREDOMINANTLY
PLATELET in COMPOSITION
FEWER PLATELETS in THROMBUS: RBC
& FIBRIN MAKE UP MOST OF THROMBUS
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L LDL
L LDL
L LDL
ARTERIAL THROMBOSIS
VENOUS THROMBOSIS
SIMILAR and DISSIMILAR?
PRESENCE OF MICRO-ALBUMINURIA
PREDICTS BOTH ARTERIAL & VENOUS DISEASE
L LDL
L LDL
L LDL
ARTERIAL THROMBOSIS
VENOUS THROMBOSIS
ANTI- PLATELET AGENTS
ANTI- COAGULANTS
FIBRINOLYTIC AGENTS
ANTI- PLATELET AGENTS
FIBRINOLYTIC AGENTS
ANTI- COAGULANTS
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COAGULATION PATHWAYS & ANTICOAGULANTS
•Vitamin K antagonists •Direct FXa inhibitors •Heparin / LMWH •Pentasaccharides
•Direct Thrombin Inhibitors
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HEPARIN
or
Related
drugs
FRIEND OR
FOE
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HEPARIN
Bleeding risk Major bleeding events
PE events Symptomatic DVT VTE-related mortality
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Are all critical care patients candidates for pharmacologic VTE prophylaxis?
Though less than the incidence in patients undergoing major surgery, the risk of VTE in the medically ill is NOT NEGLIGIBLE Highest risk include those with * recent history of VTE or surgery * admission to ICU * heart failure * active cancer
Edelsberg J,Hagiwara M etal. Am J Health Sys Pharm 2006
Kakkar AK, New Eng J Med 2011
RCT: 8300 acutely ill patients decompensated CHF active cancer severe systemic infection plus Chronic Lung Disease obesity previous VTE advanced (>60 years) age
PHARMACOLOGIC THROMBOPROPHYLAXIS
DID NOT REDUCE RISK OF P.E., SUDDEN DEATH,
CARDIOPULMONARY DEATH BUT DID REDUCE
INCIDENCE OF DVT
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BUT …
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CURRENT STAND
The American College of Physicians DOES NOT support the application of performance measures in medical patients that promotes universal VTE prophylaxis regardless of risk
Amir Q, Chou R etal
for the Clinical Guidelines Committee of the ACP ACP Clinical Practice 2011
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Summary
VTE in ICU a significant problem? Is failure to initiate VTE prophylaxis where appropriate dangerous?
YES
YES
Is there a guide to making pharmacologic prophylaxis better than educated guesswork?
YES
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Admitted for medical illness
Assess for VTE risk
Assess for bleeding risk
VTE risk OUTWEIGHS bleeding risk
Bleeding risk OUTWEIGHS
VTE risk
Weigh VTE risk against
bleeding risk
PROPHYLAXIS
NONE
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SUMMARY of CURRENT RECOMMENDATIONS
Mechanical prophylaxis against VTE with graduated compression stockings IS NOT recommended
Pharmacologic prophylaxis with heparin or related drugs is appropriate in medically ill patients with significant VTE risk where the risk outweighs the bleeding risk
Amir Q, Chou R etal
for the Clinical Guidelines Committee of the ACP ACP Clinical Practice 2011
PRIMUM NON
NOCERE CTA
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