Call to Action to Prevent VTE in Hospitalized Patients

Henke PK, Kahn SR, Pannucci CJ, et al.
Call to Action to Prevent Venous Thromboembolism in Hospitalized Patients: A Policy Statement From the American Heart Association. Circulation 2020;May 7:[Epub ahead of print].

The following are key points to remember from this American Heart Association (AHA) policy statement on preventing venous thromboembolism (VTE) in hospitalized patients:

  1. Hospital-acquired VTE, which occurs within 3 months after hospitalization, accounts for >50% of the population burden of VTE in the United States. However, thromboprophylaxis remains underused or misapplied with relatively low public- and provider-awareness given the high degree of public health burden.
  2. Treatment for acute VTE is costly (estimated $12,000-$15,000 per person in 2014) with a high degree of hospital re-admission (18% at 30 days) and recurrence (10-30% within 5 years). Long-term complications include the post-thrombotic syndrome (30-50% following proximal deep vein thrombosis [DVT]) and chronic thromboembolic pulmonary hypertension (CTEPH; 4% following pulmonary embolism [PE]), contributing to an annual preventable cost of $7-$10 billion per year from hospital-acquired VTE.
  3. Common medical illnesses are associated with hospital-acquired VTE. These include infection, acute stroke, and inflammatory conditions (e.g., inflammatory bowel disease, autoimmune disorders).
  4. Cancer accounts for one-fifth of incident VTE cases, a seven-fold higher risk as compared to patients without cancer. This is even higher in select cancer types (e.g., pancreatic, brain). Rates of VTE in patients hospitalized with cancer have nearly doubled between 1995 (3.5%) and 2012 (6.5%). However, patients hospitalized with cancer are less likely to receive VTE prophylaxis than patients hospitalized without cancer.
  5. Hospital-acquired VTE is common in patients undergoing surgical procedures. Risk is highest following neurological, orthopedic, oncological, trauma, or emergency surgery (estimated 2-3%).
  6. Patient awareness of hospital-acquired VTE risk is low. In fact, in a large global survey from 2014, only half of survey respondents were aware of DVT and PE. This was far lower than other thrombotic conditions (heart attack 88%, stroke 85%). Global initiatives (e.g., World Thrombosis Day) reach large audiences, but require coordinated efforts across public health, clinical practice, and private sectors to achieve sustainable achievements.
  7. VTE prevention in the hospital setting has been extensively studied. Guidelines recommend the use of risk assessment models (e.g., Caprini, Rogers, Padua, and IMPROVE scores) to identify at-risk patients for whom chemoprophylaxis is recommended. The Khorana score can be used to guide chemoprophylaxis in patients with cancer.
  8. While most patients receiving chemoprophylaxis do so using a fixed-dose, one-size-fits-all approach, evidence suggests that many patients may not receive adequate prophylaxis with this strategy. Using a weight-based approach may improve dosing, especially for patients with obesity (another VTE risk factor).
  9. The role of post-hospital chemoprophylaxis for patients hospitalized for an acute medical illness remains ill defined. While there are two Food and Drug Administration (FDA)-approved medications (rivaroxaban and betrixaban), clinical trial evidence has been mixed and some guidelines have recommended against routine use in patients without cancer.
  10. While numerous risk assessment models for hospital-acquired VTE exist (see point #7 above), overall use of chemoprophylaxis remains low or inappropriately applied. Some studies suggest that only one-half of at-risk patients receive prophylaxis, while other studies show higher use (>75%) but also overuse among low-risk patients.
  11. Numerous studies have demonstrated the benefit of computer decision support systems to guide VTE chemoprophylaxis orders for hospitalized patients. However, even when ordered, >10% of prescribed anticoagulant doses are often not given, reducing the efficacy of this intervention. Reasons for missed doses include patient- and provider-level factors.
  12. The AHA recommends that VTE risk assessment and reporting be performed for all hospitalized patients and that these data be used to benchmark hospitals for comparison and pay-for-performance programs.
  13. The AHA supports appropriations for collaborations between public health, clinical practice, and the private sector to improve public awareness of VTE.
  14. The AHA supports national tracking of objectively confirmed VTE using standardized definitions within 90 days of hospitalization.
  15. The AHA recommends a central steward of data tracking of VTE risk assessment, use of chemoprophylaxis, and rates of VTE across all hospitals.

Clinical Topics: Anticoagulation Management, Cardio-Oncology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Vascular Medicine, Anticoagulation Management and Venothromboembolism, Pulmonary Hypertension, Interventions and Vascular Medicine

Keywords: Anticoagulants, Cardiotoxicity, Chemoprevention, Hypertension, Pulmonary, Neoplasms, Obesity, Postphlebitic Syndrome, Postthrombotic Syndrome, Primary Prevention, Pulmonary Embolism, Risk Assessment, Risk Factors, Vascular Diseases, Vascular Surgical Procedures, Venous Thromboembolism, Venous Thrombosis

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